Southeastern Renal Dialysis, Lc - Ft Madison

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 50072 Based on review of facility policy, Emergency Preparedness information review, and staff interviews, the facility failed to have a system in place that addressed patient populations specific to this facility. Failure to address patient populations specific to this facility could limit staff and other emergency medical personnel’s ability to provide care and services or respond appropriately in the event of an emergency which could potentially place patients at risk for adverse outcomes. The facility reported an in-center hemodialysis patient census of 35 patients at the time of the recertification survey. Findings of the review include: 1. Review of the facility’s Emergency Preparedness binder and daily patient schedule showed the facility did not address patient populations to identify those who may have additional response needs in the event of an emergency. 2. Review of the facility’s policy titled Southeastern Renal Dialysis L.C. Emergency Preparedness and Response, dated 07/01/22, states “Using the patient evacuation priority list, remove patients from machines and assist to exit or designated safe areas. If patients require assistance, ask other to help.” While the facility has a policy in place to identify those who would require additional assistance in the event of an emergency or evacuation, facility staff have not implemented the policy. 3.During an interview with the Facility Administrator on 06/05/24 at 9:45 am, they acknowledged neither the daily schedule or any other document addresses the facility’s patient population and specific needs in the event of an emergency or evacuation. 4. During an interview with the Nurse Manager on 06/04/24 at 5:00 pm, they acknowledged there is no written documentation to indicate which patients may need additional assistance in the event of an emergency.”

“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: 36083 Based on documents review, observation and interviews, the facility did not ensure interdisciplinary team approach to set, review, and address a common goal for fluid management for 1 of 1 patient in the sample reviewed for fluid management (Patient #4). The facility reported a census of 35 patients at the time of the survey. Findings include: 1. The policy titled, Patient Assessment/Reassessment, dated 7/1/22, directs the facility’s interdisciplinary team (IDT) to provide each patient with an individualized and comprehensive assessment of his/her needs, which will be used for the development of the patient’s plan of care and expectations of care. The policy indicates that the IDT members work sequentially using medical records as the chief means of communication as well as collaboratively meeting to discuss patient status and the evolving plan of care. The policy also indicates working as a team allows for working toward common goal, and pooling expertise and forum for problem solving. The policy further indicates patient’s assessment and plan of care includes addressing fluid management needs, where interdialytic weight gains, target weight, and related intradialytic symptoms are assessed, along with analysis of potential root causes. 2. During observation on 6/3/24 at 1:24 PM, Patient Care Technician (PCT) A was initiating the dialysis treatment for Patient #4 at Station #8. In the process, Patient #4 complained about feeling awful, and PCT A responded saying to “see” how much fluids will be taken off and how it would help relieve Patient #4’s discomfort. 3. Patient #4’s comprehensive plan of care completed on 2/7/24, indicated a target weight of 89.5 and interdialytic (between treatments) weight of 2.1 (kilograms). 4. The IDT notes for the months of 4/24 and 5/24, showed conflicting assessment and target weight goals for the management of Patient #4’s fluid status, as follows: A) The blood pressure/fluid management section of the IDT notes (1) completed on 4/17/24, indicated Patient #4’s weights were above the target weight goal and with high interdialytic weights, as follows: - On 4/1/24, 100.8 pre-treatment weight (pre wt), 96.7 post-treatment weight (post wt), and 4.4 interdialytic weight (inter wt); - On 4/3/24, 98.9 pre wt, 97.2 post wt, and 2.2 inter wt; - On 4/5/24, 98.5 pre wt, 97.2 post wt; - On 4/8/24, 100.6 pre wt, 98.3 post wt, and 3.4 inter wt; - On 4/12/24, 104.7 pre wt, 99.8 post wt, and NA inter wt; - On 4/15/24, 104.9 pre wt, 100.7 post wt, and 5.1 inter wt. B) The fluid section of IDT notes (2), with a completion date of 4/17/24, noted a dry weight of 93. The notes indicated Patient #4 had no issues, and was stable with fluid status. C) The blood pressure/fluid management section of the IDT notes (1) completed on 5/13/24, also showed that Patient #4’s weights were above the target weight goal and with high interdialytic weights, as follows: - On 4/29/24, 102.9 pre wt 102.9, 99.9 post wt, and 3.4 inter wt; - On 5/1/24, 103.7 pre wt, 100.7 post wt, and 3.8 inter wt; - On 5/3/24, 102.8 pre wt, 100.6 post wt; - On 5/6/24, 104.6 pre wt, 102.7 post wt, and 4 inter wt; - On 5/8/24, 105.1 pre wt, 102.2 post wt, and 2.4 inter wt; - On 5/9/24, 101 pre wt, 99.2 post wt; - On 5/10/24, 102.2 pre wt, 101.2 post wt, and 3 inter wt. The notes indicated Patient #4 had problems “having relatively high ... weight gains” and getting off weight. The notes indicated a prescription of 200 milligram torsemide (diuretic) “to help decrease weight gain and edema.” D) The fluid section of IDT notes (2), completed on 5/15/24, showed dry weight of 93. The notes indicated Patient #4 had stable fluid status, and no interventions were indicated. 5. A review of Patient #4’s treatment flowsheets from 5/20/24 to 5/31/24, showed ongoing and consistent problem with fluid management, where Patient #4’s pre and post treatment weights were high, which did not meet target weight, as follows: - On 5/20/24, the pre wt was 104.10, and the post wt was 99.0. The treatment notes showed Patient #4 complained about feeling tired, not feeling well and feeling “yucky” during the treatment, and ended treatment 20 minutes early. - On 5/22/24, the pre wt was 102.50, and the post wt was 100.70. The treatment notes showed Patient #4 reported stomach upset with “her stomach scoped” on 5/21/24. The treatment notes also showed Patient #4 had to get off treatment early due to clotted lines, and did not meet target weight. - On 5/24/24, the pre wt was 102.9, and the post wt weight was 99.6. The treatment notes indicated Patient #4 felt unwell throughout the treatment, and did not meet target weight. - On 5/27/24, the pre wt was 103.4, and the post wt was 100. The treatment notes showed that Patient #4 did not meet target weight due to not feeling well during the treatment. - On 5/29/24, the pre wt was 103.40, and the post wt was 100.9. The treatment notes showed Patient #4 felt unwell during the treatment and did not meet target weight. - On 5/31/24, the pre wt was 103.5, and the post wt was 100.9. The treatment notes indicated Patient #4 felt unwell and had low blood pressure during the treatment, and that Patient #4 did not meet target weight. 6. On 6/4/24 at 5:05 PM, as requested, the Administrator provided and verified the contents of a copy of Patient #4’s weight flowsheet history for the month of 4/24, which showed Patient #4 consistently reported for treatment with high fluid gains, with interdialytic weight gain above target, and then went off treatments without achieving target weights. 7. On 6/5/24 at 8:30 AM, the Registered Dietician (RD) verified that IDT notes (2) contradicted the assessment as noted in IDT notes (1). The RD stated, “we’re recording the fluid data differently” and verified that IDT notes (1) indicated Patient #4 had stable fluid status with the dry weight noted. The RD acknowledged the importance of evidence to show that all team members set a common goal and implementing interventions towards attaining that goal.”