Davita Radburn Dialysis

“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: 37656 Based on a review of one of two medical records for a new patient (Patient 5), staff interview, and review of facility documents, it was determined the facility failed to ensure that the Registered Nurse reassesses a patient with elevated intradialytic blood pressure (BP). The facility failed to ensure that abnormal blood pressure (BP) readings occurring during hemodialysis treatment were reported to, assessed by, and acknowledged by, a Registered Nurse (RN). Findings include: A review of P5’s medical record revealed the following: The Patient Summary report indicated a medication order, dated 10/2/23, “... Clonidine 0.1 Milligram Oral Every 4 hours as needed ...”. The Plan of Care dated 12/29/23, stated, “... BP and Fluid Management Goal ... Achieve BP control as specified by the patient’s physician ... Goal not met. EDW and BP meds to be adjusted per MD to meet goal ...” A review of the hemodialysis treatment flowsheet, dated 12/9/23, indicated the following: 07:33 AM: BP 187/112, treatment was initiated by a Registered Nurse (RN). 08:02 AM: BP - 178/111, The RN noted that the BP was high. There was no documented evidence that Clonidine was administered to P5. 10:32 AM: BP - 167/107 11:02 AM: BP - 190/117 11:03 AM: BP - 191/115, P5’s treatment was terminated and the RN discharged the patient. There was no documented evidence that the RN performed a re-assessment of the patient’s blood pressure prior to discharge, or administered Clonidine per physician’s order. On 12/12/23, P5’s treatment was initiated by a RN at 07:52 AM, the BP was 163/106. 08:03 AM: BP- 178/101, 08:33 AM: BP- 171/99, RN stated in his/her notes: BP high asymptomatic, 10:33 AM: BP- 169/104 11:03 AM: BP- 175/120 11:10 AM BP - 191/115 11:23 AM BP - 191/124, RN note: BP high asymptomatic. There was no documented evidence that Clonidine was administered prior to discharge on 12/12/23. During an interview on 12/21/23 at 2:55 PM, Staff (S) 1, the Facility Administrator, stated that the RN should have re-assessed P5’s blood pressure and should have administered Clonidine during treatment or prior to discharge. A review of the facility policy and procedure titled, Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment, revision date: April 2021, states, “... INTRADIALYTIC DATA COLLECTION/ASSESSMENT ... 11. ... The licensed nurse will use her/his clinical judgment based on the individual patient needs to determine if any clinical interventions are necessary. ... POST TREATMENT DATA COLLECTION/ASSESSMENT ... 16. ... The licensed nurse will assess the patient prior to discharge. ... ABNORMAL FINDINGS ... the following are considered abnormal findings ... and documented on the patient’s medical record ... Blood Pressure: Pre dialysis: ... Systolic greater than 180 mm/Hg (millimeter/Mercury) or less than 90 mm/Hg ... Diastolic greater than or equal to 100 mm/Hg ...Blood Pressure -Intradialytic...difference of 20 mm/hg increase or decrease from patient’s last intradialytic treatment BP reading... Blood Pressure Post Treatment: ... Sitting BP for patients that cannot stand: ... Sitting BP greater than 140 mm/Hg or less than 90 mm/Hg ... Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg ...” N.J.A.C. 8:43A-24.13(b)”

“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: 48966 Based on two of two observations of medication administration, staff interviews, and a review of facility policy and procedure, it was determined the medical director failed to ensure that all staff administer heparin in accordance with facility policy. Findings include: On 12/20/23 at 12:00 PM, in Station 17, during an initiation of a hemodialysis treatment through an arteriovenous fistula, the following was observed: Staff (S) 10, a Registered Nurse, attached a heparin filled syringe to the venous needle and slowly injected the heparin with a back-and-forth motion. After waiting one minute and thirty seconds, S10 proceeded to attach the dialysis lines to the fistulas needles and initiated treatment. During an interview on 12/20/23 at 12:06 PM, S10 stated, “the dwell time for the heparin loading dose is three to five minutes and I think I did that.” On 12/20/23 at 12:08 PM at Station #20, Staff (S) 9, a Patient Care Technician, cannulated the patient’s arteriovenous access. S10 slowly injected a heparin-filled syringe into the venous access with a back and forth motion. S9 immediately proceeded to attach the dialysis lines to the fistula needles and initiate treatment. During an interview at 12:14 PM, S9 was asked how long should you wait after heparin has been administered before the hemodialysis treatment can be initiated. S9 was not able to answer and proceeded to ask S10 what the time should be. S9 then responded, “Three to five minutes. The heparin loading dose needs to dwell prior to initiation of treatment.” S9 confirmed that she did not wait the correct amount of time after the heparin was administered. A review of the facility policy and procedure titled, “AV Fistula Or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) And Administration Of Heparin Loading Dose,” revised in October 2022, stated, “... 28. Attach heparin loading dose to venous fistula needle, as applicable. Unclamp and gently flush heparin back and forth 3-5 times into fistula or graft. Reclamp ... 29. Do not initiate dialysis for a minimum of three (3) to five (5) minutes after administering heparin loading dose. ...” N.J.A.C. 8:43A-9.3 (a)”