Fmc - Raleigh Dialysis Clinic Inc.

“PR-INFORMED OF INTERNAL GRIEVANCE PROCESS CFR(s): 494.70(a)(14) The patient has the right to- (14) Be informed of the facility’s internal grievance process; This Standard is not met as evidenced by: 38766 Based on policy and procedure review, grievance log review, and staff interview the facility failed to recognize and respond to concerns for 2 of 6 grievances reviewed (Patients #9 & #13). The findings included: A review on 08/13/2024 of a policy titled “Patient Grievances” published 01/02/2024, revealed “... Responsibility: Nurse in Charge or Team Leader: Meeting with the patient/representative within 72 hours of being notified of a grievance... Clinical Manager (CM) ...Meeting with the patient/representative within 5 days to discuss the grievance, resolve it as quickly as possible, and provide periodic updates to the patient...” A review of the grievance log and reports on 08/13/2024 for the past twelve months revealed nine grievances. The review revealed a grievance was filed on 07/16/2024 by patient #9 related to issues with cannulating her access and machine breakdown. The review revealed no documentation of resolution, follow-up with the patient, or service recovery (closing of the grievance) was noted in the grievance. A review of a grievance was filed on 07/17/2024 by patient #13 related to issues with his estimated dry weight, medication administration, and treatment start time. The review revealed no resolution documentation, follow-up with the patient, or service recovery was noted in the grievance. An interview on 08/13/2024 with the SW revealed that the SW was responsible for following up with patients and documenting the service recovery after the clinic had resolved the grievance. The interview revealed with the FA being new, she did not know to report the grievances to the SW for follow-up and service recovery could be done. The interview confirmed that the staff failed to follow the policy.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 38766 Based on a review of policy and procedures, medical records review, and staff interviews, the facility staff failed to perform and or document every 30-45-minute monitoring of patients during dialysis treatments for 8 (eight) of 12 (twelve) in-patient records reviewed (Patient #1, #2, #5, #6, #7, #3, #8, and #10). Findings included: A review on 08/13/2024 of the facility’s policy and procedure, “Patient Assessment and Monitoring” published 05/01/2023, revealed “...During Treatment Obtaining 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 per state regulations...” 1. An open medical record review on 08/13/2024 for Patient #1 revealed an 80-year-old male was admitted to the facility for ICHD treatments on 05/21/2024. A review of the treatment sheet dated 07/23/2024 revealed the treatment started at 1155 and ended at 1608 (253 minutes). The treatment flowsheet revealed no documented vital signs from 1434 through 1609 (93 minutes). A review of the treatment flowsheet dated 08/05/2024 revealed the treatment started at 1235 and ended at 1438 (123 minutes). The treatment flowsheet revealed no documented vital signs from 1330 through 1553 (143 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 08/15/2024 at 1225 with PCT #3 revealed safety monitoring, including the patient’s vital signs, should be performed and documented at least every 30 minutes. The interview revealed that the new staff received education on ensuring that the patient’s vital signs data had crossed over into the patient’s medical record. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed that the staff was responsible for monitoring and documenting the patient’s blood pressure and pulse every 30 to 45 minutes or more frequently as needed. The interview confirmed that the staff did not follow the policy. 2. An open medical record review on 08/14/2024 for Patient #2 revealed a 78-year-old female admitted to the facility for ICHD treatments on 02/07/2022. A review of the treatment sheet dated 07/24/2024 revealed the treatment started at 1104 and ended at 1457 (237 minutes). The treatment flowsheet revealed no documented vital signs from 1300 through 1402 (62 minutes). A review of the treatment flowsheet dated 08/02/2024 revealed the treatment started at 1048 and ended at 1454 (245 minutes). The treatment flowsheet revealed no documented vital signs from 1057 through 1205 (68 minutes), and from 1335 through 1432 (57 minutes. A review of the treatment sheet dated 08/05/2024 revealed the treatment started at 1054 and ended at 1446 (232 minutes). The treatment flowsheet revealed no documented vital signs from 1107 through 1204 (57 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 08/15/2024 at 1225 with PCT #3 revealed safety monitoring, including the patient’s vital signs, should be performed and documented at least every 30 minutes. The interview revealed that the new staff received education on ensuring that the patient’s vital signs data had crossed over into the patient’s medical record. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed that the staff was responsible for monitoring and documenting the patient’s blood pressure and pulse every 30 to 45 minutes or more frequently as needed. The interview confirmed that the staff did not follow the policy. 3. An open medical record review on 08/14/2024 for Patient #5 revealed a 78-year-old female was admitted to the facility for ICHD treatments on 06/06/2024. A review of the treatment sheet dated 08/06/2024 revealed the treatment started at 0747 and ended at 1120 (210 minutes). The treatment flowsheet revealed no documented vital signs from 0933 through 1037 (66 minutes). A review of the treatment flowsheet dated 08/08/2024 revealed the treatment started at 0948 and ended at 1253 (186 minutes). The treatment flowsheet revealed no documented vital signs from 1049 through 1141 (52 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 08/15/2024 at 1225 with PCT #3 revealed safety monitoring, including the patient’s vital signs, should be performed and documented at least every 30 minutes. The interview revealed that the new staff received education on ensuring that the patient’s vital signs data had crossed over into the patient’s medical record. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed that the staff was responsible for monitoring and documenting the patient’s blood pressure and pulse every 30 to 45 minutes or more frequently as needed. The interview confirmed that the staff did not follow the policy. 4. An open medical record review on 08/14/2024 for Patient #6 revealed a 27-year-old female admitted to the facility for ICHD treatments on 06/01/2020. A review of the treatment sheet dated 07/25/2024 revealed the treatment started at 1243 and ended at 1647 (237 minutes). The treatment flowsheet revealed no documented vital signs from 1434 through 1534 (60 minutes). A review of the treatment flowsheet dated 07/27/2024 revealed the treatment started at 1257 and ended at 1642 (225 minutes). The treatment flowsheet revealed no documented vital signs from 1334 through 1430 (56 minutes). A review of the treatment sheet dated 08/03/2024 revealed the treatment started at 1240 and ended at 1645 (245 minutes). The treatment flowsheet revealed no documented vital signs from 1504 through 1605 (61 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 08/15/2024 at 1225 with PCT #3 revealed safety monitoring, including the patient’s vital signs, should be performed and documented at least every 30 minutes. The interview revealed that the new staff received education on ensuring that the patient’s vital signs data had crossed over into the patient’s medical record. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed that the staff was responsible for monitoring and documenting the patient’s blood pressure and pulse every 30 to 45 minutes or more frequently as needed. The interview confirmed that the staff did not follow the policy. 5. An open medical record review on 08/15/2024 for Patient #7 revealed a 42-year-old male was admitted to the facility for ICHD treatments on 02/20/2024. A review of the treatment sheet dated 07/27/2024 revealed the treatment started at 1306 and ended at 1640 (274 minutes). The treatment flowsheet revealed no documented vital signs from 1306 through 1408 (62 minutes). A review of the treatment flowsheet dated 08/03/2024 revealed the treatment started at 0605 and ended at 1016 (241 minutes). The treatment flowsheet revealed no documented vital signs from 0619 through 0716 (56 minutes). A review of the treatment sheet dated 08/06/2024 revealed the treatment started at 0813 and ended at 1123 (190 minutes). The treatment flowsheet revealed no documented vital signs from 1007 through 1100 (53 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 08/15/2024 at 1225 with PCT #3 revealed safety monitoring, including the patient’s vital signs, should be performed and documented at least every 30 minutes. The interview revealed that the new staff received education on ensuring that the patient’s vital signs data had crossed over into the patient’s medical record. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed that the staff was responsible for monitoring and documenting the patient’s blood pressure and pulse every 30 to 45 minutes or more frequently as needed. The interview confirmed that the staff did not follow the policy. 6. An open medical record review on 08/14/2024 for Patient #3 revealed a 53-year-old female was admitted to the facility for ICHD treatments on 05/30/2023. A review of the treatment sheet dated 07/25/2024 revealed the treatment started at 1241 and ended at 1609 (208 minutes). The treatment flowsheet revealed no documented vital signs from 1436 through 1539 (63 minutes). A review of the treatment flowsheet dated 07/27/2024 revealed the treatment started at 1239 and ended at 1623 (224 minutes). The treatment flowsheet revealed no documented vital signs from 1506 through 1603 (57 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 08/15/2024 at 1225 with PCT #3 revealed safety monitoring, including the patient’s vital signs, should be performed and documented at least every 30 minutes. The interview revealed that the new staff received education on ensuring that the patient’s vital signs data had crossed over into the patient’s medical record. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed that the staff was responsible for monitoring and documenting the patient’s blood pressure and pulse every 30 to 45 minutes or more frequently as needed. The interview confirmed that the staff did not follow the policy. 7. An open medical record review on 08/15/2024 for Patient #8 revealed a 77-year-old male was admitted to the facility for ICHD treatments on 02/05/2019. A review of the treatment sheet dated 07/26/2024 revealed the treatment started at 0625 and ended at 0926 (181 minutes). The treatment flowsheet revealed no documented vital signs from 0707 through 0803 (56 minutes). A review of the treatment flowsheet dated 08/03/2024 revealed the treatment started at 1158 and ended at 1510 (192 minutes). The treatment flowsheet revealed no documented vital signs from 1302 through 1403 (61 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 08/15/2024 at 1225 with PCT #3 revealed safety monitoring, including the patient’s vital signs, should be performed and documented at least every 30 minutes. The interview revealed that the new staff received education on ensuring that the patient’s vital signs data had crossed over into the patient’s medical record. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed that the staff was responsible for monitoring and documenting the patient’s blood pressure and pulse every 30 to 45 minutes or more frequently as needed. The interview confirmed that the staff did not follow the policy. 8. An open medical record review on 08/15/2024 for Patient #10 revealed a 63-year-old male was admitted to the facility for ICHD treatments on 07/02/2019. A review of the treatment sheet dated 08/10/2024 revealed the treatment started at 0704 and ended at 1047 (223 minutes). The treatment flowsheet revealed no documented vital signs from 0901 through 1006 (65 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 08/15/2024 at 1225 with PCT #3 revealed safety monitoring, including the patient’s vital signs, should be performed and documented at least every 30 minutes. The interview revealed that the new staff received education on ensuring that the patient’s vital signs data had crossed over into the patient’s medical record. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed that the staff was responsible for monitoring and documenting the patient’s blood pressure and pulse every 30 to 45 minutes or more frequently as needed. The interview confirmed that the staff did not follow the policy.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 38766 Based on policies and procedures review, medical records review, and staff interviews, the facility’s IDT members failed to identify a patient as unstable and perform a monthly reassessment or revision of the plan-of-care for 1 of 1 sampled patient after an extended hospitalization (Patient #2). Findings included A review on 08/14/2024 of the facility’s policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care” revised 07/03/2023 revealed “...CIA/POC for Unstable Patients Unstable patients must be reassessed by the IDT monthly. Monthly reassessment and any POC updates related to the reason the patient is considered ‘unstable’ must be documented until the issues have been resolved or the IDT (including the patient if possible) determines that the condition is chronic. The following are unstable criteria: a. Hospitalization of more than 15 days with discharge occurring within the last 30 days. ...” Medical record review on 08/14/2024 of Patient #2 revealed the patient was admitted to the facility on 02/07/2022 for in-center hemodialysis treatment. A review of the record revealed the patient was admitted to the hospital from 04/022024 through 04/22/2024 (20 days) with an admitting diagnosis of “coronary artery disease (CAD) and peripheral artery disease (PVD)” and a discharge diagnosis of “1. CAD 2. PAD 3. Bacteremia 4. Junctional Bradycardia...” The review revealed the patient’s previous plan of care was an annual plan of care on 02/28/2024 with documentation that the patient was “stable.” The review revealed no documentation that a monthly reassessment or revisions of the plan of care was done considering the patient as unstable by the IDT after the hospitalization. An interview on 08/14/2024 at 1515 with the Social Worker revealed that the clinic had a computer system to determine unstable patients based on frequent recurrences of hospitalization. The interview revealed that the Social worker did not know why patient #2 was not flagged by the computer system. The social worker expressed that she would ask the unit secretary to notify her when a patient was hospitalized to better track hospitalized patients. The algorithm did not recognize the extended hospital stays as unstable. An interview on 04/18/2024 at 1330 with the Charge Nurse revealed we (the clinic) had a computer system that identified unstable patients based on the number of hospitalizations in one month and length of hospital stay of 15 days or greater. The interviewer revealed, “I am not sure why we missed this one.””

“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: 38766 Based on policy review, medical record review, and staff interview, the facility staff failed to follow the adequacy plan of care by failing to dialyze patients at the prescribed treatment duration time and/or obtain a signed against medical advice (AMA) form for 2 of 12 (Patient #5, and #10) sampled in-center hemodialysis records. Findings included: A review on 08/14/2024 of the policy and procedure “Early Termination or Arriving Late for Treatment” revised 11/07/2022 revealed, “...Early termination ...The RN who evaluates the patient must document the rationale for early termination and reinforce the consequences of not receiving the entire prescribed treatment. The RN is responsible to... document on the ‘AMA’, or Against Medical Advice form...” 1. Medical record review on 08/14/2024 for Patient #5 revealed a 53-year-old female admitted to the facility for ICHD treatments on 05/30/2023. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for 240 minutes. The review of the treatment sheet dated 07/25/2024 revealed that the patient received dialysis for 204 minutes (32 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 07/27/2024 revealed that the patient received dialysis for 224 minutes (16 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 08/08/2024 revealed that the patient received dialysis for 184 minutes (56 minutes less than the prescribed 240 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 07/25/2024, 07/27/2024, and 08/08/2024. The review revealed no completed AMA form for early termination of the treatment on 07/25/2024, 07/27/2024, and 08/08/2024. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed early termination was considered any treatment less than the prescribed duration time. The interview revealed the expectation was that the staff would educate the patient on the risks of early termination of treatments and the benefits of getting the full prescribed treatment. The interview revealed that the staff would document the education in the patient’s medical record. The staff were expected to obtain a signed AMA form from the patients when treatments were terminated early. 2. Medical record review on 08/15/2024 for Patient #10 revealed a 63-year-old male admitted to the facility for ICHD treatments on 07/02/2019. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for 270 minutes. The review of the treatment sheet dated 08/03/2024 revealed that the patient received dialysis for 21 minutes (56 minutes less than the prescribed 270 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 08/03/2024. The review revealed no completed AMA form for early termination of the treatment on 08/03/2024. An interview on 08/15/2024 at 1410 with the Charge Nurse revealed early termination was considered any treatment less than the prescribed duration time. The interview revealed the expectation was that the staff would educate the patient on the risks of early termination of treatments and the benefits of getting the full prescribed treatment. The interview revealed that the staff would document the education in the patient’s medical record. The staff were expected to obtain a signed AMA form from the patients when treatments were terminated early. NC00207303”