Concerto Dialysis

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 34411 Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed, the Facility failed to ensure that the Nephrologist was notified of a patient’s change in condition/abnormal finding, as required by policy. Findings include: 1. “The Facility’s policy titled, “Monitoring and Documentation, Pre, During, and Post Treatment (dated 7/2018), was reviewed, and required, “...All assessment data is documented in the patient record ...An abnormal finding confirmed by RN [registered nurse] will be reported to the Nephrologist for orders and intervention(s) as necessary.” 2. The clinical records of Pt #1 was reviewed on 1/22/2024. Pt #1 was admitted on 10/7/2023, with a diagnosis of ESRD (end stage renal disease). Pt #1’s nursing notes were reviewed and included the following nursing note: - On 10/12/2023 at 7:21 PM, documented by E #6 (RN): “tx completed. Resident needed O2 via nc [nasal cannula] d/t [due to] spO2 [oxygen level] 59 % [normal range above 90 %], with 3 LPM O2, it increased to 93 %. Also needed suctioning... SNF [skilled nursing facility] nurse made aware of low spO2 with RA [room air] and needing suctioning... A/o [alert and oriented] x2-3 which is her baseline ...spO2 93% on RA off for about 5 minutes, with no complaints of difficulty in breathing.” - E #6’s nursing note included notification to the SNF nurse. However, the nursing note did not include notification to the attending Nephrologist regarding the change in condition/abnormal finding. 3. On 1/23/2024 at 11:15 AM, a telephone interview was conducted with Pt #1’s Attending Nephrologist (MD #1). MD #1 stated that MD #1 would expect the nurses to contact MD #1 in the event that the patient’s oxygen level was as low as 59 % or for other abnormal findings as well. MD #1 stated that MD #1 did not receive communication regarding Pt #1’s event. MD #1 stated that sometimes the nurses use judgement and just notify the nursing home nurse.”

“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, observation, and interview, it was determined that for 3 of 4 patients (Pt #4, Pt #5, Pt #6) observed for order verification, the Facility failed to ensure that the dialysate bath; blood flow rate, and dialysis flow rate were set on the hemodialysis machine, as prescribed. Findings include: 1. “The Facility’s policy titled, “Extracorporeal Circuit Preparation, Priming, and Recirculation Using the Baxter AK 98 Dialysis Machine” (dated 6/2023), was reviewed, and required, “Preparation for Treatment: Verify dialysis prescription ...” 2. The clinical record of Pt #4 was reviewed on 1/22/2024. Pt #4 was admitted on 12/27/2023, with a diagnosis of ESRD (end stage renal disease). The hemodialysis treatment order (dated 12/29/2023), included a prescribed blood flow rate at 400 ml/min (millimeters per min) and a dialysate bath at 3 K (potassium) 2.5 Ca (calcium). 3. The clinical record of Pt #5 was reviewed on 1/22/2024. Pt #5 was admitted on 11/11/2022, with a diagnosis of ESRD. The hemodialysis treatment order (dated 1/19/2024), included a dialysis flow rate at 700 ml/min; dialysate bath at 1 K (potassium), 2.5 calcium; and sodium at 137. 4. The clinical record for Pt #6 was reviewed on 1/22/2024. Pt #6 was admitted on 3/7/2023, with a diagnosis of ESRD. The hemodialysis treatment order (1/9/2024), included a dialysate temperature to be set at 37 degrees. 5. On 1/22/2024, between 9:30 AM and 12:45 PM, an observational tour of the dialysis treatment area at L#1 was conducted, and the following was observed: - At Station #1, Pt #4’s prescription/order was verified on the hemodialysis machine, with the Patient Care Technician (E #8). Pt #4 s blood flow rate was at 300 (not the prescribed 400) and the dialysate bath was a 2K, 2.5 Ca (not the prescribed 3 K, 2.5 Ca). - At Station #2, Pt #5’s prescription/order was verified on the hemodialysis machine, with E #8. Pt #5’s dialysate flow rate was set at 600 ml/min (not the prescribed 700 ml/min); blood flow rate was set at 200 ml/min (not the prescribed 350 ml/min); and dialysate bath was a 3K, 2.5 Ca (not the prescribed 1K, 2.5 Ca). - At Station #4, Pt #6’s prescription order was verified with the Registered Nurse (E #5). Pt #6’s dialysate temperature was set 35 degrees (not the prescribed 37.0 degrees). 6. On 1/22/2024 at 12:45 PM, an interview was conducted with the Registered Nurse (E #5). E #5 stated that prescriptions should be followed as ordered and should be verified when the patient is put on the machine. E #5 stated that sometimes the dialysate temperature is set lower if the patient’s blood pressures are running low, but an order is needed to change it.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that for 2 of 2 patients observed (Pt #2, Pt#3), the Facility failed to ensure that post-treatment assessments were completed, per policy. Findings include: 1. The Facility’s policy titled, “Monitoring and Documentation, Pre, During, and Post Treatment” (dated 7/2018), was reviewed, and required, “ ...Pre and post dialysis assessment will include, but not be limited to, the following: Weight. Lungs. Edema ...The post dialysis assessment will be done by the Registered Nurse [RN] before discharge of the patient from the treatment area. All assessment data is documented in the patient record.” 2. On 1/22/2024 between 9:30 AM and 12:45 PM, an observational tour of the dialysis treatment area at L#1 was conducted. During the tour, termination of patients’ hemodialysis treatments were observed and the following was noted: - Pt #2’s treatment was terminated at 9:36 AM. Pt #2 exited the treatment area at approximately 10:15 AM. - Pt #3’s treatment was terminated at 9:54 AM. Pt #3 exited the treatment area at approximately 11:00 AM. Pt #2 or Pt #3 were not physically weighed on the scale to obtain post-treatment weights prior to exiting. A post assessment, including listening to lungs and checking for edema (swelling), was not completed by the RN (E #5). 3. On 1/22/2024 at 11:45 PM, an interview was conducted with the Registered Nurse (E #5). E #5 stated that sometimes the patient’s weights are just calculated by subtracting the fluid removal from the pre-weight, and not physically weighed. 4. On 1/22/2024 at 12:45 PM, an interview was conducted with a RN (E #6). E #6 stated that the RN should do the same post-assessments as the pre-assessments that would include assessing for swelling; listening to lungs; making sure vital signs are stable; and assessing post-treatment weights.”