Tri- State Dialysis - Dubuque

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 36083 Based on documents review, interviews, and observation, the facility did not ensure correct needle size for 1 of 4 patients observed for prescription verification (Patient #11). The facility reported a census of 93 in-center hemodialysis patients at the time of the survey. Findings include: 1. The policy titled, “FISTULA/GRAFT GUIDELINES AND INITIATING HEMODIALYSIS” revised on 1/30/25, provides that its purpose is for safe and effective long-term use of fistulas (a surgically created blood vessel for dialysis needle placement) and grafts (a surgically created blood vessel for dialysis needle placement). The policy directs staff members to cannulate new fistulas with 17-gauge needles X2 weeks, then 16-gauge needles X2 weeks, then 15-gauge needle with a blood flow rate (BFR) of 200-300 milliters per minute for the first 2-4 weeks, and then increase BFR and needle size as the access tolerates. 2. During interview and observation on 3/10/25 at 12:50 PM, patient care technician (PCT) D read Patient #11’s dialysis prescription to include a 16 gauge needle. PCT D acknowledged that prescribed needle gauge size are to be reviewed before initiation of treatment and verified during every half-hour assessments. PCT then showed Patient #11’s dialysis setting, which showed the ongoing dialysis treatment had been running for 1 hour and 20 minutes that indicated 2 re-checks (12:00 PM and 12:30 PM) after the start of treatment. Patient #11’s ongoing dialysis treatment also revealed that a 15 gauge needle was used against the 16 gauge needle as prescribed. PCT D verified that the wrong needle gauge was used for Patient #11. 3. Patient #11’s treatment kardex/flowsheet dated 3/10/25 showed the dialysis treatment started at 11:31 AM. Patient #11’s kardex/flowsheet indicated a prescription for 16 gauge needles on the arterial and venous dialysis sites. 4. On 3/11/25 at 11:30 AM, PCT D stated that physicians prescribed needle sizes for patients, depending on the maturitiy of the fistula. PCT D also stated, “for some reason I thought [Patient #11] was on gauge 15 but should be on gauge 16, and that was an error [on 3/10/25].” 5. On 3/11/25 at 12:01 PM, the director of dialysis (DD) stated expectations for staff members to follow prescriptions as written in the patient’s kardex. 6. On 3/11/25 at 12:31 PM, the medical director (MD) stated that patients with arteriovenous fistulas start with smaller gauge needles and then progress to the bigger (start at 17, then go to 16, until they get to 15). The MD acknowledged that if it was determied that a patient could tolerate a 15 gauge needle, then the order would be changed.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 51639 Based on policy review, record review, and staff interviews the facility failed to ensure staff notified the physician when the patient’s estimated dry weight (EDW) was greater than or equal to 2 kg over their prescribed target weight. EDW is a measure of the patient’s fluid volume status after the completion of the hemodialysis treatment. Failure to evaluate the patient’s post hemodialysis dry weight could potentially result in inadequate or excessive fluid removal. Inadequate or excessive fluid removal during the dialysis treatment could potentially cause shortness of breath, hypertension/hypotension, and edema, all possibly causing harm or the need for hospitalization. The facility staff reported a census of 93 in-center hemodialysis patients, 30 peritoneal dialysis patients and 5 home hemodialysis patients at the time of the survey. Findings for 2 patient medical records reviewed (Patient’s #2 and #5) include: 1. Review of the facility’s policy titled, “Estimated Dry Weight”, review date: 4/26/2021, stated in part, “If patient post-dialysis weight is >1kg under the target weight or ?2kg greater than target, notify the physician or nurse practitioner prior to patient discharge.” 2. Review of the treatment flow sheet for Patient #2 dated 2/27/25 showed a physician’s prescribed EDW order for 53.5kg and a post hemodialysis weight of 55.9kg. Further review of the post dialysis assessment on the flow sheet revealed that there was no documentation that the physician was notified of the patient leaving 2.4kg over their target weight. a. Review of the treatment flow sheet for Patient #2 dated 3/01/25 showed a physician’s prescribed EDW order for 53.5kg and a post hemodialysis weight of 55.7kg. Further review of the post dialysis assessment on the flow sheet revealed that there was no documentation that the physician was notified of the patient leaving 2.2kg over their target weight. b. Review of the treatment flow sheet for Patient #2 dated 3/04/25 showed a physician’s prescribed EDW order for 53.5kg and a post hemodialysis weight of 55.7kg. Further review of the post dialysis assessment on the flow sheet revealed that there was no documentation that the physician was notified of the patient leaving 2.2kg over their target weight. 3. Review of the treatment flow sheet for Patient #5 dated 2/22/25 showed a physician’s prescribed EDW order for 67kg and a post hemodialysis weight of 71.2kg. Further review of the post dialysis assessment on the flow sheet revealed that there was no documentation that the physician was notified of the patient leaving 4.2kg over their target weight. a. Review of the treatment flow sheet for Patient #5 dated 3/01/25 showed a physician’s prescribed EDW order for 67kg and a post hemodialysis weight of 70kg. Further review of the post dialysis assessment on the flow sheet revealed that there was no documentation that the physician was notified of the patient leaving 3kg over their target weight. b. Review of the treatment flow sheet for Patient #5 dated 3/08/25 showed a physician’s prescribed EDW order for 67kg and a post hemodialysis weight of 69kg. Further review of the post dialysis assessment on the flow sheet revealed documentation that the physician was not notified of the patient leaving 2kg over their target weight. 4. During an interview with RN (Registered Nurse) E on 3/11/25 at 11:45 AM, they confirmed that patient that leave 2kg or greater post dialysis should be documented on the bottom of the patient’s flowsheet as well as documentation of the notification to the physician. After reviewing flow sheets for Patient #2 and Patient #5, RN E confirmed the missing documentation and noted there is an opportunity for staff education.”