Fmc - Southwest

“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: 50873 Based on interview, record review, and facility policy review, the facility failed to monitor patients’ vital signs according to their policy for 6 (Patients #1, #2, #4, #5, #6 and #7) of 7 sampled patients. Failure to monitor patients’ vitals according to the facility’s policy provided an opportunity for changes to the patients’ condition during dialysis treatments to be unrecognized and unaddressed and negatively impact the care provided to the 61 patients who received dialysis treatments at the facility. The findings include: Review of facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, indicated “Purpose The purpose of this policy is to provide guidance to [facility name] direct patient care staff on assessment and monitoring patients before, during and after treatment.” The policy specified, “During Treatment * Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. * Document machine parameters and safety checks every 30 [minutes] or more often as needed but not to exceed 45 minutes or per state regulations. Follow the steps below for monitoring patient and machine parameters during treatment. 1. Blood pressure Record blood pressure: * Recheck blood pressures after a drop that requires interventions such as administering normal saline. * Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to the nurse: * Systolic blood pressures greater than 180 mmHg [millimeters of mercury] * Diastolic blood pressure greater than 100 mmHg. * Blood Pressure less than or equal to 100 mmHg systolic. Pulse Record pulse. Verify pulses manually if automated readings display below 60 or greater than 100 beats per minute [bpm]. * Report to the nurse patients whose heart rates have dropped below 60 [bpm] risen above 100 [bpm] or become irregular.” 1. Patient #1’s treatment sheet dated 11/17/2025, revealed during treatment the patient had a blood pressure reading of 191/110 millimeters of mercury (mmHg) at 9:01 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. Patient #1’s treatment sheet dated 11/19/2025, revealed during the treatment the patient had a blood pressure reading of 180/107 mmHg (sitting) and 173/104 mmHg (seated) at 6:56 AM, 170/101 mmHg at 7:13 AM, 158/101 mmHg at 9:04 AM, 160/101 mmHg at 9:41 AM, 146/103 mmHg at 10:03 AM, 161/107 mmHg at 10:42 AM, 173/109 mmHg at 11:01 AM, 173/109 mmHg at 11:17 AM, and 179/104 mmHg at 11:18 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. Patient #1’s treatment sheet dated 11/21/2025, revealed during treatment the patient had a blood pressure reading of 174/101 mmHg at 8:04 AM, 167/101 mmHg at 8:05 AM, and 161/103 mmHg at 9:02 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. Patient #1’s treatment sheet dated 11/28/2025, revealed during treatment the patient had a blood pressure reading of 181/109 mmHg at 7:34 AM, 167/101 mmHg at 8:05 AM, and 175/106 mmHg at 11:15 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. The treatment sheet further revealed there was no evidence the patient’s vital signs were checked during treatment for 57 minutes, from 9:04 AM to 10:01 AM. 2. Patient #2’s treatment sheet dated 11/24/2025, revealed during treatment the patient had a blood pressure reading of 164/103 millimeters of mercury at 2:32 PM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. 3. Patient #3’s treatment sheet dated 11/17/2025, revealed no evidence the patient’s vital signs were checked for 59 minutes, from 8:01 AM to 9:00 AM. Patient #3’s treatment sheet dated 11/17/2025, revealed during treatment the patient had a blood pressure reading of 57/40 millimeters of mercury (mmHg) at 7:34 AM, 89/59 mmHg at 9:00 AM, and 79/41 mmHg at 8:01 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. Patient #3’s treatment sheet dated 11/19/2025, revealed during treatment the patient had a blood pressure reading of 89/57 mmHg at 8:33 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. Patient #3’s treatment sheet dated 11/21/2025, revealed during treatment the patient had a blood pressure reading of 152/102 mmHg at 6:30 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. Patient #3’s treatment sheet dated 11/24/2025. revealed no evidence the patient’s vital signs were checked for 50 minutes, from 6:10 AM to 7:00 AM. Patient #3’s treatment sheet dated 11/24/2025, revealed during treatment the patient had a heart rate of 109 beats per minute (bpm) at 9:30 AM, 106 bpm at 9:53 AM, and 103 bpm at 9:58 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal heart rate. 4. Patient #4’s treatment sheet dated 11/24/2025, revealed during treatment the patient had a heart rate of 50 beats per minute (bpm) at 6:55 AM, 56 bpm at 7:00 AM, 53 bpm at 8:32 AM, 50 bpm at 9:05 AM, 53 bpm at 9:30 AM, and 59 bpm at 10:03 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal heart rate. Patient #4’s treatment sheet dated 11/28/2025, revealed during treatment the patient had a heart rate of 53 bpm at 7:30 AM, 54 bpm at 8:03 AM, and 53 bpm at 9:29 AM, and 58 bpm at 9:59 AM and there was no evidence the licensed nurse was notified of the patient’s abnormal heart rate. 5. Patient #6’s treatment sheet dated 11/20/2025, revealed no evidence the patient’s vital signs were checked for 59 minutes, from 9:03 AM to 10:02 AM. 6. Patient #6’s treatment sheet dated 11/22/2025, revealed during treatment the patient had a blood pressure reading of 207/141 millimeters of mercury (mmHg) at 12:32 PM, 197/132 mmHg at 12:41 PM, 213/144 mmHg at 1:01 PM, 199/130 mmHg at 2:01 PM, 197/129 mmHg at 2:32 PM, 191/126 mmHg at 3:01 PM, 191/126 mmHg at 3:19 PM, and 209/132 mmHg (seated) and 197/137 mmHg (standing) at 3:20 PM and there was no evidence the licensed nurse was notified of the patient’s abnormal blood pressure. During an interview on 12/03/2025 at 2:28 PM, Patient Care Technician (PCT) #9 stated PCTs were supposed to check a patient’s vital signs at least every 30 minutes. PCT #9 stated if anything was out of the ordinary, the PCT should report it to the registered nurse and document the notification. During an interview on 12/04/2025 at 2:45 PM, the Medical Director confirmed the facility expectation that patients be monitored per policy and that any deviations from the norm should be documented to include any notifications that a staff member might have made.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 50873 Based on record review, interview, and facility policy review, the facility failed to ensure patients’ dialysis prescriptions were delivered as ordered for 7 (Patients #1, #2, #3, #4, #5, #6, and #7) of 7 patients in the medical record review sample. The findings include: Review of facility policy, “Patient Assessment and Monitoring,” published 05/01/2023, indicated “Purpose The purpose of this policy is to provide guidance to [facility name] direct patient care staff on assessment and monitoring patients before, during and after treatment.” The policy specified, “3. Machine Parameters and Extracorporeal Circuit Check machine setting and measurements: * Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. * Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” 1. Patient #1’s treatment sheet dated 11/19/2025, revealed the patient’s dialysis machine was set for a dialysate flow rate (DFR) of 800 from 7:31 AM until 9:04 AM and 500 from 10:03 AM until 11:17 AM. The dialysis prescription indicated that the DFR should have been set for 600. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. Patient #1’s treatment sheet dated 11/24/2025, revealed the patient’s dialysis treatment time was three hours and 43 minutes. The dialysis prescription indicated that the treatment time should have been four hours. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. Patient #1’s treatment sheet dated 11/26/2025, revealed the patient’s machine was set for a blood flow rate (BFR) of 400 from 10:32 AM until 11:05 AM. The dialysis prescription indicated that the BFR should have been set for 450. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. 2. Patient #2’s treatment sheet dated 11/26/2025, revealed the patient’s dialysis treatment time was two hours and 33 minutes. The dialysis prescription indicated that the treatment time should have been three hours. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. 3. Patient #3’s treatment sheet dated 11/26/2025, revealed the patient’s machine was set for a blood flow rate (BFR) of 300 from 7:01 AM until 8:31 AM, when it was lowered to 280 until 9:30 AM. The dialysis prescription indicated that the BFR should have been set for 450. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. 4. Patient #4’s treatment sheet dated 11/28/2025, revealed the patient’s machine was set for a blood flow rate (BFR) of 450 from 7:20 AM until 9:59 AM. The dialysis prescription indicated that the BFR should have been set for 400. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. 5. Patient #5’s treatment sheet dated 11/22/2025, revealed the patient’s dialysis treatment time was one hour and 27 minutes. The dialysis prescription indicated that the treatment time should have been four hours. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. Patient #5’s treatment sheet dated 11/25/2025, revealed the patient’s dialysis treatment time was 53 minutes. The dialysis prescription indicated that the treatment time should have been four hours. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. Patient #5’s treatment sheet dated 11/25/2025, revealed the patient’s machine was set for a dialysate flow rate (DFR) of 500 from 11:14 AM until 11:37 AM. The dialysis prescription indicated that the DFR should have been set for 800. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. Patient #5’s treatment sheet dated 11/27/2025, revealed the patient’s dialysis treatment time was one hour and 28 minutes. The dialysis prescription indicated that the treatment time should have been 4 hours. The treatment sheet further revealed, the patient’s machine was set for a blood flow rate (BFR) of 400 from 5:23 AM until 6:33 AM. The dialysis prescription indicated that the BFR should have been set for 450. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. 6. Patient #6’s treatment sheet dated 11/27/2025, revealed the patient’s machine was set for a blood flow rate (BFR) of 450 from 5:45 AM until 6:32 AM. The dialysis prescription indicated that the BFR should have been set for 400. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. 7. Patient #7’s treatment sheet dated 11/20/2025, revealed the patient’s dialysis treatment time was one hour and 48 minutes. The dialysis prescription indicated that the treatment time should have been three hours and 30 minutes. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. Patient #7’s treatment sheet dated 11/29/2025, revealed the patient’s dialysis treatment time was two hours and two minutes. The dialysis prescription indicated that the treatment time should have been three hours and 30 minutes. The record revealed no evidence of documentation that provided a rationale for the deviation from the patient’s dialysis prescription. During an interview on 12/03/2025 at 2:28 PM, Patient Care Technician (PCT) #9 stated that if the staff were unable to achieve a patient’s prescribed BFR, the staff should document the reason why. PCT #9 confirmed Patient #5’s treatment on 11/27/2025 was not at the prescribed BFR. During an interview on 12/04/2025 at 11:08 AM, the Clinical Manager confirmed the facility’s expectation that patients’ treatments were conducted as prescribed and that any deviations from the order should be documented and a rationale provided. During an interview on 12/04/2025 at 2:45 PM, the Medical Director confirmed the facility’s expectation that patients’ treatments were conducted as prescribed and any deviations be documented with a rationale.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 50873 Based on interview, record review, and facility policy review, the facility failed to report adverse events for 2 (Patient #1 and Patient #4) of 7 sampled patients. The findings include: Review of facility policy titled, “Patient Safety Reporting and Documentation,” published 09/02/2025, indicated “Purpose The purpose of this policy is to provide guidelines for all clinical staff on identifying, reporting and documenting patient related Near Misses, Safety Events and Serious Safety Events in the In-Center and Home Therapy setting to: * Provide a standardized process for management of all patient related safety events as defined in this policy * Promote a culture of patient safety.” The policy specified, “Definitions Near Miss Near Miss does not result in patient clinical harm, either through early detection or sheer luck. It is an unsafe situation that is indistinguishable from a safety event except for the outcome. Safety Event Safety event results in mild to moderate patient clinical harm, not due to an underlying disease or condition. Requires additional monitoring, intervention, and/or medical care. Serious Safety Event Serious safety event that results in severe to life threatening patient clinical harm, not due to an underlying disease or condition. Requires lifesaving or major medical intervention that may result in hospitalization and/or death.” Per the policy, “When a Near Miss, Safety Event or Serious Safety Event occurs, staff are required to report, document, and review the event as noted in this policy.” 1. Patient #1’s treatment sheet dated 11/21/2025, indicated Patient Care Technician (PCT) #8 documented that the patient’s goal was incorrectly set, which resulted in the patient becoming sick. The facility “Adverse Event Report” for the timeframe 12/01/2024 to 12/01/2025, revealed no evidence of the adverse event for Patient #1 recorded by PCT #8 for 11/21/2025. During an interview on 12/04/2025 at 11:08 AM, the Clinical Manager (CM) stated she would not have considered Patient #1’s goal being incorrectly set as a reportable adverse event. After review of the facility policy, the CM stated based on the facility policy, Patient #1’s goal being incorrectly set was a reportable error. 2. Patient #4’s treatment sheet dated 11/19/2025, indicated the patient was not able to tolerate their prescribed blood flow rate without becoming short of air, despite being on 5 liters of supplemental oxygen by way of a nasal cannula. Per the treatment sheet, the patient was stabilized and tolerated their dialysis treatment for a short period of time before they presented with chest pain. Patient #4’s treatment sheet revealed post treatment vital signs were not completed due to the patient being discharged to the hospital. The facility “Adverse Event Report” for the timeframe 12/01/2024 to 12/01/2025, revealed no evidence of the adverse event for Patient #4 for 11/19/2025. During an interview on 12/04/2025 at 12:39 PM, the Clinical Manager stated the facility expectation was for an adverse event form to be filled out for any patient that was sent out of the clinic by way of emergency medical services and confirmed this was not done for Patient #4 on 11/19/2025. During an interview on 12/04/2025 at 2:45 PM, the Medical Director (MD) stated he was not sure what events were supposed to be reported per facility policy but that the staff should report events per facility policy. The MD stated t he was not aware that all adverse events were not being reported.”