Fkc Passaic

“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: 48966 Based on review of one of one medical record (Patient (P) 1) reviewed for low blood pressures, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that systolic blood pressure readings less than 100 mm/hg (millimeters of mercury) occuring before and during hemodialysis treatments are reported to the Nephrologist and interventions for patient needs are implemented. Findings include: On 2/1/24, a review of P1’s medical record revealed the following: The “Treatment Data” portion of the dialysis treatment flowsheet, dated 2/13/23, stated the following blood pressure (BP) measurements and “Comments”: 10:49 AM: BP 81/46; The pre-treatment reading was documented by the Registered Nurse (RN). 10:58 AM: BP 71/38; “... treatment initiated without problem; denies complaints; Patient alert ...” documented by the Registered Nurse (RN). 11:32 AM: BP 83/38; “... denies complaints; Patient alert ...” documented by the RN. 12:01 PM: BP 73/42; “... denies complaints; Patient alert ...” documented by the Patient Care Technician (PCT). 12:36 PM: BP 70/45; “... resting comfortably notified; denies complaints; low BP ...” documented by the PCT. 13:00 PM: BP 76/42; “... denies complaints; Patient alert ...” documented by the RN. 13:31 PM: BP 73/43; “... denies complaints; Patient alert ...” documented by the RN. 14:01 PM: BP 72/39; “... denies complaints; Patient alert ...” documented by the RN. 14:24 PM: BP 81/32; “... denies complaints; Patient alert, Treatment discontinued without problem ...” documented by the RN. A pre-treatment “Nursing Evaluation” note documented by the RN on 2/13/23 at 4:16 PM stated, “... late entry- alert and oriented, respiratory rate regular ... treatment started without problems. ...” A post-treatment “Nursing Evaluation” note documented by the RN on 2/13/23 at 4:16 PM stated, “... treatment discontinued without problems, ultrafiltration goal achieved, alert and oriented, pulse and respiratory rate regular, ... discharged to home with stable vital signs.” The medical record did not contain documentation of interventions taken in response to the systolic blood pressure measurements of less than 100 mm/hg or documentation that the Nephrologist was informed of the low blood pressures. The “Treatment Data” portion of the dialysis treatment flowsheet, dated 2/15/23, revealed the following blood pressure measurements and “Comments”: 11:58 AM: BP 80/48; “... denies complaints; started ...” documented by a RN. 12:08 PM: BP 92/30; “... access visible ...” documented by a RN. 12:29 PM: BP 122/___; “... arousable when called; moans ...” documented by a RN. 12:34 PM: BP 100/25; “... ended ...” documented by a RN. A pre-treatment “Nursing Evaluation” note documented by the RN on 2/15/23 at 12:21 PM stated, “... patient asleep, arousable, opens eyes when called, BP on the low side. Spoke to assigned RN at nursing home and claimed patient has stable BP and continue to just moan a lot, shakes his head when asked if patient is in pain, treatment started without problem, monitored ...” A post-treatment “Nursing Evaluation” note by the RN on 2/15/23 at 1:11 PM stated, “... patient found unresponsive, CPR [Cardiopulmonary Resuscitation] done, EMS [Emergency Medical Services] came ...” 13:30 PM, “... Patient on the way to hospital, CPR in progress ...” The above findings had no documentation by the RN of interventions implemented for the systolic blood pressure measurements of less that 100 mm/hg, or that the Nephrologist was informed of the low blood pressures. On 2/1/24 at 12:29 PM, upon interview, Staff (S) 4, the Medical Director, stated that the staff will call him/her with low and elevated BP readings for guidance. At 1:20 PM, the dialysis treatment flowsheet dated 2/13/23 was reviewed with S1, the Clinical Manager. S1 stated that the flowsheet lacked evidence that the nephrologist was made aware of the low BP readings. S1 explained that when a patient’s systolic BP reading is less than 100, the doctor is usually notified. Upon review of the blood pressures listed above, S1 also indicated that he/she would expect to see documentation of a normal saline bolus given to P1. S1 stated that when a patient has a low blood pressure, the RN should put the patient’s feet up, give a normal saline bolus, and lower the ultrafiltration goal. S1 stated, “these are the usual interventions for low BP, the RN’s are doing it but are not documenting it.” S1 confirmed there was no documentation of any interventions for P1’s systolic blood pressure less that 100 mm/hg on the dialysis flowsheet dated 2/13/23. At 1:42 PM, during a review of the dialysis flowsheet, dated 2/15/23, S1 stated that P1 had low BP readings. S1 stated there was no documented intervention by the RN or documentation that the Nephrologist was called. S1 also stated that P1 had catheter issues during this treatment and that the treatment was discontinued early. S1 stated that there was no documentation by the RN regarding the catheter problems and early termination of treatment. A review of the facility policy and procedure titled, “Patient Assessment and Monitoring,” published on 5/1/23 stated, “... Data Collection ... RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed ... Step 1 ... Pre- Treatment ... Record blood pressure. Verify: ... systolic blood pressure less than or equal to 100 mm/hg (millimeters of mercury) systolic during treatment ... Step 3 document findings and interventions in the medical record. Contact the physician as needed for additional orders based on assessment findings and clinical judgment ... During Treatment ... Step 1 ... Blood Pressure ... Record blood pressure. Recheck blood pressures after a drop that requires interventions such as administering normal saline. Reposition electronic cuff or use manual cuff for aberrant blood pressure readings. Report to the nurse: ... Blood pressure less than or equal to 100 mm/hg systolic ... document any findings and interventions in the medical record ...” A review of the facility policy and procedure titled, “Hypotension,” published on 5/2/22, stated, “... Treating Hypotension ... Step 1. Recheck blood pressure and compare to previous blood pressures. Step 2. If the blood pressure is verified low, place patient in modified Trendelenburg position (trunk and head are horizontal, legs elevated 30 to 45 degrees, flexing at the hips). Step 3. Reduce ultrafiltration [UF] to minimum (300 ml/hour) or turn the UF “OFF”. Note: Decreasing the ultrafiltration rate to minimum is preferred. Step 4. Administer normal saline bolus of 100-200 mls (milliliters) as ordered by the treating physician ...””