Fmc - Battle Creek South

“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: 38304 Based on record review and interview, the facility failed to ensure staff notified the registered nurse (RN) per facility policy of elevated blood pressure (BP) readings in 1 (Patient #3) of 5 records reviewed for BP, failed to ensure the RN provided medication to treat sustained elevated BP readings per facility policy in 1 (Patient #1) of 5 records reviewed for BP, and failed to document target weights (TW) which consistently fell outside facility parameters per facility protocol/expectations in 2 (Patients #1, 4) of 5 records reviewed for TW, resulting in the potential for the continuance of uncontrolled BP readings, unrecognized changes in volume status, and poor patient outcomes for all 41 in-center hemodialysis patients currently receiving treatment. Findings include: P-1: This patient was admitted to the facility on 3/20/2023 with diagnoses which included end-stage renal disease, hypertension, diabetes-type 2, and anemia. P-1 was receiving treatments 3 times per week (Mon-Wed-Fri) for an ordered duration of 4 hours and 30 minutes each treatment. On 6/25/24, record review noted P-1 was admitted to the hospital on 4/15/24 through 4/18/24 for “Hypertensive crisis” and again on 5/8/24 through 5/9/24 for “Hypertensive crisis”. Further record review on 6/25/24 of P-1’s seven most recent dialysis treatment sheets (6/21/24 - 6/7/24), revealed to following concerns relating to BP and TW recordings: On 6/19/24, after the first four BP recordings (1217 to 1431) which were within safety parameters, P-1’s BP increased as follows: 1503: BP was 192/105-no documentation that the nurse was notified by CCHT (Certified Clinical Hemodialysis Technician) Staff L. 1536: BP was 171/112-no documentation that RN (Staff H) had offered or administered P-1 with PRN (as needed) BP medication for pressures exceeding “SBP (systolic blood pressure) of 190 or DBP (diastolic blood pressure) of 110” per facility policy referenced below. 1644: Post-treatment: BP recording (late by 23 minutes per facility policy below) was 183/117 by RN (Staff I). No documentation was evidenced in the medical record that Staff I had re-checked P-1’s BP or had offered/administered any BP medication before sending patient home. On 6/14/24: Dialysis treatment initiated at 1216 with a pre-treatment BP of 139/87. 1232: BP was 186/118-no documentation that the nurse was notified by PCT (patient care technician) Staff C who is currently in training. 1302: BP was 190/119-no documentation that the nurse was notified by CCHT Staff J. 1331: BP was 188/112-no documentation that the nurse was notified by CCHT Staff V. 1401: BP was 210/183-no re-check and no documentation that the nurse was notified by PCT Staff C. 1431: BP was 187/113-no documentation that the nurse was notified by PCT Staff C. On 6/10/24: Dialysis treatment initiated at 1219 with a pre-treatment BP of 162/110. 12 of 12 BP recordings had a DBP which exceeded 100 (per PCT and RN documentation), and 4 of 12 BP recordings which exceeded 110. No documentation was evidenced in the medical record that Staff H (RN in training) had offered/administered P-1 any BP medication before sending the patient home with a BP of 188/112. On 6/7/24: Dialysis treatment initiated at 1228 with a pre-treatment BP of 155/81. 1229: BP was 161/104-no documentation that the nurse was notified by CCHT Staff L. 1232: BP was 189/117-no documentation that the nurse was notified by CCHT Staff L. 1306: BP was 179/117-no documentation that the nurse was notified by CCHT Staff G. 1334: BP was 182/114-no documentation that the nurse was notified by CCHT Staff L. 1401: BP was 170/117-no documentation that the RN (Staff M) had offered/administered any BP medication. 1432: BP was 186/117-no documentation that the RN (Staff W) had offered/administered any BP medication. 1503: BP was 171/111-no documentation that the RN (Staff W) had offered/administered any BP medication. 1533: BP was 178/108-within parameters as RN (Staff M) had documented the BP reading. 1605: BP was 191/122-no documentation that the nurse was notified by CCHT Staff L. 1646: BP was 218/145-no documentation was evidenced in the medical record that RN Staff W had re-checked P-1’s BP or had offered/administered any BP medication before sending patient home. The only narrative evidenced in the “Post-Dialysis Vitals and Evaluation” by Staff W was, “No new findings.” Additional record review of P-1’s post-treatment TW’s (7 of 7) had significantly exceeded the facility’s established parameters of +/- 0.5 kg. which was confirmed per interview with Staff A and Staff S on 6/26/24 at 1255. No policy per Facility Administrator (Staff A), was provided upon request due to no policy language existing regarding this topic. No documentation was found in the medical record of staff informing the physician during the noted timeframe of dialysis treatments above (6/7/24 - 6/21/24). The ordered TW of 88 kg. with an upper limit of 88.5 kg. applied to all 7 reviewed dialysis treatments and are documented as follows: 6/21/24: Post-treatment TW was 91.5 kg. (3.0 kg. over limit). 6/19/24: Post-treatment TW was 92.3 kg. (3.8 kg. over limit). 6/17/24: Post-treatment TW was 94.0 kg. (5.5 kg. over limit). 6/14/24: Post-treatment TW was 95.1 kg. (6.6 kg. over limit). 6/12/24: Post-treatment TW was 95.5 kg. (7.0 kg. over limit). 6/10/24: Post-treatment TW was 96.9 kg. (7.4 kg. over limit). 6/07/24: Post-treatment TW was 96.6 kg. (7.1 kg. over limit). An interview was conducted on 6/26/24 at 1305 with the Facility Administrator (Staff A), Director of Operations (Staff S), and covering Medical Director (Staff B) who reviewed and acknowledged the above findings. Staff B reviewed physician notes for evidence which explained why the target weight was not adjusted per Staff B interview concerning facility expectations/protocol. No evidence was found during review. The facility failed to adhere to its policies/procedures and expectations concerning BP and TW to optimize clinical outcomes for P-1. Facility Policy “Routine Protocols for Hemodialyis-2024 FMC Battle Creek 4370” (effective 1/1/2024 or date of admission) stated, “PRN medications: Clonidine (BP medication) 0.1 mg. PO (by mouth) every 1 hour (max of 3 doses), PRN if SBP >190 or DBP > 110 per nursing judgement/MD order. Call MD if remains high per nursing judgement.” 47976 **Policy titled “Patient Assessment and Monitoring” (published 5/1/23) stated on page 4 under “During Treatment”, it should be reported to the nurse if “Systolic blood pressures greater than 180 mm/Hg” and “Diastolic blood pressure greater than 100 mm/Hg.” P-3:This 45-year-old patient was admitted to this dialysis facility on 1/17/24 with the diagnosis of end stage renal disease and was receiving dialysis treatments 3 times per week. During record review of the last 6 treatment sheets on 6/25/24, it was noted the blood pressure readings by the patient care technician (PCT) were recorded as follows: On 3/25/24: 178/103 at 1218 201/85 at 1230 On 4/1/24: 204/105 at 1235 There was no documented evidence of these values being reported to the registered nurse to be assessed per facility policy. The Facility Administrator (Staff A) was interviewed on 6/26/24 at 1115 regarding the expectation for a PCT reporting blood pressures that are out of range to the nurse on duty. Staff A reported staff are expected to follow the policy above for when to notify the nurse. Staff A acknowledged there is no documentation of the nurse being notified in the above examples. P-4: This 68-year-old patient was admitted to this dialysis facility on 6/2/23 with the diagnosis of end stage renal disease and was receiving dialysis treatments 3 times per week. During record review on 6/25/24, it was determined the estimated dry weight (EDW, post-dialysis) was ordered to be 68 kilograms (kg). Upon review of the last 6 treatment sheets, it was determined the pre-dialysis weights to post-dialysis weights (EDW) were recorded as follows: On 6/10/24: Pre-dialysis = 77.4 kg, Post-dialysis = 72.8 kg (4.6 above target weight (TW)) On 6/12/24: Pre-dialysis = 77.9 kg, Post-dialysis = 73.0 kg (4.9 above TW) On 6/14/24: Pre-dialysis = 76.0 kg, Post-dialysis = 71.9 kg (4.1 above TW) On 6/17/24: Pre-dialysis = 77.4 kg, Post-dialysis = 73.5 kg (3.9 above TW) On 6/19/24: Pre-dialysis = 76.6 kg, Post-dialysis =72.8 kg (3.8 above TW) On 6/21/24: Pre-dialysis =77.2 kg, Post-dialysis =73.8 kg (3.4 above TW) Each daily treatment note indicated the patient did not meet the prescribed EDW due to a large fluid gain, however, there was no indication of communication with the interdisciplinary team or physician regarding a need to change the parameters to address this. Staff A was interviewed on 6/26/24 at 0915 regarding the expectation for changing an EDW that has been consistently not met. Staff A reported the expectation is that if the patient is plus or minus 0.5 kg from their EDW for more than 3 treatments in a row, the EDW should be discussed by the IDT and physician and adjusted as needed. Staff A was asked why the EDW was not adjusted for P-4. Staff A stated she was unsure how this patient had been missed and acknowledged the findings.”

“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: 47976 Based on record review and interview, the facility failed to deliver the prescribed dialysate flow rate (DFR) for 1 (P-3) of 5 records reviewed, resulting in the potential to impact the adequacy of dialysis for all 41 patients served by this facility. Findings include: **Policy titled “Patient Assessment and Monitoring” (published 5/1/23) revealed on page 6 that “During Treatment” under “Machine Parameters and Extracorporeal Circuit” to “Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” P-3: This 45-year-old patient was admitted to this dialysis facility on 1/17/24 with the diagnosis of end stage renal disease and was receiving dialysis treatments 3 times per week. During record review on 6/25/24, it was determined the dialysate flow rate (DFR) was ordered at 800 millimeters/minute (mL/min). Upon review of the last 6 treatment sheets, it was determined the DFR was run incorrectly as follows: On 3/22/24, the DFR was run at 600 mL/min for the entire treatment (from 1225 to1626 = 4 hours and 1 minute) There was no documentation regarding the reason the DFR was not met or being run as prescribed. The Facility Administrator (Staff A) was interviewed on 6/26/24 at 1115 regarding the expectation when a DFR is run differently from what was ordered. Staff A reported staff should be documenting a reason on the treatment sheet. Staff A was unable to provide documented evidence of why the DFR was run incorrectly on that day and acknowledged the findings.”