Davita East Valley Dialysis

“CFC-MEDICAL RECORDS CFR(s): 494.170 This Condition is not met as evidenced by: 40945 Based on interview, and document review the facility did not follow orders for DNR/DNI (do-not resuscitate, do- not intubate) code status which resulted in the patient one (P1) receiving cardiopulmonary resuscitation (CPR), against his wishes, when he experienced a cardiac arrest event. The immediate jeopardy began on 9/30/24, when the facility failed to follow orders for DNR/DNI (do-not resuscitate, do- not intubate) code status which resulted in the patient one (P1) receiving cardiopulmonary resuscitation (CPR), against his wishes, when he experienced a cardiac arrest event. The facility administrator, and manager of clinical services were notified of the immediate jeopardy on 11/19/24 at 4:48 p.m. The immediate jeopardy was removed on 11/20/24 at 2:48 p.m., but non-compliance remained at the CONDITION LEVEL. Findings Include: P1 was admitted to dialysis on 3/6/23, with diagnoses of end stage renal dialysis (ESRD), chronic kidney disease (CKD), and heart failure. Review of the undated dialysis care plan, and physician orders documented in the facility’s medical record at the time of P1’s cardiac event on 9/30/24 indicated P1 was a Full Code. Review of the Patient Discharge summary identified on 9/6/24, P1 returned from a 3-day hospital stay. The Pt discharge summary and which included medication changes, indicated P1’s code status as No CPR- Do NOT intubate. The discharge summary revealed on 9/6/24, nursing staff had reviewed and implemented medication changes. There was no evidence to support staff accurately reconciled all information/orders noted in the hospital discharge summary or alerted the attending physician to a discrepancy of code status against the current Full Codes status the facility had recordered in the medical record. P1’s progress notes identified on 9/30/24, at approximately 12:57 p.m. P1 became unresponsive at the end of dialysis treatment. No blood pressure (B/P) was found, 1500 milliliters (mL) saline was given, and CPR was initiated. 911 was called and emergency medical services (EMS) responded at approximately 1:04 p.m.. EMS took over life sustaining measures. P1 was transferred to the local emergency department (ED). P1 expired on 10/1/24. P1 died on 10/1/24, after life sustaining measures were discontinued on 9/30/24, per P1’s wishes and advanced directives. During an interview on 11/18/24, at 12:43 p.m. P1’s family member (FM)-A stated P1 was a DNR/DNI at the time of his facility admission on 3/6/23. FM-A stated when she arrived to pick up P1 from dialysis on 9/30/24, she saw EMS onsite. FM-A stated dialysis staff told her it was P1 in the ambulance and that P1 had coded (been provided CPR). FM-A stated staff had indicated they had used the automated external defibrillator (AED) and shocked P1. FM-A stated when she arrived at the ED she told staff he had an advance directive of DNR/DNI and they stopped treatment. P1 passed the next day. FM-A further stated P1’s nephrologist and facility medical doctor (MD)-A called her a few days after P1 had passed away and indicated he was not aware of P1’s code status and that he should have been aware of P1’s wishes to be DNR/DNI. FM-A also stated P1 had been a DNR-DNI for years and had an Advanced Directives Plan which indicated his wishes and noted the facility should have had this on file for him. During an interview on 11/19/24, at 10:28 a.m. registered nurse (RN)-A stated it was important to go thru all patient’s paperwork from clinics and hospitals to ensure all current active orders and any changes in patients’ status are identified. RN-A verified she had processed P1’s orders following his hospital stay on 9/6/24. RN-A stated she did not notice in the discharge summary P1’s wishes were to be a DNR/DNI but should have. RN-A stated it was important for patient’s wishes to be honored, and life sustaining measures should not have been implemented for P1. RN-A stated in the event of a cardiac emergency, nursing staff are instructed to verify code status in the computer-CWOW (Center Without Walls), and the red Code Status binder located on the unit. During an interview on 11/19/24, at 3:01 p.m. RN-B (nurse on duty the day of incident) identified during P1’s emergency, staff did not verify code status in the electronic medical record as they are “familiar with patients”. RN-B stated prior to initiating CPR the policy and procedure directs nursing staff to verify the patients code status prior to initiating CPR. When staff were notified P1 was a DNR by FM-A, they did review their medical record. The medical record remained unchanged and was listed as Full Code as staff failed to clarify and update the facility medical record when the Hospital discharge orders denoted a change in code status to DNR. During an interview on 11/19/24, at 11:24 a.m. facility social worker (SW)-A stated part of her responsibilities is educating patients on advanced directives to ensure their wishes are being honored. SW-A stated P1 had indicated to her he had an Advanced Care Plan but that P1 had never brought it in. SW-A stated she had not asked P1 additional questions about the Advanced Care Plan, nor did she get clarification if it included wishes to be DNR/DNI. SW-A stated the accuracy of a patient’s Code Status was important to ensure patient’s wishes are followed in the event of an emergency. SW-A reviewed P1’s hospital discharge paperwork dated 9/6/24, which indicated P1 was DNR-No CPR. SW-A stated had she been made aware of this change in code status, she would have gone to the medical provider to have this addressed. During an interview on 11/19/24, at 10:42 a.m. medical doctor (MD)-A stated he had no knowledge until after the event that P1’s wishes were to be a DNR/DNI and had he known otherwise, he would have completed a new POLST and visited with P1 regarding his wishes. MD-A stated this was a failure and weakness in the system and CPR and life sustaining measures should not have been initiated for P1. MD-A verified in P1’s discharge summary from his hospital stay from 9/4/24, thru 9/6/24, clearly indicated P1’s code status as a DNR-NO CPR. MD-A further stated P1’s code status of No CPR- Do NOT intubate should have been identified not only by the facilities nursing staff at the time they had received the hospital discharge orders, but also himself. During an interview on 11/19/24, at 11:24 a.m. facility administrator (FA)-A verified RN-A had processed P1’s hospital orders on 9/6/24, which indicated P1 was to be a DNR/DNI. FA-A stated RN-A should have seen that P1 was a DNR/DNI, but she did not. FA-A stated P1’s change in code status was missed and because of this, life sustaining measures were implemented. FA-A stated at the time of the event P1 was still listed as a Full Code. FA-A stated CPR was initiated because the facility failed to identify the DNR status and clarify the order which noted the change. The facility policy titled Advance Directives and DNR Policy, revision date 10/2023, directed staff to inform patients of their right to have Advance Directives, the DaVita policy regarding Advance Directives and that Advance Directives will be honored at DaVita facilities. Further, this policy will establish a process for validating and implementing a Health Care Proxy and/or a Do-Not-Resuscitate (DNR) Order. The facility policy titled Physician Orders for Patient Care, revision date 10/2024, directed staff to verify that all orders are properly documented, transcribed, verified, and implemented in a timely manner for patient care in DaVita facilities and hospital programs which meet all DaVita, Federal and applicable State regulations. The immediate jeopardy that began on 9/30/24, was removed on 11/20/24 at 2:48 p.m., when the facility re- reviewed all current patient’s orders to ensure their wishes for code status are accurately reflected and required documentation is in place, and re-educated all nurses and patient care technicians (PCT’s) regarding facility policies and procedures related to Code status/CPR policies. This was verified thru interviews and review of facility documentation.”