Fmc Dialysis Services North Ramsey

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 38766 Based on policy review, observation, and interview, the facility administration failed to display a copy of the patient’s rights in 1 of 1 observation of the facility. Findings included: A review of facility policy, “Patient Rights and Responsibilities” published 04/04/2021, revealed “... Policy ...Dialysis facilities must prominently display a copy of the patient’s rights in a visible and accessible area in the facility and must include contact information for the State survey agency and ESRD Network...” Observation on 05/21/2024 at 0930 upon entering the facility, revealed a copy of the patient’s rights was not displayed in the patient lobby and /or the treatment area. An interview on 05/23/2024 at 0950 with the Clinical Manager revealed that the board with the patient rights and responsibilities and all the important numbers “should have been posted in the lobby.” The interview revealed that the board was removed from the lobby during renovation back in December 2023. The Clinical Manager reported that “we will have copies of the Patients’ Rights available in the lobby until we have a new board.””

“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 on patients during dialysis treatments for 4 of 8 patients reviewed (Patient #4, #1, #6, and #2). Findings included: A review on 05/09/2024 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 05/22/2024 for Patient #4 revealed a 67-year-old male admitted to the facility for ICHD treatments on 01/09/2019. A review of the provider orders for Patient Management Services written on 01/19/2024 revealed, “BP pre/post dialysis q30 min (every 30 minutes) while on dialysis and PRN and Pulse pre/post dialysis, q30 minutes while on Dialysis and PRN.” A review of the treatment sheet dated 05/08/2024 revealed the treatment started at 1156 and ended at 1537 (221 minutes). The treatment flowsheet revealed no documented vital signs from 1156 through 1330 (94 minutes). A review of the treatment flowsheet for 05/15/2024 revealed the treatment started at 1158 and ended at 1634 (276 minutes). The treatment flowsheet revealed no documented vital signs from 1228 through 1323 (55 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 05/23/2024 with the CM revealed that once a patient was on the machine, the staff was responsible for collecting and documenting the patient’s blood pressure and pulse every 30 to 45 minutes. The interview confirmed that the staff did not follow the policy. Interview on 05/23/2024 at 1315 with PCT/CCHT/Preceptor #1 revealed safety monitoring to include the patient’s vital signs, should be performed and documented at least every 30 minutes and as needed for patients exhibiting any symptoms. 2. An open medical record review on 05/21/2024 for Patient #1 revealed a 74-year-old male admitted to the facility for ICHD treatments on 01/16/2024. A review of the provider orders for Patient Management Services written on 05/06/2024 revealed, “BP pre/post dialysis q30 min (every 30 minutes) while on dialysis and PRN and Pulse pre/post dialysis, q30 minutes while on Dialysis and PRN.” A review of the treatment sheet dated 05/09/2024 revealed the treatment started at 1047 and ended at 1451 (244 minutes). The treatment flowsheet revealed no documented vital signs from 1324 through 1423 (59 minutes). A review of the treatment flowsheet for 05/14/2024 revealed the treatment started at 1054 and ended at 1450 (236 minutes). The treatment flowsheet revealed no documented vital signs from 1100 through 1226 (86 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 05/23/2024 with the CM revealed that once a patient was on the machine, the staff was responsible for collecting and documenting the patient’s blood pressure and pulse every 30 to 45 minutes. The interview confirmed that the staff did not follow the policy. Interview on 05/23/2024 at 1315 with PCT/CCHT/Preceptor #1 revealed safety monitoring to include the patient’s vital signs, should be performed and documented at least every 30 minutes and as needed for patients exhibiting any symptoms. 3. An open medical record review on 05/22/2024 for Patient #6 revealed an 84-year-old female admitted to the facility for ICHD treatments on 11/29/2018. A review of the provider orders for Patient Management Services written on 12/25/2023 revealed, “BP pre/post dialysis q30 min (every 30 minutes) while on dialysis and PRN and Pulse pre/post dialysis, q30 minutes while on Dialysis and PRN.” A review of the treatment sheet dated 05/13/2024 revealed the treatment started at 1329 and ended at 1714 (225 minutes). The treatment flowsheet revealed no documented vital signs from 1555 through 1714 (79 minutes). A review of the treatment flowsheet for 05/17/2024 revealed the treatment started at 1341 and ended at 1655 (194 minutes). The treatment flowsheet revealed no documented vital signs from 1601 through 1655 (54 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 05/23/2024 with the CM revealed that once a patient was on the machine, the staff was responsible for collecting and documenting the patient’s blood pressure and pulse every 30 to 45 minutes. The interview confirmed that the staff did not follow the policy. Interview on 05/23/2024 at 1315 with PCT/CCHT/Preceptor #1 revealed safety monitoring to include the patient’s vital signs, should be performed and documented at least every 30 minutes and as needed for patients exhibiting any symptoms. 4. An open medical record review on 05/22/2024 for Patient #2 revealed a 47-year-old female admitted to the facility for ICHD treatments on 02/22/2024. A review of the provider orders for Patient Management Services written on 04/16/2024 revealed, “BP pre/post dialysis q30 min (every 30 minutes) while on dialysis and PRN and Pulse pre/post dialysis, q30 minutes while on Dialysis and PRN.” A review of the treatment sheet dated 05/07/2024 revealed the treatment started at 1210 and ended at 1537 (187 minutes). The treatment flowsheet revealed no documented vital signs from 1327 through 1425 (58 minutes). The review revealed the facility staff failed to monitor the patient every 30 to 45 minutes during the hemodialysis treatment. An interview on 05/23/2024 with the CM revealed that once a patient was on the machine, the staff was responsible for collecting and documenting the patient’s blood pressure and pulse every 30 to 45 minutes. The interview confirmed that the staff did not follow the policy. Interview on 05/23/2024 at 1315 with PCT/CCHT/Preceptor #1 revealed safety monitoring to include the patient’s vital signs, should be performed and documented at least every 30 minutes and as needed for patients exhibiting any symptoms.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 38766 Based on policy and procedure review, medical record reviews, and staff interviews, the facility failed to ensure staff performed access evaluation per policy before the start of treatments for 2 of 6 treatments via an Arterio-venous fistula/graft (AVF/AVG) cannulation procedures (Patient #7). Findings included: A review on 05/23/2024 of the facility policy titled “Patient Assessment and Monitoring” published 05/01/2023 revealed, “...Pre-Treatment: Follow the steps below for obtaining pre-treatment assessment data: ... Access: Record access findings. Evaluate the patient’s access per policy: Ask: complaints of pain, numbness, tingling, coldness and tenderness, fever, look, listen, and feel.” An open medical record review on 05/23/2024 for Patient #7 revealed a 58-year-old female admitted to the facility for ICHD treatments on 01/21/2016. A review of the provider orders for treatment written on 04/16/2024 revealed that the patient was to be treated via an AVF. A review of treatment records from 05/06/2024 through 05/20/2024 (6 treatment records) revealed no documentation of the patient’s access evaluation on 05/06/2024 and 05/10/2024. The review revealed that the facility staff failed to evaluate and record the patient’s access per policy on 05/06/2024 and 05/10/2024. An interview on 05/23/2024 at 1225 with the Charge Nurse (CN) revealed that a pre-treatment access evaluation was required to be completed and documented in the treatment record by the Patient Care Technician before the start of every treatment. The interview confirmed that the facility policy was not followed.”