Lewis-Clark 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, 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 1 of 6 ICHD patients (Patient #2) whose treatment records were reviewed. This resulted in elevated blood pressures not being reported to the RN for further evaluation, and had the potential for negative outcomes for all patients receiving ICHD. Findings include: A facility procedure titled “Charge Nurse Notification Protocol,” dated 7/18/2024, with titled section “Intradialytic” stated “Blood Pressure Systolic > 180 or <90 or any significant change in pressure,” required nurse notification. This policy was not followed. An example included: Patient #2 was a 82 year old female who received ICHD. Patient #2’s medical record included the following treatment sheets that included elevate blood pressure results were not being reported to the RN per policy. Examples include but are not limited to: Patient #2’s record included a treatment sheet dated 9/20/24. At 12:01 PM, Patient #2’s blood pressure was documented as 184/117 mmHg. There was no documentation Patient #2’s elevated blood pressure was reported to the RN. Patient #2’s record included a treatment sheet dated 9/20/24. At 2:32 PM, Patient #2’s blood pressure was documented as 186/74 mmHg. There was no documentation Patient #2’s elevated blood pressure was reported to the RN. Patient #2’s record included a treatment sheet dated 9/18/24. Between 10:31 AM and 12:31 PM the following blood pressures were not reported to the RN. 10:31 AM - 193/84 mmHg. 11:01 AM - 192/105 mmHg. 11:31 AM - 192/73 mmHg. 12:02 PM - 193/95 mmHg. 12:31 PM - 182/82 mmHg. Patient #2’s record included a treatment sheet dated 8/21/24. At 1:31 PM, Patient #2’s blood pressure was documented as 211/67 mmHg. There was no documentation Patient #2’s elevated blood pressure was reported to the RN. Patient #2’s record included a treatment sheet dated 8/21/24. At 2:01 PM, Patient #2’s blood pressure was documented as 186/93 mmHg. There was no documentation Patient #2’s elevated blood pressure was reported to the RN. The FA and Charge Nurse were interviewed together on 10/09/24 beginning at 9:00 AM and Patient #2’s record was reviewed in their presence. The FA confirmed the above blood pressures should be reported to the nurse on duty. She confirmed this did not follow facility policy. The facility failed to follow their policy regarding nurse notification of out of parameter vital signs.”

“GOV-ID GOV BODY W/FULL AUTHORITY/RESPONS CFR(s): 494.180 The ESRD facility is under the control of an identifiable governing body, or designated person(s) with full legal authority and responsibility for the governance and operation of the facility. The governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patients ’ personal and property rights, and to the general operation of the facility. This Standard is not met as evidenced by: 39430 Based on observation, medical record review, policy review, and staff interview, it was determined the Medical Director failed to ensure there was a policy dictating approved facility practices for low or high blood pressure for 2 of 6 patients (Patients #2, and#3) receiving ICHD whose records were reviewed. This resulted in the potential for negative patient outcomes to occur. Findings include: A facility procedure titled “Charge Nurse Notification Protocol,” dated 7/18/2024, with titled section “Intradialytic” stated “Blood Pressure Systolic > 180 or <90 or any significant change in pressure.” The FA was interviewed on 10/01/24 beginning at 2:15 PM. When asked for a policy dictating nurse action for out of range intradialytic blood pressures and required follow up, the FA stated there was not a corresponding policy to address or prescribe actions to be taken beyond notification of charge nurse. She stated there were standing orders for hypotension but that required nurse evaluation and follow up to be utilized. The nurse was notified per medical record review but no additional action or evaluation on behalf of the nurse was documented. Examples include: 1. Patient #2 was a 82 year old female who received ICHD. Patient #2’s medical record included the following treatment sheets that included elevate blood pressure that were reported to the RN but no follow up assessment or acknowledgement was performed by the RN. Examples include but are not limited to: a. Patient #2’s record included a treatment sheet dated 9/02/24. At 3:01 PM, Patient #2’s blood pressure was documented as 211/151 mmHg. The technician documented “BP high, RN Aware” There was no documentation the RN acknowledged or assessed Patient #2’s elevated BP. b. Patient #2’s record included a treatment sheet dated 9/20/24. At 12:01 PM, Patient #2’s blood pressure was documented as 184/117 mmHg. There was no documentation Patient #2’s elevated blood pressure was reported to the RN. Patient #2’s record included a treatment sheet dated 9/20/24. At 2:32 PM, Patient #2’s blood pressure was documented as 186/74 mmHg. There was no documentation Patient #2’s elevated blood pressure was reported to the RN. Patient #2’s post treatment blood pressure was recorded at 197/80 mmHg, signed off by the RN. There was no evaluation of Patient #2’s elevated intradialytic blood pressure or elevated post treatment blood pressure. The FA and Charge Nurse were interviewed together on 10/09/24 beginning at 9:00 AM and Patient #2’s record was reviewed in their presence. The FA confirmed the above blood pressures should be reported to the nurse on duty. Additionally, she stated it is the expectation of the facility that the RN follow up and document acknowledgment and/or assessment and any interventions performed. The Charge Nurse confirmed the missing documentation. 2. Patient #3 was a 79 year old female who received ICHD. Patient #3’s medical record included the following treatment sheets that included a decrease in blood pressure that was reported to the RN but no follow up assessment or acknowledgement was performed by the RN. An example includes but is not limited to: Patient #3’s treatment sheets included the following unreported blood pressures. Significant change in pressure was documented with a blood pressure of 98/37 on treatment date on 9/16/24 at 10:31 AM. The tech note stated “RN notified.” Patient #3’s treatment sheets did not include any additional RN follow up or additional interventions to address and/or manage Patient #3’s low blood pressure. The FA was interviewed on 10/1/24 at 2:15 PM. She confirmed that there was no documented follow up and there is an expectation of follow up with low diastolic pressure as documented. The FA also confirmed that there was not an explicit policy outlining follow up expectations. The Governing Body failed to adopt and enforce comprehensive operating policies to protect patients’ health and safety.”