Davita Panola Dialysis

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 03383 Based on a review of medical records, staff interviews, and review of the facility’s Policies and Procedures (P & P), it was determined that the Medical Director failed to ensure that one of one patient (P#1) who experienced chest pain while at this facility, received care and supervision appropriate to the patient’s medical needs. The facility failed to reassess, monitor, and take steps to manage P#1’s chest pain for over two hours while she waited for the EMS (Emergency Medical System) to arrive. The facility census was 24. Findings include: Cross Reference V715: Failure of the medical director to ensure that all P & P relative to patient care were adhered to by all staff.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 03383 Based on a review of facility records and staff interviews, it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This failure had the potential to negatively affect the health and safety of 30 in-center hemodialysis patients who were receiving hemodialysis treatment at this facility. Findings include: Cross Reference V715: Failure of the medical director to ensure that all P & P relative to patient care were adhered to by all staff.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 03383 Based on a review of medical records, staff interviews, and review of the facility’s Policies and Procedures (P & P), it was determined that the Medical Director failed to ensure that two of two Registered Nurses, adhered to the facility’s P & P relative to chest pain. On 2/28/24 at 9:00 a.m., a determination was made that a situation in which the facility’s noncompliance with 42-CFR Part 494.150 - Responsibilities of the Medical Director, resulted in an Immediate Jeopardy (IJ) that placed the health and safety of one of one patient (P#1) who experienced chest pain while at this facility, at risk for serious harm. The facility failed to reassess, monitor, and take steps to manage P#1’s chest pain for over two hours while she waited for the EMS (Emergency Medical System) to arrive. The facility census was 24. The Facility Administrator was informed of the IJ finding on 2/28/24 at 9:00 a.m. The noncompliance related to the IJ was identified to have existed on 11/6/23 at 9:30 a.m. The IJ situation was abated during the survey on 2/28/24 at 4:00 p.m. Findings were: A review of P#1’s medical records showed the following: - Treatment Details Report (TDR) dated 11/6/23 showed Close Treatment Reason “PATIENT C/O (complained of) CHEST PAIN, EMS (Emergency Medical System) CALLED BUT THEY NEVER SHOWED UP. PATIENT CALL (sic) FAMILY TO TRANSFER HER TO ER (Emergency Room). DR NOTIFIED”. - There was also a documentation that showed “Patient arrived to (sic) HD (Hemodialysis) unit complaining of chest pain. NP (Nurse Practitioner) at chairside, ordered patient to go to ER (Emergency Room). EMS called twice at 730 am (sic) and 830 am (sic) but never arrived. Patient called family member to transfer her to ER. At 930am (sic) patient left HD unit with family member and was transferred to ER. Patient was alert and oriented. V/S (vital signs) stable 118/56 pulse 82”. The Physician Notification box was checked. During an interview on 2/28/24 at 9:50 a.m., the Nephrologist/Medical Director (MD) stated he was not notified of the patient’s complaint of chest pain. - A review of the Hemodialysis Follow-up Note entered by the Nurse Practitioner (NP) on 11/6/24 at 11:29 a.m. stated: Patient is a (sic) 85 year old female patient who is seen on hemodialysis for ESRD (End Stage Renal Disease). New Complaints (sic): Chest pain; EMS in (sic) route to transport to ER. On O2 (oxygen) for support. Blood Pressure (BP): 113/61 Pulse: 71 Temp (temperature): Afebrile (no fever)... - An interview with the NP on 2/27/24 at 11:50 a.m. revealed that P#1’s dialysis was not started due to complaint of chest pain but did not describe chest pain. NP stated P#1 did not appear to be in distress; her color was good and she was mentally clear. Also stated that she arrived between 8:45 a.m. and 9:00 a.m., which was the time she usually arrives at the facility. There was a lack of documented reassessments or steps taken to manage P#1’s chest pain. There was no documented evidence that Staff monitored P#1’s vital signs, oxygen saturation, or level of chest pain for over two hours while she waited for the EMS to arrive at the facility other than the above mentioned assessment and vital signs. - A review of the medical record dated 11/6/23 and electronically signed by a D.O. (Doctor of Osteopathic Medicine), Emergency Medicine showed the following: History of Present Illness Mode of Arrival: ... ambulance “...presenting with cardiac arrest.”... Time of death was confirmed at 12:15 PM. Final Diagnosis: Cardiac arrest During an interview with the Facility Administrator (FA) on 2/27/24 at 11:59 a.m., she stated “this has never happened before that it has taken EMS this long”. Stated my team is pretty good about taking care of the patients. The patient was put on oxygen. FA agreed that documentation was lacking to show the care P#1 received on 11/6/23. - An interview with the MD on 2/28/24 at 9:50 a.m. revealed that 911 was called as soon as the patient arrived. MD stated they ran through the whole ordeal; it is the expectation of staff to triage the patient, take a set of vitals including pulse oxymeter, and notify the doctor. When asked by this surveyor if he was notified by staff about the patient’s chest pain on 11/6/23, he answered “No”. Surveyor asked MD if staff was supposed to notify MD about chest pain, and MD stated, “Yes”. MD indicated that P#1 did not have a history of cardiac issues, this was new for her. Also stated, “It is pretty sad EMS did not arrive; based on vitals, the patient’s condition was non-emergent; the patient had underlying risk factors but was deemed stable. Stated I believe patient received adequate assessment. Surveyor handed MD the TDR and other medical records for review. MD agreed that the documentation was minimal and did not show adequate monitoring. A review of Procedure: 1-10-02 titled, “Chest Pain/Angina” dated April 2023 stated: 2. Licensed nurse teammate assesses patient. 6. Notify nephrologist for orders. 7. Administer medications as ordered. 8. Administer oxygen as ordered. 9. If pain persists, discontinue treatment. Notify nephrologist and arrange transport of patient via EMS to emergency room. 10. Document orders, event, action taken and patient response to treatment in patient’s electronic health record. A review of Policy: 1-10-01 last revised April 2023 titled, “MEDICAL EMERGENCY” dated April 2023 stated the following: In the event of a medical emergency, the charge nurse will: 1. Initiate emergency treatment according to signs and symptoms shown by the patient. 2. Monitor the patient. 3. Contact the patient’s nephrologist. If unable to reach patient’s nephrologist, contact the Medical Director. 4. lf the situation warrants, contact emergency medical system: 911 or Hospital Code Team, as applicable. 7. Based on nurse’s assessment a reasonable attempt will be made to notify the patient’s designated contact/personal representative (as reflected in the patient’s medical record) of the patient’s change in condition or transfer to a hospital. This notification may include any follow up instructions for the patient related to patient’s change in condition. 8. Nurse in charge is to notify Facility Administrator (FA)/Program Manager/designee. The FA/Program Manager/designee is to notify the patient’s nephrologist, Medical Director, Manager of Clinical Services (MCS), Regional Operations Director, and DaVita Risk Manager. 9. Document events in the patient’s medical record. The Immediate Jeopardy was abated on 2/28/24 at 4:00 p.m. upon completion of the following: - An in-service was conducted on 2/28/24 by the Facility Administrator and Director of Clinical Services on Policy and Procedure: 1-10-01 titled, “Medical Emergency” and Policy: 1-03-08 titled, “Pre, Intra, Post Treatment Data Collection, Monitoring and Nursing Assessment”, with 100% of clinical staff in attendance. - A Governing Body Meeting was held on 2/28/24.”