Fms Dialysis Services of Oxford

“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 patient monitoring every 30-45-minute during dialysis treatments for four (4) of nine (9) in-patient records reviewed (Patient #7, #1, #8, and #3). Findings included: A review on 04/16/2025 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 04/17/2025 for Patient #7 revealed that a 33-year-old male was admitted to the facility for ICHD treatments on 11/26/216. A review of the treatment sheet dated 03/21/2025 revealed the treatment started at 0851 and ended at 1408 (317 minutes). The treatment flowsheet revealed no documented vital signs from 0938 through 1141 (123 minutes) and 1141 through 1244 (63 minutes. A review of the treatment flowsheet on 03/31/2025 revealed the treatment started at 0800 and ended at 1334 (334 minutes). The treatment flow sheet revealed no documented vital signs from 0932 through 1042 (70 minutes), 1104 through 1201 (57 minutes), and again at 1307 (66 minutes). A review of the treatment sheet dated 04/02/2025 revealed the treatment started at 0716 and ended at 1322 (366 minutes). The treatment flow sheet revealed no documented vital signs from 0732 through 0837 (65 minutes). The review revealed the facility staff failed to monitor the patient every 30-45 minutes during the hemodialysis treatment per the facility policy. An interview on 04/17/2025 at 1325 with Staff #2 revealed that the staff should take the patient’s vital signs and safety checks every 30 to 45 minutes. The staff confirmed that the policy required these checks to be performed and documented every 30 to 45 minutes or more frequently as needed. 2. An open medical record review on 04/16/2025 for Patient #1 revealed that a 69-year-old female was admitted to the facility for ICHD treatments on 01/16/2025. A review of the treatment sheet dated 04/05/2025 revealed the treatment started at 0742 and ended at 1144 (242 minutes). The treatment flow sheet revealed no documented vital signs from 1007 through 1103 (56 minutes). A review of the treatment sheet dated 04/10/2025 revealed the treatment started at 0725 and ended at 1131 (246 minutes). The treatment flow sheet revealed no documented vital signs from 1038 through 1132 (54 minutes). A review of the treatment sheet dated 04/12/2025 revealed the treatment started at 0754 and ended at 1201 (247 minutes). The treatment flow sheet revealed no documented vital signs from 1040 through 1201 (81 minutes). The review revealed the facility staff failed to monitor the patient every 30-45 minutes during the hemodialysis treatment per the facility policy. An interview on 04/17/2025 at 1325 with Staff #2 revealed that the staff should take the patient’s vital signs and safety checks every 30 to 45 minutes. The staff confirmed that the policy required these checks to be performed and documented every 30 to 45 minutes or more frequently as needed. 3. An open medical record review on 04/17/2025 for Patient #8 revealed that an 83-year-old female was admitted to the facility for ICHD treatments on 10/22/2015. A review of the treatment sheet dated 03/21/2025 revealed the treatment started at 1352 and ended at 1558 (126 minutes). The treatment flow sheet revealed no documented vital signs from 1434 through 1534 (61 minutes). A review of the treatment sheet dated 04/07/2025 revealed the treatment started at 1304 and ended at 1554 (170 minutes). The treatment flow sheet revealed no documented vital signs from 1304 through 1406 (62 minutes). A review of the treatment sheet dated 04/09/2025 revealed the treatment started at 1245 and ended at 1546 (181 minutes). The treatment flow sheet revealed no documented vital signs from 1337 through 1440 (63 minutes). The review revealed the facility staff failed to monitor the patient every 30-45 minutes during the hemodialysis treatment per the facility policy. An interview on 04/17/2025 at 1325 with Staff #2 revealed that the staff should take the patient’s vital signs and safety checks every 30 to 45 minutes. The staff confirmed that the policy required these checks to be performed and documented every 30 to 45 minutes or more frequently as needed. 4. An open medical record review on 04/16/2025 for Patient #3 revealed that a 79-year-old female was admitted to the facility for ICHD treatments on 05/17/2024. A review of the treatment sheet dated 03/21/2025 revealed the treatment started at 1306 and ended at 1628 (202 minutes). The treatment flow sheet revealed no documented vital signs from 1332 through 1435 (63 minutes). A review of the treatment sheet dated 04/09/2025 revealed the treatment started at 1202 and ended at 1506 (176 minutes). The treatment flow sheet revealed no documented vital signs from 1338 through 1437 (59 minutes). The review revealed the facility staff failed to monitor the patient every 30-45 minutes during the hemodialysis treatment per the facility policy. An interview on 04/17/2025 at 1325 with Staff #2 revealed that the staff should take the patient’s vital signs and safety checks every 30 to 45 minutes. The staff confirmed that the policy required these checks to be performed and documented every 30 to 45 minutes or more frequently as needed.”

“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 and interviews with patients and staff, the facility failed to ensure mobile devices were not used in the patient care area. Findings included: Review on 04/16/2025 of the facility’s policy titled “Use of Portable Electronic Communication Devices” effective 12/15/2020 revealed, “...Portable Communication Devices-Clinical Environments: Employees in clinical setting are permitted to use portable communication devices during break or meal periods, however: Devices must be kept out of patients and clients, and used only in a break room or other non-public location, ...Important: Patient care employees are prohibited from carrying cell phones, and portable communication devices into patient care areas...” An interview on 04/16/2025 at 1015, with Patient #9, indicated that Named Staff (Staff #3) would be wearing her Bluetooth earpiece while on the treatment floor. An interview on 04/16/2025 at 1025 with Staff #5 revealed that Named Staff (Staff #3 and #4) would be wearing their Bluetooth in their ears while on the treatment floor. The staff reported that management had addressed it during a meeting, however, it continued to happen. An interview on 04/16/2025 at 1215 with staff #3 revealed that the staff was not supposed to use electronic devices such as cell phones, laptops, computers, Bluetooth, or MP3 players where patients could see them. The staff reported that management had a meeting with all staff regarding the use of electronic devices on the floor and the expectation of staff compliance. An interview on 04/16/2025 at 1635 with Staff #6 revealed that no electronic devices were allowed on the treatment floor. Staff #6 reported that patients had complained about certain staff wearing Bluetooth, and the clinic manager had reeducated the staff; however, the staff behaviors had not changed. The interview revealed that Staff #6 believed that staff wearing Bluetooth devices had affected the response to machine alarms. An interview on 04/17/2025 at 1415 with the Director of Operations (DO) revealed that it had been an ongoing issue with the staff wearing Bluetooth. It has been an ongoing conversation that started on 03/05/2024. The DO attempted to address the issue by educating on safety risks. The staff was re-educated on the fact that the device could interfere with the response to the machine alarm. The interview revealed that the DO had to prioritize a lot of things. That is why management has not taken action against these staff. NC00229096, NC00229178, NC00229225, & NC00229466.”