Davita Westview Dialysis

“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: 44774 Based on record review and interview the agency failed to monitor and report episodes of hypertension to the physician, in 2 of 10 active dialysis patients. (Patients #1 and #6) Findings include: 1. A review of a facility policy revised April 2024, titled ‘PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT’ stated, “ ... Data Collection includes but is not necessarily limited to: ... ii. Measurement of Blood Pressure (BP) ... PRE-TREATMENT DATA COLLECTION/ASSESSMENT ... 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse ... 6. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The physician ... will be notified of any concerns that may preclude the initiation of dialysis ... INTRADIALYTIC DATA COLLECTION /ASSESSMENT ... b. At a minimum, obtain and document the following: ... i. Blood Pressure ... POST TREATMENT DATA COLLECTION ... 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings ... 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse ... 17. Licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician ... is necessary prior to discharge of the patient form the facility ... ABNORMAL FINDINGS ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ... Blood Pressure: Pre-Dialysis: Systolic Greater than 180 mm/Hg or less than 90 mm/Hg ... Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg ... Blood Pressure-Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg ... Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg ... Blood Pressure Post Treatment: ... Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg ... Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg ... Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg ... Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg ...” 2. A review of the clinical record for Patient #6 evidenced an order for ‘Clonidine (medication which lowers blood pressure) 0.1 mg, orally, every 4 hours as needed’ with no parameters for administration. Review of the 09-28-2024 treatment run for Patient #6 evidenced the following: 10:28 AM, Initiation of treatment B/P of 186/92. 10:30 AM, B/P 169/86, 11:00 AM, B/P 127/82 11:31 AM, B/P 134/73 11:35 AM, B/P 131/73 11:51 AM, B/P 124/71, “ ... RN notified; patient states they feel like their BP is dropping ...” 11:51 AM, B/P 124/71, “ ... BP recheck ...” 12:00 PM, B/P 140/73 12:30 PM, B/P 144/78, “ ... Patient states their head hurts, RN notified ...” 1:00 PM, B/P 161/91 1:30 PM, B/P 139/87 2:00 PM, B/P 120/66 2:28 PM, B/P 104/46, “ ... Treatment terminated ...” There was no indication the physician was made aware of the elevated reading at 10:28 AM, nor the drop in B/P at 11:21 AM or the lower diastolic reading at 2:28 PM. Review of the 09-26-2024 treatment run for Patient #6 evidenced the following: 10:09 AM, Initiation of treatment, B/P 222/111, “ ... Treatment started without complications ...” 10:10 AM, manual entry, “ ... pre bp high [charge nurse] notified ...” 10:30 AM, B/P 202/100 11:00 AM, B/P 165/96 11:30 AM, B/P 167/88 12:00 PM, B/P 147/82 12:31 PM, B/P 122/99, “ ... retake ...” 12:32 PM, B/P 139/73 1:00 PM, B/P 142/89 1:30 PM, B/P 148/85 2:00 PM, B/P 97/69 2:10 PM, B/P 113/75 2:12 PM, B/P 110/63, “ ... Treatment terminated ...” Nursing ‘Pre’ comments indicated, “HTN noted. Pt states [they] do not take BP meds before [treatment] due to dropping too low during treatment.”. There was no indication the physician was made aware of the elevations in the systolic or diastolic B/P. Review of the 09-24-2024 treatment run for Patient #6 evidenced the following: 10:22 AM, Initiation of treatment, B/P 214/105 11:06 AM, B/P 145/89 11:30 AM, B/P 174/95 12:00 PM, B/P 173/95 12:30 PM, B/P 167/92 1:00 PM, B/P 160/79 1:30 PM, B/P 123/80 2:01 PM, B/P 177/88 2:21 PM, B/P 159/64, “ ... Treatment terminated ...” Nursing ‘Pre’ comments indicated, “Patient set for a 0.4 challenge due to elevated B/P, bringing UFG up to 1.2”. There was no indication the physician was made aware of the elevations in the systolic or diastolic B/P. Review of the 09-21-2024 treatment run for Patient #6 evidenced the following: 10:00 AM, Initiation of treatment, B/P 189/98 10:32 AM, B/P 153/93 11:02 AM, B/P 131/81 11:32 AM, B/P 143/88 12:02 PM, B/P 143/81 12:32 PM, B/P 145/78 1:02 PM, B/P 103/67 1:16 PM, B/P 139/76 1:32 PM, B/P 125/76 2:02 PM, B/P 164/111, “ ... Treatment terminated ...” There was no indication the physician was made aware of the elevations in the systolic or diastolic B/P or the drop in the systolic pressure at 1302. Review of the 09-19-2024 treatment run for Patient #6 evidenced the following: 10:20 AM, Initiation of treatment, B/P 225/110, “ ... treatment started without complications ...” 10:34 AM, “ ... [charge nurse] notified of high bp ...” 10:32 AM, B/P 221/115 11:00 AM, B/P 134/84 11:20 AM, B/P 108/59 11:30 AM, B/P 128/69 12:30 PM, B/P 166/92 1:00 PM, B/P 188/100 1:30 PM, B/P 183/99, “ ... retake ...” 1:58 PM, B/P 222/147 2:02 PM, B/P 218/105, “ ... Treatment terminated ...” There was no indication the physician was made aware of the elevations in the systolic or diastolic B/P or the drops in systolic pressure at 1120. Review of the 09-17-2024 treatment run for Patient #6 evidenced the following: 10:20 AM, Initiation of treatment, B/P 192/117, “ ... treatment started without complications ...” 10:38 AM, “ ... Treatment initiated with asymptomatic hypertension ...” 11:00 AM, B/P 168/94 11:15 AM, B/P 129/78, “ ... patient c/o feeling dizzy 100 ml normal saline administered; head back ...” 11:31 AM, B/P 156/85 12:00 PM, B/P 163/85 12:30 PM, B/P 164/85 1:00 PM, B/P 179/88 1:30 PM, B/P 169/89 2:00 PM, B/P 180/85 2:10 PM, B/P 188/91, “ ... Treatment terminated ...” There was no indication the physician was made aware of the elevations in the systolic or diastolic B/P. 3. On 10-03-2024 at 1:00 PM, when queried as to how patients with chronic elevations in blood pressures are addressed, Registered Nurse (RN) 7 indicated patients are provided with education regarding diet and medication, and there are sometimes standing orders for Clonidine. When queried as to Clonidine orders being in place for patients without blood pressure parameters, indicated this would likely be indicated for patients with systolic blood pressures over 200 mm/Hg, but would depend on whether that particular patient’s blood pressure was prone to dropping too quickly. Indicated Clonidine would be given at the nurses discretion. 4. On 10-04-2024 at 9:44 AM, Doctor 3, regarding Patient #6, indicated Clonidine would be appropriate with systolic blood pressures of 170mm/Hg [or greater], unless the patient’s heart rate was under 60 beats per minute. Indicated, wondered if the Clonidine ordered was part of a DaVita protocol, as they had not ordered this, and would have expected nursing to reach out for blood pressure parameters. Indicated had not received communication from nursing regarding Patient #6’s recent serial elevated systolic readings above 200 mm/Hg and diastolic readings above 100 mm/Hg. Indicated would be investigating further. 44354 5. A review of the clinical record for Patient #1 indicated an order for Clonidine 0.1 mg every 4 hours as needed with no parameters for administration. A review of the treatment record for 09-10-2024 at 10:37 AM indicated Patient #1’s blood pressure(BP) was 178/83 and a noted “Treatment initiated with asymptomatic [sic] hypertension.” 11:14 AM BP 184/81 11:32 AM BP 204/114 11:34 AM BP 188/90 12:02 AM BP 185/91 12:35 AM BP 177/91 1:03 PM BP 178/75 1:32 PM BP 174/78 2:02 PM BP 182/78 2:33 PM BP 182/88 2:40 PM BP 212/81. Medications administered were Micera (treatment of low red blood cells), Venofer (treatment of iron deficiency), Tums (treatment of high levels of phosphorous), and Calcitriol (calcium supplement). No indication the physician was notified of elevated blood pressures. A review of the treatment record for 09-19-2024 at 10:31 AM indicated Patient #1’s BP was 199/88 and treatment was initiated. 11:03 PM BP 188/80 12:02 PM BP 174/80 1:03 PM BP 183/84 1:32 PM 194/84 2:03 PM 217/97 2:04 PM BP 223/104 2:15 PM BP 160/104 2:17 PM BP 192/90 The treatment was terminated. Medications administered were Venofer, Tums, Calcitriol, and Fluzone (influenza vaccine), and no indication the physician was notified of elevated blood pressures. A review of the treatment record for 09-27-2024 at 3:54 PM Patient #1’s BP was 184/85 4:01 PM BP 210/93 4:08 PM BP 204/92 4:31 PM BP 205/95 4:55 PM BP 197/82 5:01 PM BP 196/79 5:31 PM BP 180/80 6:01 PM BP 182/71 6:31 PM BP 186/77 7:01 PM BP 196/80 7:14 PM BP 184/82 7:31 PM BP 206/89 7:53 PM BP 162/78 The treatment was terminated. Medications administered were Mircera, Venofer, and Calcitrol, and there was no indication the physician was notified of elevated blood pressures. 6. During an interview via phone on 10-04-2024 at 9:06 AM the Clinical Manager, Registered Nurse (RN), reported physicians are contacted often. The connection was lost, and the facility administrator relayed the clinical manager had informed them the blood pressure notifications and medications were reviewed and administering medication for elevated blood pressure was at the” nurses’ discretion.””