Fmc - Davenport

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 36083 Based on documents review, observations, and staff interviews, the facility failed to follow medication order to hold heparin dose for 1 of 1 patient (Patient #8) observed for initiation of dialysis treatment and who reported a recent fall. The facility reported a census of 61 in-center hemodialysis patients at the time of the survey. Findings include: 1. The policy titled, “Patient Assessment and Monitoring” dated 5/1/23 noted pre-treatment assessment data to be obtained included evaluation of “changes since last treatment” and reports from patient such as a fall since the last treatment. The policy indicates that the nurse will review the data collected, document findings and interventions in the medical record, and contact the physician as needed for additional orders based on assessment findings and clinical judgment. 2. During observation for initiation of dialysis via a central venous catheter (CVC)on 10/8/24 at 12:28 PM, Patient #8 reported a fall to patient care technician (PCT) B. PCT B notified registered nurse (RN) C regarding Patient #8’s report of fall. At 12:29 PM, RN C stated they were going to hold Patient #8’s heparin, and would have to notify the nephrologist first about Patient #8’s fall. However, at 12:30 PM, PCT B pushed an intravenous medication via Patient #8’s CVC. PCT B verified by showing the label on the syringe, which was still attached to Patient #8’s CVC that she administered 2,000.00 units of heparin bolus dose. 3. Patient #8’s treatment sheet on 10/8/24, showed a note, “Heparin held per [Dr. Mann].” The treatment sheet showed that Patient #8 received 2,000.00 units of heparin despite the doctor’s order to hold. 4. On 10/10/24 at 10:05 AM, the medical director (MD) stated that staff members did not follow orders when they administered Patient #8’s heparin dose despite an order to hold.”

“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, observations, and staff interviews, the facility did not ensure correct dialysis prescription for 1 of 4 patients (Patient #2) observed for prescription verification. The facility reported a census of 61 in-center hemodialysis patients at the time of the survey. Findings include: 1. The procedure titled, “Pre-Treatment Safety Checks Procedure” dated 2/6/23, notes that the purpose of the procedure is to provide guidance on performing safety checks prior to each hemodialysis treatment. The procedure indicates two direct patient care staff members are to conduct pre-dialysis safety checks prior to initiation of treatment by verifying elements including: prescribed dialyzer, dialysate flow rate, and prescribed dialysate composition. The procedure also indicates once the patient is seated, the clinician initiating treatment must verify the prescribed set up matches the patient’s prescription including: dialyzer, dialysate composition, dialysate flow rate, time, and temperature. 2. On 10/8/24 at 10:45 AM, patient care technician (PCT) A showed Patient #2’s dialysis prescription, as follows: dialysate 3 K (potassium) and 2.5 Ca (calcium), dialyzer Optiflux 160NRe, dialysate flow rate (DFR) 600, blood flow rate (BFR) 400, and temperature 35.5. However, Patient #2’s ongoing treatment showed incorrect elements, as follows: dialysate 2 K and 2.5 Ca, dialyzer Optiflux 180NRe, DFR 800, BFR 450, and temperature 37. PCT A verified Patient #2 was not undergoing treatment as prescribed, and said, “I don’t know why. I did not set this up.” At 10:50 AM, PCT A moved Patient #2’s dialysate delivery hose connector from the 2 K and 2.5 Ca port to the 3 K and 2.5 Ca port. 3. Patient #2’s treatment sheet dated 10/8/24, PCT A confirmed Patient #2’s identity and dialysis orders at 7:23 AM; and at 7:33 AM, registered nurse (RN) C gave nursing approval for starting Patient #2’s treatment. The treatment sheet showed Patient #2 started dialysis treatment at 7:42 AM, (or 3 hours into treatment before PCT A administered the correct dialysate of 3 K and 2.5 Ca). Patient #2’s dialysis treatment ended at 11:45 AM, and remained with dialyzer Optiflux 180NRe, DFR 800, BFR 450, and temperature 37. The treatment sheet also showed Patient #2’s weight after treatment was 2.9 kilograms (kg) greater that expected dry weight (EDW). The treatment sheet indicated Patient #2’s awareness to monitor fluid and the risk of potential fluid overload. 4. On 10/9/24 at 12:20 PM, the clinical manager (CM) stated staff reported the error regarding Patient #2’s treatment on 10/8/24. The CM stated she did not have any answer as to why the error occurred but the process involved verification of prescription before initiating treatments. 5. On 10/10/24 at 10:05 AM, the medical director (MD) stated expectation for staff members to follow facility protocol regarding 2-staff prescription verification before initiating patients’ dialysis treatments.”