Ghs Western Regional Home Dialysis

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 15195 Based on Quality Assessment Performance Improvement (QAPI) record review and interview, the facility failed to document evaluation of data and implementation of actions plans for reducing peritoneal infections in patients for six of six months (8/15/23 through 1/23/24) of QAPI meeting minutes and data reviewed, resulting in the unsatisfactory outcomes for those peritoneal dialysis patients with infections. Findings include: On 2/27/24 at approximately 1430, phone interview with the Medical Director A revealed that reducing infections was a priority quality measure for improvement. On 2/27/24 at approximately 1530, review of six of six months (8/15/23 through 1/23/24) of QAPI meeting minutes and data with Home Dialysis Nurse B, revealed that peritoneal dialysis patients had at least one peritoneal related infection every month (except in the early December 7, 2023 data). The January 23, 2024 comments documented 12/20/23 infections “2 exit site infections ..(also) 1 tunneled catheter infection.” The rate of peritoneal infection had increased from 2.16 to 4.01 rate per 100 patient months. A comprehensive analysis of the increasing rate and action plans to decrease infections had not been documented in QAPI. This was verified by Home Dialysis Nurse B. On 2/27/24 at approximately 1600, review of the facility policy titled “Quality Assessment Performance Improvement (QAPI) Program, revised 5/18/23” documented “...Action plans are developed at the QAPI meeting as necessary.””

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 47415 Based on interview, and record review, the staff failed to keep accurate and complete medical records and adhere to policy and procedure regarding dialysate flow rate (DFR) orders being updated to meet hemodialysis machine (Tablo) specifications for 1 (P-1) of 2 home hemodialysis patients reviewed resulting in inaccurate medical records. Findings include: On 2/27/24 at 1430, Home Dialysis Nurse Staff B was queried in the facility office as to if there was a reason the dialysate flow rate (DFR) was not run as prescribed in physician treatment order (dated 12/26/23 - DFR was precribed at 800). Staff B stated the DFR on Tablo hemodialysis machines can only be set to maximum of 300 and drop down on medical record software may not go as low as 200. Staff B also stated that the prescription order (dated last changed on 12/12/23) may have been a carryover from an incenter-treatment. On 2/27/24 at 1445, record review of Tablo Hemodialysis System user manual (page 201) specifications revealed that dialysis flow range: 50 -300 milliliters/minute (mL/min). On 2/27/24 at 1500, review of the medical record revealed that P-1 in 8 of 8 treatment sheets dated (2/12/24, 2/13/24, 2/15/24, 2/16/24, 2/19/24, 2/20/24, 2/23/24, 2/26/24) revealed: Treatment sheet dated 2/12/14: DFR documented as running at 200 in the hemodialysis session data section of the flowsheet for the entire treatment session from 1904- 2217. Treatment sheet 2/13/24: DFR documented as running at 200 in the hemodialysis session data section of the flowsheet for the entire treatment session from 1553-1906. Treatment sheet 2/15/24: DFR documented as running at 200 in the hemodialysis session data section of the flowsheet for the entire treatment session from 1306-1619. Treatment sheet 2/16/24: DFR documented as running at 200 in the hemodialysis session data section of the flowsheet for the entire treatment session from 1553-1906. Treatment sheet 2/19/24: DFR documented as running at 200 in the hemodialysis session data section of the flowsheet for the entire treatment session from 1252-1604. Treatment sheet 2/20/24: DFR documented as running at 200 in the hemodialysis session data section of the flowsheet for the entire treatment session from 1721-2033. Treatment sheet 2/23/24: DFR documented as running at 200 in the hemodialysis session data section of the flowsheet for the entire treatment session from 1553-1906. Treatment sheet 2/26/24: DFR documented as running at 200 in the hemodialysis session data section of the flowsheet for the entire treatment session from 1239-15. No documentation found in the medical record as to why the treatments were set at a DFR other than what was prescribed. Policy titled, “Processing Physician/Advanced Practitioner Orders and all Progress notes, dated 5/2021 states: “Staff may only accept orders from a physician ...All physician orders are to be processed ...completing electronic medical record format appropriately ...Transient treatment and medication orders must be reviewed and approved by facility Medical Director/physician designee/APP prior to patient being treated ...””