Davita Dialysis Care of Rutherford County

“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 facility policy review, medical record review, and staff interview, the facility patient care staff failed to notify the nurse of elevated blood pressure readings in 4 of 6 ICHD sampled records (Patient #2, #3, #4, and #6) and the licensed nurse failed to administer Clonidine and to notify the MD/FNP [Medical Doctor/Family Nurse Practitioner] per the facility’s Blood Pressure Protocol for 1 of 1 ICHD records sampled that met the facility’s established parameters for the administration of Clonidine (Patient #3). Findings included: 1. Review on 03/06/2024 of the facility’s policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” Revision Date: October 2023, revealed “...INTRADIALYTIC DATA COLLECTION /ASSESSMENT ... Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre, intra, or post treatment data collection will be documented and immediately reported to the licensed nurse. An assessment by the nurse prior to initiation of dialysis, during dialysis, and/or prior to discharge will be triggered by an abnormal finding. The medical record should indicate the finding, the intervention, physician notification, physician orders, and the patient response... 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy) ... ABNORMAL FINDINGS ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ... Blood pressure: Pre-dialysis: * Systolic greater than 180 ... or less than 90 ... * Diastolic greater than or equal to 100 ... Blood Pressure-Intradialytic: * Difference of 20 ... increase or decrease from patient’s last intradialytic treatment BP reading ... Blood Pressure Post Treatment: * If the patient can stand: - Standing systolic BP greater than 140 ....or less than 90 - Standing diastolic BP greater than 90 ....or less than 50 ... * Sitting BP of patient’s that cannot stand: * Sitting systolic BP greater than 140 ....or less than 90 * Sitting diastolic BP greater than 90 ....or less than 50 ...” a. Medical record review on 03/05/2024 for Patient #2 (ICHD #2) revealed the patient was admitted to the facility on 05/12/2018 for ICHD treatment. Review of the treatment flowsheet dated 02/17/2024 revealed the patient dialyzed from 0709-1115. Review of the treatment flowsheet revealed Patient #2’s blood pressures were as follows: At 0901, BP of 131/76, 152/84 at 0931 (30 minutes later with an increased difference of 20 in SBP from last reading), and 134/108 at 1001 (30 minutes later with a, increased difference of 20 in DBP from last reading). Further review of the treatment flowsheet revealed at 1031, the patient’s BP was 112/65, 94/54 at 1101, 68/43 at 1114, and 80/40 at 1115 and 153/136 at 1420. Review of the medical record revealed no documented nursing notification by the patient care staff of the patient’s intradialytic blood pressure readings per policy. Interview on 03/05/2024 at 0945 revealed the facility’s Medical Director was out of country and unavailable for interview. Interview on 03/07/2024 at 1715 with the FA revealed the staff were expected to notify the nurse of any changes in the patient’s condition, including blood pressure readings, and to document nursing notification in the medical record. Interview revealed, “The Pre, Post and Intradialytic note should include any abnormal symptoms (hypotension, hypertension, cramping, etc.). Anything abnormal to [the patient’s] baseline, SBP less than 100, greater than 180, or a difference of 20 mmHg should be reported.” b. Medical record review on 03/05/2024 for Patient #3 (ICHD #3) revealed the patient was admitted to the facility on 03/12/2020 for ICHD treatment. Review of the treatment flowsheet dated 03/02/2024 revealed the patient dialyzed from 0909-1314 with a pre-treatment BPs of 213/94 standing and 249/99 sitting. Review of the treatment flowsheet revealed the pre-treatment nursing assessment was completed by RN #1 at 0845. Further review of the treatment flowsheet revealed Patient #3’s blood pressures were as follows: At 0909, BP of 221/98, 242/103 at 0931, and 202/89 at 1001. Review of the medical record revealed no documented nursing notification by the patient care staff of the patient’s elevated blood pressure readings per policy. Interview on 03/05/2024 at 0945 revealed the facility’s Medical Director was out of country and unavailable for interview. Interview on 03/07/2024 at 1715 with the FA revealed the staff were expected to notify the nurse of any changes in the patient’s condition, including blood pressure readings, and to document nursing notification in the medical record. Interview revealed, “The Pre, Post and Intradialytic note should include any abnormal symptoms (hypotension, hypertension, cramping, etc.). Anything abnormal to [the patient’s] baseline, SBP less than 100, greater than 180, or a difference of 20 mmHg should be reported.” c. Medical record review on 03/06/2024 for Patient #4 (ICHD #4) revealed the patient was admitted to the facility on 10/17/2023 for ICHD treatment. Review of the treatment flowsheet dated 03/02/2024 revealed the patient dialyzed from 1135-1536. Review of the treatment flowsheet revealed the post-treatment BPs at 1539 were 167/102 standing and 173/101 sitting. Review of the treatment flowsheet dated 02/27/2024 revealed the patient dialyzed from 1106-1503. Review of the treatment flowsheet revealed the post-treatment BPs at 1504 were 185/105 standing and 171/101 sitting. Review of the medical record revealed no documented nursing notification by the patient care staff of the patient’s elevated blood pressure readings post-treatment per policy. Interview on 03/05/2024 at 0945 revealed the facility’s Medical Director was out of country and unavailable for interview. Interview on 03/07/2024 at 1715 with the FA revealed the staff were expected to notify the nurse of any changes in the patient’s condition, including blood pressure readings, and to document nursing notification in the medical record. Interview revealed, “The Pre, Post and Intradialytic note should include any abnormal symptoms (hypotension, hypertension, cramping, etc.). Anything abnormal to [the patient’s] baseline, SBP less than 100, greater than 180, or a difference of 20 mmHg should be reported.” d. Medical record review on 03/06/2024 for Patient #6 (ICHD #6) revealed the patient was admitted to the facility on 02/12/2024 for ICHD treatment. Review of the treatment flowsheet dated 02/21/2024 revealed the patient dialyzed from 1142-1552. Review of the treatment flowsheet revealed the patient’s blood pressures as follows: BP of 131/74 at 1404 and 164/116 at 1432 (with an increased difference of 20 in SBP and DBP from last reading). Review of the medical record revealed no documented nursing notification by the patient care staff of the patient’s intradialytic elevated blood pressure reading per policy. Interview on 03/05/2024 at 0945 revealed the facility’s Medical Director was out of country and unavailable for interview. Interview on 03/07/2024 at 1715 with the FA revealed the staff were expected to notify the nurse of any changes in the patient’s condition, including blood pressure readings, and to document nursing notification in the medical record. Interview revealed, “The Pre, Post and Intradialytic note should include any abnormal symptoms (hypotension, hypertension, cramping, etc.). Anything abnormal to [the patient’s] baseline, SBP less than 100, greater than 180, or a difference of 20 mmHg should be reported.” 2. Review on 03/06/2024 of the facility’s “Blood Pressure Protocol” Effective: 08/09/2023, revealed “Hypertension SBP >200 and or DBP >110 Pre Treatment 1. Initiate treatment and monitor vitals every 30 minutes. 2. At 60 minutes if over parameters administer clonidine [used to treat high blood pressure] 0.1mg [milligram] 3. Monitor vital signs every 30 minutes. 4. At 60 minutes after administration of Clonidine if BP continues over parameters notify MD/FNP [Medical Doctor/Family Nurse Practitioner] Intradialytic 1. Repeat above steps beginning at #2 ... *IF AT ANYTIME THE PATIENT BECOMES SYMPTOMATIC TREAT SYMPTOMS AND NOFITY RN/MD/FNP.” a. Medical record review on 03/05/2024 for Patient #3 (ICHD #3) revealed the patient was admitted to the facility on 03/12/2020 for ICHD treatment. Review of the treatment flowsheet dated 02/27/2024 revealed the patient dialyzed from 0908-1200 with pre-treatment BPs of 155/83 standing and 105/66 sitting. Review of the treatment flowsheet revealed the nursing pre-treatment assessment was completed by RN #1 at 0908. Further review of the treatment flowsheet revealed Patient #3’s blood pressures were as follows: At 0909, BP of 229/88, 191/94 at 0931, 220/178 with “rechecking bp” noted by PCT #1 at 1001. At 1002, BP 222/178, 206/80 at 1003 with “RN @ chairside” noted by PCT #1. Further review revealed at 1031, the patient’s BP was recorded as 217/101, 226/112 at 1101, 194/91 at 1131, and 138/112 at 1200. Review of the post-treatment BPs revealed a BP of 163/87 standing and 210/102 sitting. Review of the treatment flowsheet dated 02/24/2024 revealed the patient dialyzed from 0913-1142 with a pre-treatment BP of 232/208 sitting. Review of the treatment flowsheet revealed the nursing pre-treatment assessment was completed by RN #1 at 0905. Further review of the treatment flowsheet revealed at 1010, the patient’s BP was 102/59 with a note from PCT #2 stating, “UF [Ultrafiltration] turned off due to pt complaints of being dizzy; RN aware; BFR [Blood Flow rate] to 280 Due to ap [arterial pressure] alarm.” Review of the intradialytic BP readings following the patient’s report of dizziness revealed the following: At 1031, a BP of 130/62, 1101 BP 113/91, 1132 BP 201/87, and 1142 BP 194/96. Review of the post-treatment vital signs revealed a post-treatment BP of 163/87 standing and 204/84 sitting. Review of the medical record revealed no documented nursing assessment of the patient’s elevated BPs on 02/27/2024 or 02/24/2024 by RN #1, administration of Clonidine, or notification of the MD/FNP for orders prior to discharge for BP over parameters per facility policy. Interview on 03/05/2024 at 0945 revealed the facility’s Medical Director was out of country and unavailable for interview. Interview on 03/07/2024 at 1230 with the FA revealed the Patient’s assigned nurse (RN #1) on 02/27/2024 and 02/24/2024, the patient’s assigned PCT (PCT #1) on 02/27/2024 and assigned PCT (PCT #2) were not available for interview. Interview on 03/07/2024 at 1715 with the FA revealed nursing staff should assess any reported abnormal findings, document the assessment, administer Clonidine to hypertensive patients meeting parameters outlined in the facility’s Blood Pressure Protocol with prn Clonidine orders, and notify the MD/FNP prior to the patient’s discharge if the patient’s BP is over parameters post-treatment per the facility’s protocol. Interview revealed that in review of the patient’s treatment flowsheet, the facility nursing staff failed to follow the facility’s Hypertension [elevated blood pressure] protocol.”