Magic Valley Kidney Center

“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: 39430 Based on record review, treatment sheet review, policy review, and staff interview, it was determined the facility failed to ensure all policies and procedures were adhered to by facility staff. This affected 3 of 5 ICHD patients (Patient #1, #3, and #4) whose treatment records were reviewed. This resulted in patients going over 45 minutes without vital signs during ICHD, and had the potential for negative outcomes for all patients receiving ICHD. Findings include: A facility policy titled “Patient Assessment and Monitoring,” effective 5/01/23 stated the following: - “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes.” Blood pressures were not obtained per policy. Examples include but are not limited to: 1. Patient #3 was a 49 year old male who received ICHD. Patient #3’s medical record included the following treatment sheets that included blood pressure checks not being completed every 30 minutes per policy: - Patient #3’s record included a treatment sheet dated 1/03/24. At 2:40 PM, Patient #3’s blood pressure was documented as 168/86 mmHg. There was not another blood pressure check for Patient #3 until 3:32 PM, 52 minutes later. - Patient #3’s record included a treatment sheet dated 1/03/24. At 4:06 PM, Patient #3’s blood pressure was documented as 166/86 mmHg. There was not another blood pressure check for Patient #3 until 5:06 PM, 60 minutes later. - Patient #3’s record included a treatment sheet dated 1/04/24. Patient #3 was started on treatment at 7:34 AM. There was no starting blood pressure documented and the next blood pressure was at 8:30 AM. 56 minutes after he started treatment. - Patient #3’s record included a treatment sheet dated 1/04/24. At 8:30 AM, Patient #3’s blood pressure was documented as 169/96 mmHg. There was not another blood pressure check for Patient #3 until his treatment was discontinued at 10:31 AM, 2 hours and 1 minute later. - Patient #3’s record included a treatment sheet dated 1/09/24. At 9:31 AM, Patient #3’s blood pressure was documented as 189/95 mmHg. There was not another blood pressure check for Patient #3 until 10:37 AM, 1 hour and 6 minutes later. The DO was interviewed on 1/26/24 beginning at 9:00 AM and Patient #3’s record was reviewed in her presence. She confirmed that greater than 45 minutes had passed between blood pressure readings for Patient #3 on the above days. She confirmed this did not follow facility policy. 2. Patient #1 was a 47 year old male who received ICHD. Patient #1’s medical record included the following treatment sheets that included blood pressure checks not being completed every 30 minutes per policy: - Patient #1’s record included a treatment sheet dated 12/20/23. At 9:07 AM, Patient #1’s blood pressure was documented as 143/78 mmHg. There was not another blood pressure check for Patient #1 until 10:06 AM, 59 minutes later. - Patient #1’s record included a treatment sheet dated 12/22/23. At 10:08 AM, Patient #1’s blood pressure was documented as 121/65 mmHg. There was not another blood pressure check for Patient #1 until 12:02 PM, 1 hour and 54 minutes later. - Patient #1’s record included a treatment sheet dated 1/12/24. At 10:37 AM, Patient #1’s blood pressure was documented as 139/77 mmHg. There was not another blood pressure check for Patient #1 until 11:34 AM, 57 minutes later. - Patient #1’s record included a treatment sheet dated 1/12/24. At 10:37 AM, Patient #1’s blood pressure was documented as 139/77 mmHg. There was not another blood pressure check for Patient #1 until 11:34 AM, 57 minutes later. The DO was interviewed on 1/26/24 beginning at 9:00 AM and Patient #1’s record was reviewed in her presence. She confirmed that greater than 45 minutes had passed between blood pressure readings for Patient #3 on the above days. She confirmed this did not follow facility policy. 3. Patient #4 was a 75 year old male who received ICHD. Patient #4’s medical record included the following treatment sheets that included blood pressure checks not being completed every 30 minutes per policy: - Patient #4’s record included a treatment sheet dated 12/29/23. At 10:05 AM, Patient #4’s blood pressure was documented as 99/64 mm/Hg. There was not another blood pressure check for Patient #4 until his treatment had ended at 11:10 AM, 1 hour and 5 minutes later. - Patient #4’s record included a treatment sheet dated 1/03/24. At 9:39 AM, Patient #4’s blood pressure was documented as 117/71 mm/Hg. There was not another blood pressure check for Patient #4 until his treatment had ended at 10:58 AM, 1 hour and 19 minutes later. - Patient #4’s record included a treatment sheet dated 1/19/24. At 8:32 AM, Patient #4’s blood pressure was documented as 107/64 mm/Hg. There was not another blood pressure check for Patient #4 until 11:08 AM, 2 hours and 36 minutes later. The DO was interviewed on 1/26/24 beginning at 9:00 AM and Patient #4’s record was reviewed in her presence. She confirmed that greater than 45 minutes had passed between blood pressure readings for Patient #4 on the above days. She confirmed this did not follow facility policy. The facility failed to follow their policy regarding patient monitoring during dialysis treatment.”