Davita Ottumwa Dialysis

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 36083 Based on review of facility documents, and staff interviews, the facility failed to investigate causes, and to develop and implement action plans to address 10 of 10 incidents involving medication errors, in the sample reviewed for occurrences. At the time of the survey, the facility reported a census of 26 in-center hemodialysis (ICHD) patients. Findings include: 1. The policy # 1-14-06, titled, Continuous Quality Improvement Program, revised on April 2021, provides for its purpose, “To improve patient safety and outcomes including the reduction of medical errors in accordance with the Quality Assessment and Performance Improvement (QAPI) requirements in the CMS Conditions for Coverage.” The policy directs the staff members to review issues and indicators regarding facility’s management and performance. The policy indicates that a written documentation and plans of action will be reflected in the facility’s records. 2. The policy # 13-01-02, titled, Risk Event Reporting Policy (Non-Teammate Related), with latest revision date of July 2023, outlined the facility guidelines for handling and investigating Risk Event Management (REM) Reports. The policy provides, “Any unexpected event that is inconsistent with the routine operation of a dialysis facility, routine provision of acute dialysis or ancillary renal-related services may be a risk event.” The policy also provides that such risk events include potential personal injury to a patient or “near miss” events. 3. The document titled, Monthly Facility event by location, dated 3/4/24, indicated incidents of incorrect medications on 10/2/23 for 9 patients (Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, and Patient #12). The document also indicated that on 1/29/23, Patient #9 did not receive an ordered medication. 4. On 3/6/23 at 10:30 AM, the facility administrator (FA), stated that the incident on 1/29/24 was related to a missed heparin dose for Patient #9. The FA provided an untitled document (downloaded from facility electronic record), which read “Medication Not Given SE4” with additional information noted, “PT [patient] heparin loaded and set but not unclamped pt [patient] did not receive heparin maintenance during treatment.” The record did not show the root cause for this particular incident (missed heparin dose) and how it was addressed. The FA also indicated that the “near miss” incidents on 10/2/23, related to medications for 9 patients (Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, and Patient #12) was related to error in selecting the appropriate entry for influenza vaccination, wherein the documentation showed these patients received the vaccine even though it was not yet administered to them. The FA verified the lack of documentation to show the discussions or investigation of the circumstances of the incidents and any implementation of action plans. The FA stated these incidents were not addressed because “there was no trend” identified. 5. On 2/6/22 at 10:50 AM, the FA and the manager of clinical services (MCS) verified the lack of evidence to show investigation or evaluation of the circumstances leading to the occurrences in the sample reviewed. The FA and MCS indicated these occurrences were not individually addressed, and acknowledged the risk to patients’ safety and the importance of preventing the incidents from reoccurring.”