Fmcna Southwest Wake Dialysis

“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 a review of the facility’s policies and procedures, medical records, and staff interviews, the facility’s interdisciplinary team (IDT) members failed to identify a patient as unstable and perform a monthly reassessment and a plan-of-care for one of one sampled patient with multiple hospitalizations (Patient #11). Findings included A review on 05/28/2025 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 08/20/2025 of Patient #11 indicated that the patient was admitted to the facility on 03/05/2020 for in-center hemodialysis treatment. A review of the record revealed Patient #11was admitted to the hospital on 01/15/2025 through 01/19/2025 for hypoglycemic episodes, 01/22/2025 through 01/30/2025 for nausea and abdominal pain, 02/05/2025 through 02/07/2025 for abdominal pain after meals, 02/10/2025 through 02/17/2025 with cough congestions and shortness of breath and was discharged with a diagnosis of pulmonary edema, and 02/19/2025 through 03/11/2025 with shortness of breath and bilateral flank pain. The patient was discharged with diagnoses of ischemic colitis (reduced blood flow to the colon), hypervolemia (excess volume of fluid in the body), hyperkalemia (high level of potassium), atrial fibrillation, and a code status of DNR and DNI (do not resuscitate and do not intubate). The review indicated that the patient’s Plan of Care (POC) meetings were conducted on 04/25/2024 and 04/21/2025. The patient’s current stability status was recorded as not applicable (N/A), with the next POC meeting scheduled for 04/21/2026. The review revealed that there was no documentation of monthly reassessments or revisions to the plan of care to consider the patient as unstable by the IDT after the recent hospitalizations. The review revealed that there was no documentation of monthly reassessments or revisions to the plan of care to consider the patient as unstable by the IDT after the recent hospitalizations. interview on 08/20/2025 at 1640 with the FA confirmed that Patient #11 had four hospital visits within 30 days, including one visit that lasted more than 15 days. The FA stated that, according to the policy, the patient should have been made unstable and reassessed monthly due to her declining health. The interview confirmed the findings.”

“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 records review, and staff interviews, the facility staff failed to follow the adequacy plan of care by not dialyzing 3 of 11 (Patients #7, #8, and #10) in-center hemodialysis patients at the prescribed treatment duration. Findings include: A review on 08/20/2025 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 prescribed treatment. The RN was responsible for... document on the ‘AMA’ or Against Medical Advice form...” 1. A medical record review on 08/21/2025 for Patient #7 revealed a 79-year-old male admitted to the facility for ICHD treatments on 06/21/2021. A review of the physician’s orders revealed that Patient #7 had ordered a dialysis treatment duration of 240 minutes. Review of the treatment sheet dated 08/08/2025 revealed that the treatment started at 1311 and ended at 1619 for a duration of 188 minutes (shortened by 52 minutes). Review of the treatment sheet dated 08/11/2025 revealed that the treatment started at 1313 and ended at 1633 for a duration of 200 minutes (shortened by 40 minutes). Review of the treatment sheet dated 08/13/2025 revealed that the treatment started at 1224 and ended at 1544 for a duration of 200 minutes (shortened by 40 minutes). Review of the treatment sheet dated 08/16/2025 revealed that the treatment started at 1314 and ended at 1645 for a duration of 211 minutes (shortened by 29 minutes. The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 08/08/2025, 08/11/2025, 08/13/2025, and 08/16/2025. The review revealed no completed AMA form for early termination of the treatment on 08/08/2025, 08/11/2025, 08/13/2025, and 08/16/2025. An interview with the FA on 08/21/2025 at 0910 revealed that no AMA forms were found for the patient on those dates. An interview with PCT #3 on 08/21/2025 at 0920 revealed that the PCTs were responsible for notifying nurses when patients requested to terminate their treatments early. The interview revealed that the nurses were responsible for educating patients about the risk of early termination and obtaining their signatures on the early termination consent form. 2. A medical record review on 08/20/2025 for Patient #8 revealed an 88-year-old male admitted to the facility for ICHD treatments on 11/01/2023. A review of the physician’s orders revealed that Patient #8 had ordered a dialysis treatment duration of 210 minutes. Review of the treatment sheet dated 07/25/2025 revealed the treatment started at 1147 and ended at 1445 for a duration of 178 minutes (shortened by 32 minutes). Review of the treatment sheet dated 07/30/2025 revealed the treatment started at 1133 and ended at 1445 for a duration of 192 minutes (shortened by 18 minutes). Review of the treatment sheet dated 08/01/2025 revealed the treatment started at 1141 and ended at 1446 for a duration of 185 minutes (shortened by 25 minutes). Review of the treatment sheet dated 08/04/2025 revealed the treatment started at 1149 and ended at 1446 for a duration of 177 minutes (shortened by 33 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 07/25/2025, 07/30/2025, 08/01/2025, and 08/04/2025. The review revealed no completed AMA form for early termination of the treatment on 07/25/2025, 07/30/2025, 08/01/2025, and 08/04/2025. An interview with the FA on 08/21/2025 at 0910 revealed that no AMA forms were found for the patient on those dates. An interview with PCT #3 on 08/21/2025 at 0920 revealed that the PCTs were responsible for notifying nurses when patients requested to terminate their treatments early. The interview revealed that the nurses were responsible for educating patients about the risk of early termination and obtaining their signatures on the early termination consent form. 3. A medical record review on 08/21/2025 for Patient #10 revealed a 69-year-old male admitted to the facility for ICHD treatments on 06/15/2023. A review of the physician’s orders revealed that Patient #10 had ordered a dialysis treatment duration of 240 minutes. Review of the treatment sheet dated 08/02/2025 revealed that the treatment started at 1123 and ended at 1501 for a duration of 218 minutes (shortened by 22 minutes). Review of the treatment sheet dated 08/09/2025 revealed the treatment started at 1133 and ended at 1455 for a duration of 2002 minutes (shortened by 38 minutes). Review of the treatment sheet dated 08/14/2025 revealed the treatment started at 1110 and ended at 1457 for a duration of 227 minutes (shortened by 13 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 08/02/2025, 08/09/2025, and 08/14/2025. The review revealed no completed AMA form for early termination of the treatment on 08/02/2025, 08/09/2025, and 08/14/2025. An interview with the FA on 08/21/2025 at 0910 revealed that no AMA forms were found for the patient on those dates. An interview with PCT #3 on 08/21/2025 at 0920 revealed that the PCTs were responsible for notifying nurses when patients requested to terminate their treatments early. The interview revealed that the nurses were responsible for educating patients about the risk of early termination and obtaining their signatures on the early termination consent form.”

“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 a review of the facility’s policy and procedures, observation, and staff interviews, the facility staff failed to ensure a patient’s vascular access site was washed with soap and water or an antibacterial scrub upon entering the facility for 2 of 2 patients’ AVF/G access observations (Patient #10). Findings include: Review of the facility’s policy “Access Assessment and Cannulation” published 05/05/2025 revealed “...Assessment of Vascular Access: Follow the steps below to access the vascular access: 1. Prior to treatment, ask patient to wash access area with soap and water, per hand hygiene procedure. If the patient is unable to wash their own access, the staff or care partner should wear gloves to wash the patient’s access with soap and water. Note: If unable to wash with soap and water, staff may use hand sanitizer with 60-70 percent alcohol to clean access arm ...” Observation on 08/19/2025 at 1105 revealed Patient #10 entered the treatment area, his weight was obtained, and he was escorted to Station #20 by a RN #1. Continued observation revealed PCT #2 evaluated Patient #10’s access, applied antiseptic, and proceeded with cannulation. The observation revealed that PCT #2 did not instruct Patient #10 to wash the access site with soap and water, nor did PCT #2 verify that the access site had been washed. An interview with RN #1 on 08/19/2025 at 1110 revealed that if a patient was ambulatory, the patient should have washed the access site before going to the station. The interview confirmed that the RN did not instruct the patient to wash the access site with soap and water. An interview conducted on 08/20/2025 at 1640 with the FA indicated that ambulatory patients were expected to wash their access sites upon entering the treatment floor. The interview confirmed the findings. NC00228830 NC00232860”