Davita Freedom Dialysis

“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: 38262 Based on observation, record review and interview, the facility failed to ensure facility policy was followed regarding monthly Nursing Notes for 48 of 55 in-center record reviews, and failed to ensure patients received prescribed medications for 1 of 4 treatment floor observation days. (Patient #2) Findings include: 1. A revised 10/2023 policy titled “Progress Note Policy” indicated that all nurses are required to record patient progress notes at least monthly to ensure the interdisciplinary team members have an up to date picture of the patients current status. 2. A revised 10/2023 policy titled “Medication Policy” indicated staff are to administer medications as prescribed by the physician. 3. A review of Patient monthly Nurse Notes evidenced the following: A review of the following patients records evidenced a completed monthly Nursing Note dated 05/06/2024 for Patient #45, 05/30/2024 for Patient #42. The facility failed to evidence monthly Nursing Notes were completed for June and July of 2024. A review of the following patient records evidenced a completed monthly Nursing Note dated 04/25/2024. The facility failed to evidence monthly Nursing Notes were completed for 3 months (May, June, July of 2024) on the following patients: Patient #11, Patient #12, Patient #15, Patient #16, Patient #19, Patient #27, Patient #28, Patient #29, Patient #30, Patient #36, Patient #37, Patient #39, Patient #40, Patient #41, Patient #43, Patient #55, and Patient #59. A review of the following patient records evidenced a completed monthly Nursing Notes dated 03/01/2024 for Patient #24, 03/19/2024 for Patient #32, 03/09/2024 for Patient #44, 03/23/2024 for Patient #46, 03/19/2024, 03/09/2024 for Patient #49, 03/23/2024 for Patient #56, 03/19/2024 for Patient #57. The facility failed to evidence monthly Nursing Notes were completed for 4 months (April, May, June, July of 2024). A review of the following patient records evidenced a completed monthly Nursing Notes dated 02/16/2024 for Patient #18, 02/16/2024 for Patient #20, 02/20/2024 for Patient #48, and 02/21/2024 for Patient #1, Patient #3, and Patient #21. The facility failed to evidence monthly Nursing Notes were completed for 5 months (March, April, May, June, July of 2024). The following patient records evidenced a completed monthly Nursing Note dated 02/21/2023. The facility failed to evidence the completion of monthly Nursing Notes for 1 year and 5 months on the following patients: Patient #2, Patient #4, Patient #14, Patient #36, Patient #38, Patient #46, Patient #47, Patient #51, Patient #53, Patient #54, Patient #58. A review of Patient #22’s record evidenced a monthly Nurse Note dated 01/12/2024. The facility failed to evidence a monthly Nurse Notes for six months. A review of Patient #50’s record evidenced a monthly Nurse Note dated 12/19/2023. The facility failed to evidence monthly Nurse Notes for seven months. A review of Patient #25’s record evidenced a monthly Nurse Note dated 06/23/2023. The facility failed to evidence monthly Nurse Notes for one year and one month. A review of Patient #26 and Patient #27’s records evidenced a monthly Nurse Note dated 12/29/2022. The facility failed to evidence a monthly Nurse Notes for one year and seven months. 4. During an interview on 08/15/2024 at 12:05 PM, Registered Nurse (RN) 2 stated she was not aware she had to do monthly Nurse Notes. RN 2 stated she was hired in January and she just found out about the monthly Nursing Notes. 5. During an interview on 08/15/2024 at 12:15 PM, RN 1 stated she had been on her own at the facility for a while. She stated that she was aware the monthly Nursing Notes were not done because she focused more on medications, care plans, and care activities than completing the monthly notes. She said she was not sure if the Facility Administrator (FA) was aware but she reached out to the former FA for help. She stated the Medical Social Worker (MSW) 1 reminded her about documenting missed visits in the note and she might have been the only one who knew about it. There were several float nurses that would help out but they were not allowed to do monthly Nurse Notes. RN 1 stated they hired RN 2 back in January and she did not have time to train her how to do the monthly Nurse Notes. She stated no one addressed the issue with her, not even in the weekly team meetings. 6. During an interview on 08/15/2024 at 12:30 PM, MSW 1 stated that she converses with the nurse weekly regarding the patients and was aware monthly Nursing Notes were not completed. 7. During an interview on 08/15/2024 at 12:45 PM, Registered Dietician (RD) 1 stated she noticed monthly Nurse Note were not completed. She stated she educated the nurses about completing the monthly note. RD 1 stated she attends weekly staff meetings to discuss the nutritional needs of patients. 8. During an interview on 08/15/2024 at 12:30 PM, the Manager of Clinical Services (MCS) indicated that nurses have the ability to document in other areas in the electronic medical record (EMR). The MCS stated that nurses are required to complete a monthly Nursing Note on the patient’s current status, which helps the interdisciplinary team care for the patient. 9. During an interview on 08/15/2024 at 2:00 PM, the FA stated she was not aware the nurses were not completing the monthly Nursing Notes for patients. She stated they were not tracking anything on it. 10. During an observation on 08/12/2024 at 9:40 AM, Patient #2 was seen sitting at station 10 with medication in a cup labeled Calcitriol (medication for low calcium), 08/12/2024, [RN 1]. At 10:55 AM, Patient #2 left the facility without taking the medication, which was still sitting at the station. Patient Care Technician (PCT) 1 stated she was not aware the patient had not taken the medication, but she stated she would tell the nurse. PCT 1 stated RN 2 instructed her to throw the medication away. The facility’s staff failed to ensure patient medications were administered as ordered. A review of Patient #2’s medication administration record dated 08/12/2024 evidenced RN 1 gave Calcitriol at 06:35 AM. The record failed to evidence the medication was not taken. 11. During an interview on 08/12/2024 at 10:57 AM, RN 2 stated she was covering for RN 1 because she left for an appointment and was not aware the patient had not taken their medication. RN 2 stated she did not receive a report from RN 1 prior to her leaving. RN 2 stated she did not do a post assessment on the patient before the patient left. 12. During an interview on 08/12/2024 at 1:25 PM, RN 1 stated most of the patients are good about taking their medications before leaving. RN 1 stated they were allowed to set the medication on their chair side tray and let the patient take them on their own. RN 1 stated she would document in the patient record whether they took the medication or not. 13. During an interview on 08/13/2024 at 8:10 AM, the MCS stated the nurse was allowed to set the medication on the tray if the patient does not want to take it at that time. The MCS stated the nurse should follow-up with the patient to ensure the medication was taken before leaving the station.”