Fmc Dialysis Services of Robeson County

“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 and plan-of-care for one (1) of one (1) sampled patient with an extended hospitalization (Patient #4). Findings included A review on 01/16/2025 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. ... or Marked deterioration in health status ... or Significant change in psychosocial needs ...” A medical record review on 01/16/2025 of Patient #4 revealed the patient was admitted to the facility on 03/29/2022 for in-center hemodialysis treatment. A review of the record revealed the patient was admitted to the hospital on 09/16/2024 through 10/10/2024 (24 days hospital stay) with a Primary Discharge Diagnosis of “Late acute infarct of the right corona radiata residual left-sided weakness (right-sided stroke), Fall, and Urinary Tract Infection (UTI). The review revealed that the patient’s Discharge Disposition was to a Skilled Nursing Facility (SNF). A social worker (SW) note with an encounter date of 12/06/2024 revealed, “Pt (patient) was able to share with the SW that his wife had unexpectedly passed away...” The review revealed the patient’s last Plan of Care (POC) was on 07/05/2024, the patient’s status was stable and the next POC meeting was 07/05/2025. The review revealed no documentation that a monthly reassessment or revisions of a plan of care were done to consider the patient as unstable by the IDT after a hospitalization a 24-day stay, transferred to an SNF, and after the loss of his wife. An interview on 01/16/2025 at 1420 with the CM revealed that the CM was unable to locate an unstable POC for the patient. The interview revealed the patient was hospitalized with a stroke, was sent to SNF from the hospital, and had recently lost his wife. The interview confirmed that the patient should have been made unstable. The interview revealed that the CM was the care plan manager and admitted that the patient was missing because the CM failed to read through the hospital discharge summary fully to understand the major medical changes. The interview confirmed the findings.”

“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: 38766 Based on facility policy and procedure review, medical record reviews, and staff interviews, the facility staff failed to document a complete pre-and post-treatment assessment for 1 of 10 sampled in-center hemodialysis records reviewed (Pt. #8). Findings included: A review on 01/15/2025 of the facility policy titled “Patient Assessment and Monitoring,” revised 05/01/2023, revealed, “Data Collection: Direct patient care staff may collect data such as weight, BP, pulse, respiration, temperature, general observations... The Registered Nurse will assess/reassess any findings addressed pre or during treatment as needed. Pre-Treatment ...During nursing rounds, the Registered Nurse will review the data collected above and assess the following parameters ...Assess the patient for symptoms... Lungs sounds... Edema... Heart sounds... Post-Treatment 1. ...The registered nurse will assess/re-assess post-treatment as indicated. 2. Document findings in the patient’s record...” A review on 01/15/2025 of the medical record for Patient #8 revealed a 68-year-old male admitted for In-Center Hemodialysis treatments on 08/07/2018. A review of a Treatment Flowsheet dated 10/31/2024 revealed Patient #8’s treatment started at 0605 and ended at 0950. The Flowsheet revealed no documentation of a pre-treatment or post-treatment nursing assessment. An interview on 01/16/2025 at 12:30 with the Director of Operations revealed a pre-nursing assessment should be completed and documented before the start of every treatment to ensure that the patient was safe and stable for treatment. A post-treatment evaluation was required to ensure that the patient was safe for discharge. Furthermore, if the assessment was not documented shortly after it was performed, it should be recorded as a late entry, with the completion time indicated in the record.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 38766 Based on facility policy review, personnel “Job Description” reviews, personnel file review, and staff interviews, the facility failed to ensure that direct patient care staff had current certification in CPR (Cardiopulmonary resuscitation) for one (1) of four (4) sampled personnel files (PCT #2). Findings included: Review on 01/16/2025 of the facility’s policy “Credential and Verification Requirements” effective 12/15/2020 revealed, “Introduction Certain positions within the Company require employees to have and maintain a valid credential in good standing in order to perform specific requirements of the job ... Applies to This policy applies to all newly hired and current employees ... In addition to credential requirements, this may also include other certifications, including but not limited to Cardiopulmonary Resuscitation (CPR) or Basic Life Support (BLS). A review of the facility’s “Job Description” for a “Patient Care Technician II” revealed, “Experience and Required Skills: ...*Continued employment is dependent on successful completion of the (company name) dialysis training program and successful completion of CPR certification...” A review on 01/16/2025 of PCT #2’s personnel file revealed the PCT began employment with the company on 10/17/2022. The review showed the PCT had a CPR certification on file that expired on “01/2024” and another certification with an Issue Date of 01/15/2025 with a Renew By date of 01/2027. The review revealed the PCT continued employment at the facility while not maintaining a valid CPR certification from 02/01/2024 through 01/14/2025 (almost one year). An interview on 01/16/2025 at 1555 with the Clinical Manager (CM) confirmed that the staff CPR had expired in January 2024 but thought it was going to expire at the end of January 2025. The interview revealed that the CM was responsible for keeping up with the employees’ files, and it was an oversight on her part.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 38766 Based on policy review, observations, and staff interviews, the facility staff failed to ensure a patient’s home medication was not brought to the clinic and was kept in an unable syringe in the medication drawer for 1 of 2 observations. Findings included: A review on 01/16/2025 of the facility’s policy “Medication Preparation and Administration” effective 02/06/2023 revealed, “...Labeling Reconstituted medication Solutions and Syringes All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication... Preparing and Administering Medications During Hemodialysis Treatment... Verify there is a physician order...” An observation of the medication preparation area on 01/16/2025 at 1015 revealed a locked medication cabinet near the nursing station. The observation revealed an unlabeled syringe with a clear liquid medication in a locked drawer of the medication cabinet. An interview on 01/16/2025 at 1015 with Registered Nurse (RN) #1 during the observation revealed that the nurse was unable to speak to what medication was in the syringe except that Patient #10 brought in the vial and told the nurse that he did not have a syringe at home and needed the nurse to draw up the medication for him. The interview revealed that RN #1 drew the medication, threw the vial away, and placed the syringe in the medication drawer. The interview indicated that RN #1 could not remember which medication it was. An interview on 01/16/2025 at 1645 with the Clinical Manager and the Director of Operations revealed that the nurses were not allowed to administer home medications to patients, and they were expected to properly label all prepared syringes that were not administered immediately. The interview revealed that the proper label should include the name of the medication. The interview revealed that the policy was not followed. NC00224306”