322500 New Mexico Artificial Kidney Center (Fmc)

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 35949 Based on interview and review of the facility emergency preparedness plan, the facility failed to develop specific policies and procedures to address the facility’s role under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment in alternate care sites during a declared public health emergency. Failure to develop and address the facility’s role in the provision of care and treatment during a declared public health emergency limited the facility’s ability to collaborate with local emergency officials in proactive planning in an organized and systemic response when services have been disrupted. This deficient practice had the potential to affect all patients who received dialysis treatment at this facility. Findings included: The facility undated emergency preparedness plan revealed no evidence of the description of the facility’s role under the declaration of an 1135 waiver during a public health emergency. During an interview on 07/11/2024 at 8:45 AM, the Facility Administrator confirmed the required information was not included in the facility’s emergency preparedness plan. During an interview on 07/11/2024 at 1:15 PM, the Medical Director stated the emergency preparedness plan was expected to include all the necessary components for compliance, to include the role of the facility during a declared public health emergency.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 30271 Based on observation, interview, document review, and facility policy review, the facility failed to ensure the automated electronic defibrillator (AED) patches on 1 of 1 emergency cart were not expired and were available for immediate use. The facility further failed to ensure staff checked the emergency crash cart monthly as directed by their policy. These failures had the potential to affect all patients who received dialysis treatment at the facility. Findings included: A facility policy titled, “Emergency Medication, Equipment and Supplies,” published 05/01/2023, revealed, “The emergency cart must be: * Locked when not in use * checked monthly or after use for contents, expiration dates, cleanliness, and proper functioning of all equipment.” On 07/09/2024 at 8:35 AM, the surveyor observed two adult defibrillator patches located on the emergency cart had an expiration date of 03/26/2024 and the pediatric patches had an expiration date of 02/12/2024. During an interview on 07/09/2024 at 10:15 AM, Registered Nurse (RN) #3 stated the emergency cart was inspected daily, and the expiration dates were reviewed monthly. RN #3 confirmed the defibrillator patches located on the cart were expired. During the interview with the Facility Administrator (FA) and RN #5 on 07/09/2024 at 10:25 AM, the FA stated the expectation of staff was to report any expired or nearly expired items on the emergency cart to the charge nurse to have them replaced. The FA and RN #5 confirmed the defibrillator patches located on the emergency cart were expired. During an interview on 07/09/2024 at 3:39 PM, the FA stated staff failed to complete the monthly review of emergency crash cart. Per the FA, staff thought the daily checks of the emergency crash cart was all that was required. During an interview on 07/11/2024 at 1:20 PM, the Medical Director stated staff was responsible to ensure all expired items were disposed of properly.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 30271 Based on observation, interview, and policy review, the facility failed to maintain 1 (chair at Station 20) of 9 dialysis chairs in a serviceable manner. This failed practice could lead to harm of all patients in an emergency situation if equipment is not properly maintained. Findings included: A facility policy titled, “Equipment Installation-Operation-Maintenance-Repair-and Disposal,” published 07/06/2021, revealed “Purpose: The purpose of this document is to provide instructions for the installation, operation, maintenance, repair, and disposal of equipment. Scope This policy applies to all equipment that: * Removes, infuses, touches, measures, controls, or has the potential to affect the outcome of patient treatments or dialysis fluid. * Is deemed essential in performing dialysis in a safe manner; and/or * Is essential to the safe operation of the facility. This includes, but is not limited to: * Dialysis Chairs.” The policy specified, “Repairs Any equipment or devise that is not fully functioning in accordance with [name] or company policy, must be repaired or replaced as soon as reasonably possible. If the faulty equipment poses a risk to the patient or staff the device will be immediately removed from service.” On 07/10/2024 at 9:12 AM, the dialysis chair located at Station 20 had a worn area in the middle of the seat that exposed cloth webbing through the covering. During an interview on 07/10/2024 at 10:05 AM, Patient Care Tech #7 stated the chair at Station 20 was not in serviceable condition. During an interview on 07/10/2024 at 2:40 PM, Registered Nurse (RN) #5 stated all staff were responsible to report any issues with unserviceable items on the treatment floor. RN #5 stated she expected, if a chair was unserviceable, it would be replaced with another one. RN #5 confirmed the chair at Station 20 was not in serviceable condition. During an interview on 07/10/2024 at 4:00 PM, the Facility Administrator (FA) stated he was recently made aware of the unserviceable dialysis chair at Station 20. The FA stated the chair need to replaced and repaired. During an interview on 07/11/2024 at 1:20 PM, the Medical Director stated she expected the facility to maintain equipment in a serviceable condition.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 35949 Based on interview, record review, and facility policy review, the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 7 (Patients #1, #2, #3, #4, #5, #6, and #7) of 7 sampled patients. Failure to follow the medical providers’ dialysis prescription had the likelihood to negatively impact the effectiveness of the prescribed dialysis treatments for the 65 patients who received dialysis treatments at the facility. Findings included: A facility policy titled, “Physician Order Documentation,” published 07/03/2023, indicated, “General Policy Nurse practice acts require nurses to carry out treatment care, medication administration, lab tests, procedures, and other treatments, based on physician orders.” 1. Patient #1’s “Order Summary Report,” revealed an order dated 06/24/2024, for a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min). Patient #1’s treatment sheet, dated 07/01/2024, revealed the patient’s BFR was documented as 400 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #1’s “Patient Transfer,” revealed a prescribed dialysate flow rate (DFR) of 800 mL/min dated 07/03/2024. Patient #1’s treatment sheet, dated 07/05/2024, revealed the patient’s DFR was documented as 500 mL/min from 2:08 PM until the treatment was terminated at 3:32 PM. There was no rationale documented for the change to the prescribed DFR. 2. Patient #2’s “Order Summary Report,” revealed an order dated 05/02/2024, for a prescribed dialysate flow rate (DFR) of 700 milliliters per minute (mL/min). Patient #2’s treatment sheet, dated 06/20/2024, revealed the patient’s DFR was documented as 500 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed DFR. Patient #2’s “Patient Transfer,” revealed a prescribed DFR of 700 mL/min and a treatment duration of four hours dated 06/29/2024. Patient #2’s treatment sheet, dated 07/04/2024, revealed the patient’s treatment duration was documented as three hours. There was no rationale documented for the change to the treatment duration. Patient #2’s treatment sheet, dated 07/09/2024, revealed the patient’s DFR was documented between 500 mL/min and 600 mL/min from 6:57 AM until 8:31 AM. There was no rationale documented for the change to the prescribed DFR. 3. Patient #3’s “Patient Transfer,” revealed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min) and a prescribed dialysate flow rate (DFR) of 800 mL/min dated 05/20/2024. Patient #3’s treatment sheet, dated 06/19/2024, revealed the patient’s BFR was documented as 400 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #3’s treatment sheet, dated 06/21/2024, revealed the patient’s BFR was documented as 350 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #3’s treatment sheet, dated 06/26/2024 revealed the patient’s DFR was documented between 0 mL/min and 500 mL/min from 9:02 AM until the treatment was terminated at 10:16 AM. There was no rationale documented for the change to the prescribed DFR. Patient #3’s treatment sheet, dated 06/28/2024 revealed the patient’s BFR was documented as 300 mL/min from 8:32 AM until the treatment was terminated at 10:17 AM. There was no rationale documented for the change to the prescribed BFR. Patient #3’s treatment sheet, dated 07/01/2024, revealed the patient’s BFR was documented as 375 mL/min from 7:32 AM until the treatment was terminated at 10:25 AM. There was no rationale documented for the change to the prescribed BFR. 4. Patient #4’s “Order Summary Report,” revealed an order dated 05/20/2024, for a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #4’s treatment sheet, dated 06/26/2024, revealed the patient’s BFR was documented between 250 mL/min and 350 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #4’s treatment sheet, dated 06/28/2024, revealed the patient’s BFR was documented between 300 mL/min and 350 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #4’s treatment sheet, dated 07/01/2024, revealed the patient’s BFR was documented as 350 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #4’s treatment sheet, dated 07/02/2024, revealed the patient’s BFR was documented between 300 mL/min and 350 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #4’s “Patient Transfer,” revealed a prescribed BFR of 400 mL/min dated 07/03/2024. Patient #4’s treatment sheet, dated 07/03/2024, revealed the patient’s BFR was documented between 300 mL/min and 350 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #4’s treatment sheet, dated 07/05/2024, revealed the patient’s BFR was documented as 350 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. 5. Patient #5’s “Order Summary Report,” revealed an order dated 05/02/2024, for a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min) and a prescribed dialysate flow rate (DFR) of 800 mL/min. dated 05/02/2024. Patient #5’s treatment sheet, dated 06/18/2024, revealed the patient’s BFR was documented between 400 mL/min and 440 mL/min and their DFR was documented between 500 mL/min and 770 mL/min from 10:30 AM until the treatment was terminated at 11:37 AM. There was no rationale documented for the change to the prescribed BFR and DFR. Patient #5’s treatment sheet, dated 06/22/2024, revealed the patient’s BFR was documented between 350 mL/min and 400 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #5’s treatment sheet, dated 06/25/2024, revealed the patient’s BFR was documented between 300 mL/min and 350 mL/min during the entire treatment and their DFR was documented as 500 mL/min from 10:48 AM until the treatment was terminated at 11:36 AM. There was no rationale documented for the change to the prescribed BFR and DFR. Patient #5’s treatment sheet, dated 06/27/2024, revealed the patient’s BFR was documented as 400 mL/min from 9:02 AM until the treatment was terminated at 11:16 AM. There was no rationale documented for the change to the prescribed BFR. Patient #5’s “Patient Transfer,” revealed a prescribed BFR of 450 mL/min, a prescribed DFR of 800 mL/min, and a prescribed treatment duration of three hours and 45 minutes dated 06/29/2024. Patient #5’s treatment sheet, dated 06/29/2024, revealed the patient’s BFR was documented as 400 mL/min and their DFR was documented between 500 mL/min and 600 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR and DFR. Patient #5’s treatment sheet, dated 07/04/2024, revealed the patient’s BFR was documented as 400 mL/min from 10:47 AM until the treatment was terminated at 11:50 AM. There was no rationale documented for the change to the prescribed BFR. Patient #5’s treatment sheet, dated 07/09/2024, revealed the patient’s BFR was documented between 350 mL/min and 400 mL/min from 9:24 AM until the treatment was terminated at 11:01 AM and the treatment duration was documented at three hours and 18 minutes. There was no rationale documented for the change to the prescribed BFR and treatment duration. 6. Patient #6’s “Patient Transfer,” revealed a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min) and a prescribed treatment duration of four hours and 15 minutes dated 06/07/2024. Patient #6’s treatment sheet, dated 06/21/2024, revealed the patient’s BFR was documented as 300 mL/min during the entire treatment and their treatment duration was documented as two hours and 53 minutes. There was no rationale documented for the change to the prescribed BFR and the treatment duration. Patient’s #6’s treatment sheet, dated 06/26/2024, revealed the patient’s BFR was documented as 300 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. Patient #6’s treatment sheet, dated 06/28/2024, revealed the patient’s BFR was documented as 300 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. 7. Patient #7’s “Patient Transfer,” revealed a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min) dated 06/06/2024. Patient #7’s treatment sheet, dated 06/29/2024, revealed the patient’s BFR was documented as 305 mL/min during the entire treatment. There was no rationale documented for the change to the prescribed BFR. During an interview on 07/11/2024 at 10:00 AM, Patient Care Technician (PCT) #7 stated documentation was required when a patient’s BFR, DFR, and/or duration was not as prescribed. PCT #7 stated the process for initiation of a dialysis treatment included checking the prescription and setting of the dialysis machine to those parameters. During an interview on 07/11/2024 at 12:10 PM, Registered Nurse (RN) #5 stated the process for initiation of a dialysis treatment was to review the orders and set the machine parameters based on the physician’s prescription. RN #5 stated a documented reason was expected for changes to a patient’s BFR, DFR, and/or duration. During an interview on 07/11/2024 at 1:15 PM, the Medical Director (MD) confirmed the staff were trained and expected to include reasons for changes when the prescribed BFR and/or duration was not achieved during dialysis treatments. The MD stated the DFR should always be as prescribed. During an interview on 07/11/2024 at 2:15 PM, the Facility Administrator stated the referenced treatment sheets were reviewed and lacked documentation of a rationale for the changes to the patient’s prescribed BFR, DFR, and/or treatment duration. The Facility Administrator stated the staff were trained and expected to include documentation.”

“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: 35949 Based on interview, record review, and facility policy review, the facility failed to monitor patients’ vital signs and/or machine parameters according to their policy for 7 (Patients #1, #2, #3, #4, #5, #6, and #7) of 7 sampled patients. Failure to monitor patients’ vitals and machine parameters according to the facility’s policy provided an opportunity for changes to the patients’ condition during dialysis treatments to be unrecognized and unaddressed and negatively impact the care provided to the 65 patients who received dialysis treatments at the facility. Findings included: A facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, indicated, “During Treatment * Obtain 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 or per state regulations.” 1. Patient #1’s treatment sheet, dated 06/19/2024, revealed monitoring was not documented for 50 minutes, from 10:49 AM until 11:39 AM. Patient #1’s treatment sheet, dated 06/24/2024, revealed monitoring was not documented for 52 minutes, from 10:39 AM until 11:31 AM. Patient #1’s treatment sheet, dated 06/26/2024, revealed monitoring was not documented for 49 minutes, from 11:03 AM until 11:52 AM. Patient #1’s treatment sheet, dated 07/05/2024, revealed monitoring was not documented for 78 minutes, from 11:13 AM until 12:31 PM. 2. Patient #2’s treatment sheet, dated 06/18/2024, revealed monitoring was not documented for 49 minutes, from 9:15 AM until 10:04 AM. Patient #2’s treatment sheet, dated 07/02/2024, revealed monitoring was not documented for 54 minutes, from 10:01 AM until 10:55 AM. 3. Patient #3’s treatment sheet, dated 06/19/2024, revealed monitoring was not documented for 50 minutes, from 8:33 AM until 9:30 AM. Patient #3’s treatment sheet, dated 07/01/2024, revealed monitoring was not documented for 62 minutes, from 8:02 AM until 9:04 AM. Patient #3’s treatment sheet, dated 07/05/2024, revealed monitoring was not documented for 65 minutes, from 6:33 AM until 7:38 AM. 4. Patient #4’s treatment sheet, dated 06/26/2024, revealed monitoring was not documented for 54 minutes, from 6:38 AM until 7:32 AM. Patient #4’s treatment sheet, dated 07/01/2024, revealed monitoring was not documented for 62 minutes, from 8:03 AM until 9:05 AM. Patient #4’s treatment sheet, dated 07/05/2024, revealed monitoring was not documented for 60 minutes, from 10:02 AM until 11:02 AM. 5. Patient #5’s treatment sheet, dated 06/19/2024, revealed monitoring was not documented for 50 minutes, from 10:49 AM until 11:39 AM. Patient #5’s treatment sheet, dated 06/20/2024, revealed monitoring was not documented for 60 minutes, from 9:02 AM until 10:02 AM. Patient #5’s treatment sheet, dated 06/22/2024, revealed monitoring was not documented for 73 minutes, from 8:33 AM until 9:46 AM. Patient #5’s treatment sheet, dated 06/29/2024, revealed monitoring was not documented for 73 minutes, from 10:00 AM until 11:13 AM. Patient #5’s treatment sheet, dated 07/04/2024, revealed monitoring was not documented for 129 minutes, from 9:00 AM until 11:09 AM. 6. Patient #6’s treatment sheet, dated 06/26/2024, revealed monitoring was not documented for 60 minutes, from 6:38 AM until 7:38 AM. Patient #6’s treatment sheet, dated 07/03/2024, revealed monitoring was not documented for 53 minutes, from 9:30 AM until 10:23 AM. Patient #6’s treatment sheet, dated 07/05/2024, revealed monitoring was not documented for 62 minutes, from 9:32 AM until 10:34 AM. 7. Patient #7’s treatment sheet, dated 06/18/2024, revealed monitoring was not documented for 60 minutes, from 2:04 PM until 3:04 PM. Patient #7’s treatment sheet, dated 06/27/2024, revealed monitoring was not documented for 116 minutes, from 1:07 PM until 3:03 PM. Patient #7’s treatment sheet, dated 06/29/2024, revealed monitoring was not documented for 100 minutes, from 2:03 PM until 3:43 PM. Patient #7’s treatment sheet, dated 07/04/2024, revealed monitoring was not documented for 52 minutes, from 2:10 PM until 3:02 PM. During an interview on 07/11/2024 at 10:00 AM, Patient Care Technician #7 stated she was trained and it was expected of staff to perform patient monitoring every 30 minutes. During an interview on 07/11/2024 at 12:10 PM, Registered Nurse #5 stated patient monitoring should be done every 30 minutes as trained. During an interview on 07/11/2024 at 1:15 PM, the Medical Director confirmed staff were trained and expected to monitor patients every 30 minutes. During an interview on 07/11/2024 at 2:15 PM, the Facility Administrator stated staff were trained and expected to monitor patients every 30 minutes.”