Davita South Charlotte Dialysis

“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: 35306 Based on policy review, medical record review, and staff interviews, the facility staff failed to implement the plan of care for management of bradycardia, hypertension, or hypotension in 4 of 5 (Patients #2, #3, #5, and #6) in-center patients experiencing bradycardia, hypertension, or hypotension during and post hemodialysis treatment. Findings include: Review on 10/22/2024 of the facility’s policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING, AND NURSING ASSESSMENT”, last revised 04/2024, revealed “. . . PRE-TREATMENT DATA COLLECTION/ASSESSMENT 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported.... the nurse will assess the patient prior to the initiation of dialysis... 6... The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis... INTRADIALYTIC DATA COLLECTION/ASSESSMENT... 11. Abnormal findings.... will be reported to the licensed nurse immediately... 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in the patient’s status. 13. All findings, interventions and patient response will be documented in the patient’s medical record... ABNORMAL FINDINGS .... Blood pressure: Pre-Dialysis: * Systolic greater than 180 mm/Hg or less than 90 mm/Hg * Diastolic greater than or equal to 100....or less than 50 ... Blood pressure-Intradialytic: * Systolic greater than 180....or less than 90 ... * Diastolic greater than or equal to 100....or less than 50 ... Blood Pressure Post Treatment ...* Standing systolic BP greater than 140....or less than 90 ... * Standing diastolic BP greater than 90....or less than 50 ...Sitting systolic BP greater than 140....or less than 90... * Sitting diastolic BP greater than 90....or less than 50... Heart or Pulse Rate Pre/Intra/Post: * Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat...” Review on 10/22/2024 of the facility’s policy titled, “HYPOTENSION”, last revised 10/2023, revealed “... Procedure 1. Take vital signs. Place patient in a flat supine position. 2. Decrease ultrafiltration rate (UFR) or turn off UFR depending on patient’s condition. 3. Administer normal saline bolus of 100-200 mL for severe hypotensive symptoms. Patient care technicians may give up to 200 mL and will inform licensed nurse of intervention... For less severe signs of hypotension give oral fluids... 5. Continue monitoring blood pressure. If blood pressure stabilizes, evaluate Target Weight and adjust UF as determined by patient’s condition. 6. If patient continues to show signs and symptoms of hypotension, the licensed nurse will notify physician and follow physician’s orders...” Review on 10/22/2024 of the facility’s “Physician’s Standing Orders as of 4/27/2024” revealed, “1. 100ml NS [normal saline] IV PRN [as needed] cramping, hypotension, N/V [nausea/vomiting], SOB [shortness of breath], Angina [chest pain]. NS not to exceed 500ml. If any of the following is unrelieved, notify MD... 33. Hypotension: Notify MD if BP <90/40 prior to discharging pt ...Hypertension: Clonidine 0.1mg: 1 tab PO for systolic BP > 180 or Diastolic BP >100. May repeat x1 if BP doesn’t improve in 30 minutes. Clonidine 0.1mg: 2 tabs PO for systolic BP > 220 or Diastolic > 110 x1. Call MD if BP does not improve after 60 minutes. Only initiate treatment is patient is ASYMPTOMATIC; if patient(s); if patient(s) [sic] is SYMPTOMATIC, MD is to be notified immediately...” 1. Medical record review for Patient #2 on 10/23/2024 revealed the patient was admitted to the facility on 06/12/2018 for ICHD. Review of the “Treatment Details Report” dated 10/18/2024 revealed the patient received hemodialysis from 0611-0924 (3 hours and 13 minutes). Documentation review revealed the patient was placed on hemodialysis treatment by PCT #1 at 0612. Review of the treatment data revealed at 0612: HR 45 (bradycardia); at 0631: HR 47 (bradycardia); at 0701: HR 50 (bradycardia) documented by the PCT; at 0808: HR 43 (bradycardia) documented by PCT #2; and at 0901: HR 47 (bradycardia) documented by PCT #3. Further review of post-treatment vital signs revealed at 1024: HR 66 sitting and HR 44 (bradycardia) standing. Record review failed to reveal documented nursing notification of intradialytic and post-treatment bradycardia by the PCTs. Further review revealed no nursing assessment of the patient’s bradycardia episodes during hemodialysis treatment by RN #3 on 10/18/2024. Review of the “Treatment Details Report” dated 10/16/2024 revealed the patient received dialysis from 0620-0956 for a total of 3 hours and 36 minutes. Review of the treatment data revealed the patient was placed on hemodialysis treatment by PCT #3 at 0621. Review of the treatment data revealed at 0621: HR 46 (bradycardia); at 0622: HR 56 (bradycardia); at 0631: HR 48 (bradycardia); at 0731: HR 58 (bradycardia); and at 0831: HR 57 (bradycardia) documented by the PCT. Record review failed to reveal documented nursing notification of intradialytic bradycardia episodes by the PCTs. Further review revealed no nursing assessment of the patient’s bradycardia episodes during hemodialysis treatment by RN #1 on 10/18/2024. Review of the “Treatment Details Report” dated 10/14/2024 revealed the patient received hemodialysis from 0610-0939 (3 hours and 29 minutes). Documentation review revealed the patient was placed on hemodialysis by PCT #4 at 0611. Review of the treatment data revealed at 0631: HR 49 (bradycardia); at 0801: HR 51(bradycardia); at 0831: HR 40 (bradycardia) documented by the PCT; at 0901: HR 48 (bradycardia) documented by PCT #1; and 0931: HR 48 (bradycardia) documented by PCT #4. Record review failed to reveal documented nursing notification of intradialytic bradycardia episodes by the PCTs. Further review revealed no nursing assessment of the patient’s bradycardia episodes during hemodialysis treatment by RN #3 on 10/14/2024. Interview on 10/23/2024 at 1540 with the facility’s Clinical Coordinator revealed the facility defines bradycardia as any heart rate less than 60 beats per minute. When the patient experiences bradycardia, the PCT should notify the RN. The PCT should recheck the heart rate to verify the low HR. If the HR is low and the patient is asymptomatic, the staff are to monitor the patient and vital signs more frequently. The RN should assess the patient whenever there are abnormal findings, document the assessment, and notify the provider as needed. Education on abnormal findings, with policy review, occurred on 4/16/2024, 4/18/2024, and 8/23/2024 and on the facility’s standing orders following implementation on 04/27/2024. The Clinical Coordinator would have expected the RN to be notified when the HR was persistently less than 60 beats per minute. Interview on 10/24/2024 at 1030 with the facility’s Medical Director revealed the facility had set parameters for patient vital signs and standing orders to address outliers. If the patient doesn’t meet those parameters for whatever reason, the PCT should notify the RN. The RN should assess the patient, follow facility policy and standing orders, and notify the provider as needed. Interview on 10/24/2024 at 1415 with PCT #1 revealed she was the assigned PCT for Patient #2 on 10/18/2024. When a patient’s heart rate less than 60, it should be rechecked to ensure accuracy, reported to the RN, and documented in the medical record. Following review of the “Treatment Details Report” for 10/18/2024, PCT #1 confirmed there was no documented nursing notification of intradialytic and post-treatment bradycardia by the PCTs. “We tell them but forget to document it in the medical record.” Interview on 10/24/2024 at 1500 with the Facility Administrator revealed RN #3 was not available for interview. 2. Medical record review for Patient #5 on 10/22/2024 revealed the patient was admitted to the facility on 10/30/1967 with for ICHD. Review of the “Treatment Details Report” dated 10/18/2024 revealed the patient received hemodialysis from 0556-0946 (3 hours and 50 minutes). Documentation review revealed the patient was placed on hemodialysis treatment by PCT #1 at 0556. Review of the treatment data revealed at 0557: BP 114/69 (normotensive); at 0600: BP 103/70 (normotensive); at 0630: BP 100/71; at 0702: BP 98/64; and at 0730: BP 89/55 (hypotensive), with “uf off; bp drop; rn notified” documented by the PCT. Further review revealed at 0808: BP 117/70 (normotensive), with “turned uf back on” documented by PCT #2; at 0830: BP 119/81(normotensive); at 0908: BP 100/70 (normotensive), with “Patient reports nausea; Zofran administered; Patient requested to leave UF on” documented by RN #3. Further review revealed at 0938: BP 87/57 (hypotensive) with “Patient blood pressure low; UF turned off for remainder of tx due to bp trending down” documented by RN #2. Treatment was terminated at 0946 with a BP of 105/77 documented by PCT #2. Record review revealed patient care staff failed to administer NS bolus of 100-200 mL or provide oral fluids and failed to notify the physician per physician’s standing orders and the facility’s Hypotension policy. Interview on 10/23/2024 at 1540 with the facility’s Clinical Coordinator revealed the facility defines hypotension as any BP under 90/50. When the patient experiences hypotension, the PCT should notify the RN. The PCT should recheck the BP to verify the low BP. If the BP is low and the patient is asymptomatic, the staff are to monitor the patient and vital signs more frequently. The RN should assess the patient whenever there are abnormal findings, document the assessment, and notify the provider as needed, which should have occurred in this case, due to the patient’s complaint of nausea and Normal Saline or oral fluids should have been provided per the policy and facility standing orders. Education on abnormal findings, with policy review, occurred on 4/16/2024, 4/18/2024, and 8/23/2024 and on the facility’s standing orders following implementation on 04/27/2024. The Clinical Coordinator would have expected the nursing staff to follow the facility’s Hypotension policy and standing orders. Interview on 10/24/2024 at 1030 with the facility’s Medical Director revealed the facility had set parameters for patient vital signs and standing orders to address outliers. If the patient doesn’t meet those parameters for whatever reason, the PCT should notify the RN. The RN should assess the patient, follow facility policy and standing orders, and notify the provider as needed. Interview on 10/24/2024 at 1415 with PCT #1 revealed she was the assigned PCT for Patient #5 on 10/18/2024. When a patient’s BP is less than 90/50, it should be rechecked to ensure accuracy, reported to the RN, and documented in the medical record. Following review of the “Treatment Details Reports” for 10/18/2024, PCT #1 confirmed there was no documented nursing notification of intradialytic hypotension by the PCTs. “We tell them but get busy and forget to document is in the medical record. Interview on 10/24/2024 at 1415 with PCT #1 revealed she was the assigned PCT for Patient #2 on 10/18/2024. When a patient’s heart rate less than 60, it should be rechecked to ensure accuracy, reported to the RN, and documented in the medical record. Following review of the “Treatment Details Report” for 10/18/2024, PCT #1 confirmed there was no documented nursing notification of intradialytic and post-treatment bradycardia by the PCTs. “We tell them but get busy and forget to document it in the medical record.” Interview on 10/24/2024 at 1500 with the Facility Administrator revealed RN #3 was not available for interview. 3. Medical record review for Patient #3 on 10/22/2024 revealed the patient was admitted to the facility on 09/17/2024 for ICHD. Review of the patient’s treatment orders revealed an order for Clonidine 0.1mg oral every hour as needed on 10/05/2024 by MD #1. Review of the “Treatment Details Report” dated 10/17/2024 revealed the patient received hemodialysis treatment from 0659-1107 (4 hours and 11 minutes). Documentation review revealed the patient was placed on hemodialysis treatment by PCT #3 at 0659. Further review revealed the patient’s pre-treatment BPs at 0645 were 188/113 (hypertensive) standing and 199/104 (hypertensive) sitting. Review of the treatment data revealed at 0702: BP 171/101 (hypertensive); at 0732: BP 193/119 (hypertensive); at 0802: BP 194/120 (hypertensive); at 0832: BP 173/100 (hypertensive) documented by the PCT. At 0834, “bp monitored; nurse aware” was documented by the PCT. Review of subsequent documented BP readings revealed at 0902: BP 150/83 (normotensive); at 0932: BP 165/96 (normotensive); at 1002: BP 146/80 (normotensive). Further review of the treatment data revealed at 1032, the patient’s BP reading was documented as 161/102 (hypertensive) by the PCT. The patient’s post-hemodialysis BP was 166/83 (normotensive) sitting and 132/66 (normotensive) standing. Record review failed to reveal any available documentation of a nursing assessment by RN #2 of the patient’s intradialytic hypertension or post-hemodialysis treatment. Further review revealed no available documented justification for failure to administer Clonidine 0.1mg as needed for SBP > 180 or DBP > 100 or MD notification by RN #2 per physician’s standing orders and facility policy on 10/17/2024. Review of the “Treatment Details Report” dated 10/15/2024 revealed the patient received hemodialysis from 0718-1122 (4 hours and 04 minutes). Documentation review revealed the patient was placed on hemodialysis by PCT #1 at 0720. Further review revealed the patient’s pre-treatment BPs at 0708 were 174/102 (hypertensive) standing and 197/109 (hypertensive) sitting. Review of the treatment data review revealed at 0720: BP 150/76 (normotensive); at 0732: BP 175/100 (hypertensive); at 0802: BP 186/136 (hypertensive), with “recheck bp” documented; at 0803: BP 161/121 (hypertensive), with “rise in bp noticed; rn notified” documented; at 0832: BP 188/120 (hypertensive), with “BP high; RN is aware; pt stable” documented by PCT #5; at 0902: 157/132 (hypertensive), with “recheck bp” documented by PCT #1; at 0905: BP 160/82, with “bp improving” documented by the PCT; at 0932: BP 184/125 (hypertensive), with “recheck BP” documented by the PCT; at 0933: BP 195/118 (hypertensive), with “bp elevated alert” documented by the PCT; at 1002: BP 195/105 (hypertensive); at 1032: BP 188/102 (hypertensive); at 1102: BP 138/119 (hypertensive); and at 1120: BP 167/104 (hypertensive). Review of the patient’s post-treatment vital signs at 1129 revealed BP 167/104 (hypertensive) sitting and 166/53 standing. Record review failed to reveal any available documentation of a nursing assessment of patent’s intradialytic and post-treatment hypertension. Further review revealed no available documented justification for failure to administer Clonidine 0.1mg as needed for SBP > 180 or DBP > 100 or MD notification by RN #2 per physician’s standing orders and the facility’s policy on 10/15/2024. Review of the “Treatment Details Report” dated 10/12/2024 revealed the patient received hemodialysis from 0654-1054 (4 hours and 00 minutes). Documentation review revealed the patient was placed on hemodialysis by PCT #3 at 0655. Review of the patient’s pre-hemodialysis vital signs revealed at 0643: BP 195/104 (hypertensive) standing and BP 186/113 (hypertensive) sitting. Review of the treatment data revealed at 0655: BP 156/75 (normotensive); at 0702: BP 193/111 (hypertensive), at 0703: BP 190/98; at 0732: BP 195/102 (hypertensive); at 0737: BP 197/100 (hypertensive), with “bp elevated; nurse informed” documented by the PCT; at 0802: BP 174/104 (hypertensive); at 0832: BP 178/87. Review of the patient’s post-hemodialysis vital signs at 1055 revealed BP 169/104 (hypertensive) sitting and BP 125/86 (normotensive) standing. Record review failed to reveal any available documentation of a nursing assessment of the patient’s intradialytic hypertension. Further review revealed no available documented justification for failure to administer Clonidine 0.1mg as needed for SBP > 180 or DBP > 100 or MD notification by RN #2 per physician’s standing orders and facility policy on 10/12/2024. Interview on 10/23/2024 at 1540 with the facility’s Clinical Coordinator revealed the facility defines hypertension as any BP greater than 180/100 pre-dialysis and intradialytic and any BP greater than 140/90 post-treatment. When the patient experiences hypertension, the PCT should notify the RN. The PCT should recheck the BP to verify the high BP. If the BP is high and the patient is asymptomatic, the staff are to monitor the patient and vital signs more frequently. If there are orders for Clonidine, which in this case, there was, I would expect to see documentation indicating the reason the Clonidine was not administered. The RN should assess the patient whenever there are abnormal findings, document the assessment, and notify the provider as needed. Education on abnormal findings, with policy review, occurred on 4/16/2024, 4/18/2024, and 8/23/2024 and on the facility’s standing orders following implementation on 04/27/2024. The Clinical Coordinator would have expected the nursing staff to follow the facility’s Clonidine standing orders and to notify the provider, as indicated. Interview on 10/24/2024 at 1030 with the facility’s Medical Director revealed the facility had set parameters for patient vital signs and standing orders to address outliers. If the patient doesn’t meet those parameters for whatever reason, the PCT should notify the RN. The RN should assess the patient, follow facility policy and standing orders, and notify the provider as needed. “The staff do a very good job letting us know when patients experience abnormal findings but I was not aware we failed to follow the Clonidine standing order for this patient. We can do better with our communication.” Interview on 10/24/2024 at 1315 with PCT #7 revealed he was the assigned PCT for Patient #3 on 10/15/2024 and 10/17/2024. When a patient’s systolic is greater than 190, it should be rechecked. Once verified, the RN is supposed to give Clonidine before hemodialysis treatment is initiated. Following review of the “Treatment Details Report” for 10/15/2024 and 10/17/2024, PCT #5 confirmed there was no documented nursing notification of intradialytic and post-treatment hypertension by the PCTs. RN notification of any abnormal findings “should be documented but, I’m just going to be honest; I don’t always document when I tell the nurse something off with the patient. I will do better.” Interview on 10/24/2024 at 1340 with RN #2 revealed she was the assigned RN for Patient #3 on 10/12/2024, 10/15/2024, and 10/17/2024. The facility defines hypertension as any BP greater than 180/100. When an abnormal BP occurs, the BP cuff should be readjusted and reevaluated. PCTs notify the nursing staff and we assess the patients but we can do a better job documenting our assessments during treatment. We get busy and forget to go back in and document the assessment. Clonidine should have been given or there should at least be documentation indicating why it wasn’t. We should ask the patient if they want Clonidine and document accordingly.” 4. Medical record review for Patient #6 on 10/22/2024 revealed the patient was admitted to the facility on 11/01/2007 for ICHD. Review of the patient’s treatment orders revealed an order for Clonidine 0.1mg oral every hour as needed on 5/15/2023 by MD #1. Review of the “Treatment Details Report” dated 10/19/2024 revealed the patient received dialysis from 0657-1101 (4 hours and 04 minutes). Documentation review revealed the patient was placed on hemodialysis treatment by PCT #7 at 0659. Review of the treatment data revealed a pre-treatment BP of “200/135” (hypertension) standing and “182/125” (hypertension) sitting at 0641. Further review revealed at 0659: BP 169/128 (hypertension); at 0731: BP 170/119 (hypertension); at 0801: BP 169/106 (hypertension); at 0831: BP 153/100 (hypertension); at 0901: BP 156/101(hypertension); at 0931: BP 164/113 (hypertension); at 1001: BP 161/106 (hypertension); at 1031: BP 165/115 (hypertension); at 1033: BP 95/85; and at 1101: BP 172/108 (hypertension). Record review failed to reveal documented RN notification of the patient’s intradialytic hypertensive episodes by the PCT or an intradialytic nursing assessment by RN #4. Further review revealed no available documented justification for failure to administer Clonidine 0.1mg as needed for SBP > 180 or DBP > 100 or MD notification by RN #2 per physician’s standing orders and facility policy on 10/19/2024. Review of the “Treatment Details Report” dated 10/17/2024 revealed the patient received treatment from 0713-1126 (4 hours and 15 minutes). Documentation review revealed the patient was placed on hemodialysis treatment by PCT #8 at 0713. Review of the treatment data revealed a pre-treatment BP of “205/125” (hypertension) standing and “180/118” (hypertension) sitting at 0704 documented by the PCT. Further review revealed at 0713: BP 182/119 (hypertensive); at 0731: BP 185/121 (hypertensive); at 0801: BP 175/104 (hypertensive); at 0831: BP 167/102 (hypertensive); at 0901: BP 163/98 (hypertensive); at 0931: BP 171/100 (hypertensive); at 1002: BP 178/104 (hypertensive); at 1031: BP 169/117 (hypertensive); at 1034: BP 168/111 (hypertensive); at 1101: BP 172/110 (hypertensive); and at 1124: BP 181/128 (hypertensive), with a note at 1232 (1 hr, 8 minutes) post-treatment by RN #2 stating, “Patient blood pressure is elevated; Patient is asymptomatic with each event.” Review failed to reveal documentation of RN notification of the patient’s hypertensive episodes by the PCT and RN assessment of the patient’s intradialytic hypertension. Further review revealed no available documented justification for failure to administer Clonidine 0.1mg as needed for SBP > 180 or DBP > 100 or MD notification by RN #2 per physician’s standing orders and facility policy on 10/17/2024. Review of the “Treatment Details Report” dated 10/15/2024 revealed the patient received treatment from 0656-1110 (4 hours and 14 minutes). Documentation review revealed the patient was placed on hemodialysis by PCT #7 at 0656. Review of treatment data revealed a pre-treatment BP of 198/128 (hypertension) standing and 183/119 (hypertension) sitting at 0644 documented by the PCT. Further review revealed at 0656: BP 173/113 (hypertension); at 0701: BP 183/121 (hypertension), with “Patient blood pressure is elevated; Patient is asymptomatic and states she feels fine.” documented by RN #2. Further review revealed at 0731: BP 181/127 (hypertension); at 0801: BP 171/101 (hypertension); at 0831: BP 159/102 (hypertension); at 0901: BP 144/85 (normotensive); at 0931: BP 170/105 (hypertension); at 1001: BP 179/108 (hypertension); at 1031: BP 166/109 (hypertension); and at 1101: BP 177/111 (hypertension). Record review failed to reveal documented RN notification of the patient’s intradialytic hypertensive episodes by the PCT and a documented nursing assessment of the patient’s continued intradialytic hypertension after 0731 by RN #2. Further review revealed no available documented justification for failure to administer Clonidine 0.1mg as needed for SBP > 180 or DBP > 100 or MD notification by RN #2 per physician’s standing orders and facility policy on 10/15/2024. Review of the “Treatment Details Report” dated 10/12/2024 revealed the patient received dialysis from 0656-1107 (4 hours and 11 minutes). Documentation review revealed the patient was placed on hemodialysis by PCT #10 at 0657. Review of the pre-treatment nursing assessment by RN #2 at 0651 revealed, “Oxygen in Use: O2 L / min; Shortness of Breath.” Review of the treatment data revealed a pre-treatment BP of 197/118 (hypertension) and HR 103 (tachycardia) standing and 187/116 (hypertension) and HR 100 (tachycardia) at 0634 documented by PCT #10. Further review revealed at 0657: BP 178/125 (hypertension); at 0701: BP 180/118 (hypertension); at 0731: BP 180/107 (hypertension); at 0801: BP 174/99; at 0831: BP 173/106 (hypertension); at 0901: BP 170/105 (hypertension); at 0931: BP 168/100 (hypertension); at 1001: BP 170/109 (hypertension); at 1031: BP 179/116 (hypertension); and at 1101: BP 181/119 (hypertension). Review of post-treatment vital signs at 1110 revealed BP: 178/115 (hypertension) sitting and BP: 180/108 (hypertension) standing. Review failed to reveal documentation of RN notification of the patient’s intradialytic hypertensive episodes by the PCT and a nursing assessment of the patient’s hypertension during hemodialysis treatment by RN #2. Further review revealed no available documented justification for failure to administer Clonidine 0.1mg as needed for SBP > 180 or DBP > 100 or MD notification by RN #2 per physician’s standing orders and facility policy on 10/15/2024. Interview on 10/23/2024 at 1540 with the facility’s Clinical Coordinator revealed the facility defines hypertension as any BP greater than 180/100 pre-dialysis and intradialytic and any BP greater than 140/90 post-treatment. When the patient experiences hypertension, the PCT should notify the RN. The PCT should recheck the BP to verify the high BP. If the BP is high and the patient is asymptomatic, the staff are to monitor the patient and vital signs more frequently. If there are orders for Clonidine, which in this case, there was, I would expect to see documentation indicating the reason the Clonidine was not administered. The RN should assess the patient whenever there are abnormal findings, document the assessment, and notify the provider as needed, which should have occurred on 10/12/2024 given the patient’s complaint of shortness of breath. Education on abnormal findings, with policy review, occurred on 4/16/2024, 4/18/2024, and 8/23/2024 and on the facility’s standing orders following implementation on 04/27/2024. The Clinical Coordinator would have expected the nursing staff to follow the facility’s Clonidine standing orders and to notify the provider, as indicated. Interview on 10/24/2024 at 1030 with the facility’s Medical Director revealed the facility had set parameters for patient vital signs and standing orders to address outliers. If the patient doesn’t meet those parameters for whatever reason, the PCT should notify the RN. The RN should assess the patient, follow facility policy and standing orders, and notify the provider as needed. “The staff do a very good job letting us know when patients experience abnormal findings but I was not aware we failed to follow the Clonidine standing order for this patient. We can do better with our communication.” Interview on 10/24/2024 at 1315 with PCT #7 revealed he was the assigned PCT for Patient #3 on 10/15/2024 and 10/17/2024. When a patient’s systolic is greater than 190, it should be rechecked. Once verified, the RN is supposed to give Clonidine before hemodialysis treatment is initiated. Following review of the “Treatment Details Report” for 10/15/2024 and 10/17/2024, PCT #5 confirmed there was no documented nursing notification of intradialytic and post-treatment hypertension by the PCTs. RN notification of any abnormal findings “should be documented but, I’m just going to be honest; I don’t always document when I tell the nurse something off with the patient. I will do better.” Interview on 10/24/2024 at 1340 with RN #2 revealed she was the assigned RN for Patient #3 on 10/12/2024, 10/15/2024, and 10/17/2024. The facility defines hypertension as any BP greater than 180/100. When an abnormal BP occurs, the BP cuff should be readjusted and reevaluated. PCTs notify the nursing staff and we assess the patients but we can do a better job documenting our assessments during treatment. We get busy and forget to go back in and document the assessment. Clonidine should have been given or there should at least be documentation indicating why it wasn’t. We should ask the patient if they want Clonidine and document accordingly.” Interview on 10/24/2024 at 1500 with the Facility Administrator revealed RN #4 was not available for interview.”

“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: 35306 Based on policy and procedure review, medical record review, and staff interview, the patient care staff failed to ensure the physician’s dialysis BFR prescription was followed for 1of 5 sampled ICHD record reviews (Patient #2). Findings include: Review on 11/01/2018 of the facility policy, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT,” (Policy: 1-03-08, revised April 2017), revealed “...3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment... Prescription components include but are not necessarily limited to...f. Blood flow rate g. Dialysate flow rate... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed...” Medical record review for Patient #2 on 10/23/2024 revealed the patient was admitted to the facility on 06/12/2018 for ICHD. Review of the patient’s treatment orders revealed a BFR of “450” was prescribed 10/09/2024 by MD #1. Review of the “Treatment Details Report” dated 10/15/2024 revealed the patient received dialysis from 0640-0941 (3 hours and 01 minute). Documentation review revealed the patient was placed on hemodialysis by PCT #5 at 0641. Treatment data review revealed at 0902, the BFR was lowered to 400 (50 less than prescribed) with no documented justification for the decreased rate. Review of the “Treatment Details Report” dated 10/18/2024 revealed the patient received dialysis from 0611-0924 (3 hours and 13 minutes). Documentation review revealed the patient was placed on hemodialysis by PCT #1 at 0612. Treatment data review revealed at 0731, the BFR was lowered to 400 (50 less than prescribed) and at 0808, the BFR was lowered to 350 (100 less than prescribed) with no documented justification for the decreased rate. Interview on 10/23/2024 at 1540 with the facility’s Clinical Coordinator revealed staff were expected to document the reason why the BFR was lowered. Interview on 10/24/2024 at 1030 with the facility’s Medical Director revealed the expectation was for staff to document the reason why patients are unable to achieve ordered parameters. Interview on 10/24/2024 at 1410 with PCT #5 revealed she was the assigned PCT for Patient #2 on 10/15/2024. Staff should notify the nurse and document the reason for changing the BFR, including the issue leading to the needed change. “Sometimes when we go on break, they [relieving PCT] change it [BFR], don’t document the reason for the change, and we miss it until the next check.” In review of the “Treatment Details Report” dated 10/15/2024, PCT #5 confirmed there was no documented justification available for review for the decreased BFR rate at 0902. Interview on 10/24/2024 at 1415 with PCT #1 revealed she was the assigned PCT for Patient #2 on 10/15/2024. “We are supposed to document any changes to the patient’s dialysis prescription and notify the nurse.” In review of the “Treatment Details Report” dated 10/18/2024, PCT #1 confirmed there was no documented justification available for review for the decreased BFR rate at 0731 and 0808.”