Fmc - North Avenue Dialysis Center

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34411 Based on document review and interview, it was determined that for 2 of 2 physicians (MD #1 and MD #2) observed on the dialysis treatment floor during initiation and termination of treatments, the facility failed to ensure that the proper PPE (protective personal equipment) was donned, as required. Findings include: 1. The Facility’s policy titled, “Personal Protective Equipment “, (dated 11/6/2023) was reviewed, and required, “...Employees who may have occupational exposure shall be provided without cost, appropriate PPE including gloves, fluid resistant gowns...” 2. On 2/28/2024 at 9:00 AM, an observational tour of the dialysis treatment floor was conducted. The following was observed: - At 10:45 AM, MD #1 entered the treatment area for patient rounds, during the initiation and discontinuation of treatments (turnover). MD #1 went to 5 different patient stations without a gown or gloves on as MD #1 touched either the patient’s machine or their legs for assessments. In addition, no hand hygiene was performed as MD #1 went from each patient’s chairside. - At 10:50 AM, MD #2 entered the treatment area for patient rounds, during turnover. MD #2 went to 2 different patients’ chairside and performed assessments. MD #2 did not have on a gown or gloves and no hand hygiene was performed in between the patients. 3. On 2/29/2024 at 10:00 AM, an interview was conducted with the Medical Director (MD #1). MD #1 stated that the expectation for infection control, including wearing the proper PPE, applies to all staff, vendors, and visitors.”

“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: 34411 Based on document review and interview, it was determined that for 4 of 4 (Pt #6-Pt #9) clinical records reviewed for laboratory monitoring, the facility failed to ensure that the physician was made aware critical potassium results. Findings include: 1. The facility’s policy titled, “Medical Record Documentation Standards” (dated 2/5/2024), was reviewed and required, “...All treatment information, treatment related events, changes in a patient’s condition or significant care issues must be noted and charted. Documentation must include follow-through. If physician notification is required, all such communication (including attempts at notification) should be documented...” 2. The Job Description for the Staff Registered Nurse, was reviewed on 2/29/2024, and included, “Functions as part of the hemodialysis health care team as a Staff Registered Nurse to ensure provision on a daily basis accordance with [Facility] policies, procedures, and training...Laboratory-related: Reports alert/panic and abnormal lab results to appropriate physician...” 3. The clinical record for Pt #6 was reviewed on 2/28/2024. Pt #6 was admitted on 2/2/2021, with a diagnosis of ESRD (end stage renal disease). The laboratory results were reviewed and included an elevated potassium (mineral and electrolyte that helps muscles that control your heartbeat) laboratory result on: -2/13/2024: 6.0 (high)/ (normal reference range: 3.5-5.1). 4. The clinical record for Pt #7 was reviewed on 2/28/2024. Pt #7 was admitted on 1/3/2024, with a diagnosis of ESRD. The laboratory results were reviewed and included an elevated potassium result on: - 2/12/2024: 6.2 (high). 5. The clinical record for Pt # 8 was reviewed on 2/28/2024. Pt #8 was admitted on 2/12/2024, with a diagnosis of ESRD. The laboratory results were reviewed and included an elevated potassium result on: - 2/12/2024: 6.1 (high) 6. The clinical record for Pt #9 was reviewed on 2/28/2024. Pt #9 was admitted on 12/30/2016, with a diagnosis of ESRD. The laboratory results were reviewed and included elevated potassium results on: - 2/12/2024: 6.5 (high) - 2/19/2024: 6.9 (high) - 2/26/2024: 6.6 (high) The clinical records for Pt #6, Pt #7, Pt #8, Pt #9, lacked documentation of the physician being notified of abnormal laboratory levels. 7. On 2/28/2024 at 2:10 PM, an interview was conducted with the Registered Dietician (E #6). E #6 stated that the role of the dietician with potassium monitoring, would include educating the patient on food choices that are lower in potassium. E #6 stated that a high potassium can cause heart arrythmias (irregular heartbeat). 8. On 2/29/2024 at 9:20 AM, an interview was conducted with a Registered Nurse (E #11). E #11 stated that if a patient’s potassium is out of range, the nurse should notify the MD to get orders. E #11 stated that the MD might want the lab repeated, order medication, or change the prescription (bath). E #11 stated that potassium is an important lab as this effects the heart muscle. 9. On 2/29/2024 at 10:00 AM, an interview was conducted with the Medical Director (MD #1). MD #1 stated that MD #1 would expect the nurses to notify MD #1 of potassium results 6.2 and above. MD #1 stated that, however, if the policy states for the nurses to call at 6.0 or above, the nurses should follow those guidelines.”

“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: 48264 Based on document review and interview, it was determined that for 3 of 3 patient’s (Pt. #2, Pt. #3, and Pt. #4) clinical records reviewed for fluid assessment findings, the facility failed to conduct a RN (Registered Nurse) post dialysis fluid reassessment, to ensure necessary care and services were provided to manage the patient’s volume status. Findings include: 1. On 2/28/2024, the facility’s policy titled, “Patient Assessment and Monitoring” (dated 5/01/2023) was reviewed and included, “... The Registered Nurse will assess/reassess any findings addressed pre-or during treatment... Post-Treatment ...Edema... The registered nurse will assess/reassess post treatment ...Document findings in the patient’s record ...”. 2. On 2/28/2024, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted to the facility on 12/30/2023 with a diagnosis of ESRD (end-stage renal disease). The dialysis treatment records on 2/13/2024, 2/15/2024, 2/17/2024, and 2/20/2024 indicated that Pt. #2 had edema of bilateral ankles before the dialysis treatment. The record did not include a reassessment of Pt. #2’s edema after the dialysis treatments. 3. On 2/28/2024, the clinical record for Pt. #3 was reviewed. Pt. #3 was admitted to the facility on 12/05/2023 with a diagnosis of ESRD. The dialysis treatment records on 2/14/2024, 2/19/2024, 2/21/2024, and 2/23/2024 indicated that Pt. #3 had edema of bilateral legs before the dialysis treatment. The record did not include a reassessment of Pt. #3’s edema after the dialysis treatments. 4. On 2/28/2024, the clinical record for Pt. #4 was reviewed. Pt. #4 was admitted to the facility on 1/09/2024 with a diagnosis of ESRD. The dialysis treatment records on 2/14/2024, 2/16/2024, 2/21/2024, and 2/23/2024 indicated that Pt. #4 had edema of bilateral legs before the dialysis treatment. The record did not include a reassessment of Pt. #4’s edema after the dialysis treatments. 5. On 2/29/2024 at 9:20 AM, an interview was conducted with a Registered Nurse (E #11). E #11 stated that it is the nurse’s responsibility to do a pre and post assessment on the patient. E #11 stated that a post-assessment is important so that the nurse could compare how the patient came in versus how they are leaving out. E #11 stated that if another nurse did the pre-assessment, then the nurse assigned at the end of the treatment, should do their own post-assessment. E #11 stated that assessments include listening to lungs for shortness of breath, checking for edema (swelling), seeing if the patient had a fall, and evaluation of weight/fluids. 6. On 2/29/2024, at approximately 11:00 AM, findings were discussed with E #1 (Clinic Manager). E #1 stated that the RN should complete a patient reassessment post-dialysis treatment.”

“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: 34411 Based on document review, observation, and interview, it was determined that for 1 of 1 (Pt #5) patient observed with venipuncture site clamps, the Medical Director failed to ensure that policy was adhered to, by not obtaining a physician’s order for usage of the clamp. Findings include: 1. The facility’s policy titled, “Venipuncture Site Clamps” (dated 7/5/2022), was reviewed and required, “The purpose of this procedure is to provide guidance for when pressure clamps may be used on fistula or graft cannulation sites for hemostasis [stopping of blood] post treatment ...A doctor’s order is required for clamp usage ...” 2. The clinical record for Pt # 5 was reviewed on 2/28/2024. Pt #5 was admitted on 3/26/2018, with a diagnosis of ESRD (end stage renal disease). The physician’s orders were reviewed and indicated that Pt #5 had a AVF (fistula access). Pt #5’s physician orders lacked an order for the clamp usage on the AVF. 3. On 2/28/2024 at 9:00 AM, an observational tour of the hemodialysis treatment floor was conducted. During the tour, Pt # 5 was sitting at Station #4, post treatment. Pt # 5 had a site holding clamp on the chairside table. E #8, Pt #5’s assigned Patient Care Technician, stated that 1 clamp is used on Pt #5’s site as the patient holds the other site. 4. On 2/28/2024 at 1:15 PM, an interview was conducted with the Clinical Manager (E #1). E #1 acknowledged that Pt #5’s physician orders, lacked an order for the holding clamp. E #1 stated that an order is required for the use of the holding clamp. 5. On 2/29/2024 at 10:00 AM, an interview was conducted with the Medical Director (MD #1). MD #1 stated that more than likely an order is required for the use of the holding clamp. MD #1 stated that order may be part of the standing or prn (as needed) orders.”