292500 Desert Inn Dialysis (Fmc)

“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: 39418 Based on observation, interview, record and document review, the facility failed to ensure dialysis orders were followed during the initiation of hemodialysis treatment for 1 of 6 sampled patients (Patient 1). The deficient practice had potential for a hemodialysis patient to sustain a life-threatening dialysis treatment complication. Findings include: Patient (P1) P1 had a diagnosis of End Stage Renal Disease. P1 was receiving in-center hemodialysis treatment on Tuesday, Thursday and Saturdays. On 07/30/2024 at 1:05 PM, initiation of dialysis treatment for P1 was observed at station 12. The dialysis patient care technician (PCT) was observed finishing up on the dialysis machine set up with the Registered Nurse (RN) confirming the machine conductivity (the level of all electrolytes in the final dialysate) reading from the PCT. The PCT was observed to gather all the needed supplies to access P1’s dialysis access. The RN was observed assessing P1’s health status prior to initiating the treatment. The RN was observed entering the necessary settings onto the dialysis machine based on the physician’s order screen. The PCT initiated P1’s hemodialysis treatment utilizing the dialysis central venous access port. On 07/30/2024 at 1:12 PM, the RN indicated entries of dialysis treatment orders can be entered by the PCT or RN. The RN confirmed all entries of dialysis treatment orders to the dialysis machine will be verified by the RN. The verification process was part of the initial patient assessment process and ensures the order entry into the dialysis machine is congruent with the physician’s order. On 07/30/2024 at 1:30 PM (20 minutes into P1’s treatment), review of the settings entered into dialysis machine and comparing the physician order screen was completed with the RN. During the verification process, it was identified the machine acid line was connected to the 3K (potassium) dialysate delivery port and the actual order was for 2K. The RN confirmed the acid line should have been plugged in at the 2K port not the 3K. The RN acknowledged the checking of the correct dialysate port was part of the safety checks performed before the initiation of the treatment. P1’s Treatment Sheet for 07/27/2024, documented Dialysate Composition: 2K; 2.5 Calcium, 100 Dextrose. On 07/30/2024 at 2:00 PM, the charge nurse 2 (CN2) confirmed from P1’s medical record the dialysate composition was ordered on 07/18/2024. The CN2 agreed the dialysate line should have been checked as part of the order verification process and safety checks prior to the initiation of the treatment. The CN2 indicated dialysate check was part of the audit tool to confirm the physician’s order was being followed and was implemented as part of the plan of correction from the previous survey findings. The CN2 indicated the correct acid dialysate was vital for a patient’s cardiac status and imbalanced potassium could lead to serious complications. On 07/30/2024 at 2:20 PM, the Area Team Lead acknowledged the missed physician’s order was unfortunate and preventable especially when the necessary safety checks were completed appropriately. On 07/30/2024 at 2:45 PM, the Director of Operations explained the identified RN with the missed physician order was a visiting RN from another unit. The Director acknowledged the process of verification of physician’s order was a standard procedure for all the clinics and should have been conducted for all patient treatments. The RN Rounding Tool initiated as part of the Audit Tool for the plan of correction initiated on July 1, 2024 (stated by the CN2), documented as part of the checklist item: Dialysate as ordered? Does the machine match the physician’s orders? The facility policy titled Pre-treatment Safety Checks Procedure dated 02/06/2024, documented Prescribed dialysate composition: Verify the proper delivery of dialysate prescription: Machine is connected to an acid concentrate that matches the prescription. Verify by matching label on the valve panel or concentrate jug.”

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 29141 Based on interview, record review and document review, the facility failed to 1) identify, communicate, and address a patient’s report of blood in stool and 2) ensure a prescriber’s verbal order to hold Heparin (an anti-coagulant commonly used during dialysis treatments) for a patient with suspected gastro-intestinal (GI) bleeding was transcribed and carried out for 1 of 4 sampled patients (Patient #1). The deficient practice placed the patient at risk for progressive bleeding and may have contributed to the patient’s hypotensive episode (See Tag V0507). The lack of assessment and the failure to promptly address the suspected GI bleed by transcribing the verbal order for holding the heparin, and to communicate the concern to the skilled nursing facility where the patient resided, in order to ensure a coordination of care with the primary care physician, lead to a severe health complication resulting in the transportation of the patient to a hospital, and subsequent death. The cumulative effect of these practices resulted in the failure of the facility to deliver statutorily mandated care to a patient (Patient #1).”

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 29141 Based on record review, interview, and document review, the facility failed to ensure: 1) a patient care technician did not initiate a hemodialysis treatment in a patient having abnormal vital signs before nursing assessment and physician approval was obtained, 2) a patient care technician reported abnormal vital signs to the registered nurse before the initiation of a hemodialysis treatment, 3) a registered nurse assessed a patient before the initiation of a hemodialysis treatment, and 4) the attending nephrologist or physician extender was notified about a patient having abnormal vital signs before the initiation of a hemodialysis treatment for 1 of 4 sampled patients (Patient #1). The lack of assessment and the failure to promptly address the abnormal vital signs and report findings to the attending physician, lead to a severe health complication resulting in the transportation of the patient to a hospital. The deficient practices may have led to a negative outcome as the patient suffered a cardiac arrest during dialysis, resulting in transportation to a hospital, and subsequent death (See Tag V0543). The cumulative effect of these practices resulted in the failure of the facility to deliver statutorily mandated care to a patient (Patient #1).”

“PA-ASSESS ANEMIA CFR(s): 494.80(a)(4) The patient’s comprehensive assessment must include, but is not limited to, the following: (4) Evaluation of factors associated with anemia, such as hematocrit, hemoglobin, iron stores, and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agent(s). This Standard is not met as evidenced by: 29141 Based on interview, record review and document review, the facility failed to 1) identify, communicate, and address a patient’s report of blood in stool and 2) ensure a prescriber’s verbal order to hold Heparin (an anti-coagulant commonly used during dialysis treatments) for a patient with suspected gastro-intestinal (GI) bleeding was transcribed and carried out for 1 of 4 sampled patients (Patient #1). The deficient practice placed the patient at risk for progressive bleeding. Findings include: Patient #1 (P1) P1 was admitted on 12/28/2023, with diagnoses including end stage renal disease. P1 resided in a skilled nursing facility (SNF). The hemodialysis treatment record dated 05/21/2024, revealed P1’s dialysis orders included administration of Heparin Sodium (an anticoagulant or blood thinner) 1,000 units/milliliter (ml) systemic, administer 2,000 units bolus (given at start of treatment). Administer 500 units via infusion pump (during treatment). The hemodialysis treatment record dated 05/21/2024, revealed the following pre-treatment information by the patient care technician (PCT) at 1:23 PM: - Blood pressure (BP) 92milliliters of mercury (mmHg) systolic/52 mmHg. - Heart rate (HR) 48. - New observation or complaints such as fall or injury: None. - Heparin 2,000 units bolus administered at 1:24 PM. The hemodialysis treatment record dated 05/21/2024, revealed the following pre-treatment information by the Registered Nurse (RN) at 1:35 PM: -No new gastrointestinal (GI) symptoms. -Notes: P1 reported blood in stool, Nurse Practitioner (NP) aware. Orders to follow up with primary physician. Hemoglobin (Hg) drawn. The hemodialysis treatment record dated 05/21/2024, revealed the following post-treatment information by the RN at 6:27 PM: -No complaints, no GI symptoms A physician’s order dated 05/21/2024, documented to refer P1 to primary care physician (PCP) due to complaints of blood in stool last night. On 06/12/2024 in the afternoon, the NP recounted doing rounds on 05/21/2024 and spoke with P1 during treatment. The NP indicated P1 was alert and informed the NP there was blood in the patient’s stool the evening prior. The NP reviewed P1’s Hemoglobin (Hg - an Oxygen carrying molecule in red blood cells) which revealed P1’s Hg had dropped from 11 grams per deciliter (g/dL) on 05/16/2024 down to 8.2 g/dL on 05/21/2024. The NP recalled giving the RN verbal orders to hold P1’s Heparin and to communicate an order for GI consult to the skilled nursing facility. A Pre/Post Dialysis Communication Record dated 05/21/2024 (form used to coordinate P1’s care with the SNF), lacked documented evidence the RN communicated to the SNF about the NP’s orders to refer P1 to the PCP and GI doctor due to blood in stool and to hold P1’s Heparin due to suspected GI bleed. The medical record lacked documented evidence the RN transcribed the NP’s verbal orders to hold P1’s Heparin after complaints of (c/o) blood in stool was communicated by the patient to the NP on 05/21/2024. The medical record from the skilled nursing facility where P1 resided, revealed a PCP’s order dated 05/06/2024 for Heparin Sodium 5,000 units to be administered subcutaneously three times daily for deep venous thrombosis prophylaxis. The SNF medication administration record revealed P1 received Heparin 5,000 units subcutaneously on 05/21/2024 twice, at 5:58 PM and at 9:21 PM. The SNF medical record lacked documented evidence the dialysis center had communicated the concern related to a suspected GI bleed to prevent the administration of blood thinners, and to arrange an appointment with a GI physician. The SNF medical record revealed a Pre/Post Dialysis Communication Record dated 05/21/2024. The record lacked documented evidence the hemodialysis RN communicated to the SNF about the NP’s orders to refer P1 to the PCP and GI doctor due to blood in stool and to hold P1’s Heparin due to suspected GI bleed. The hemodialysis treatment record dated 05/23/2024, revealed the following pre-treatment information by the patient care technician (PCT) at 1:20 PM: -BP 93/47 mmHg -HR 40 -New observation or complaints such as fall or injury: None - Heparin 2,000 units bolus administered at 1:21 PM A Clinical Note dated 05/23/2024, revealed at approximately 2:15 PM, NP alerted the RN of P1’s level of alertness. BP rechecked 85/52 HR 48. Attempted to arouse patient to no avail. Code status confirmed in chairside. Carotid pulse weak with agonal (gasping) breathing noted. P1 placed in modified Trendelenburg, back board placed, cardiopulmonary resuscitation (CPR) started. Emergency services arrived 2:30 PM, paramedics took over code, left clinic 2:37 PM with CPR ongoing. A Clinical note dated 05/23/2024, revealed hospital called dialysis clinic to inform P1’s death was pronounced at 3:02 PM. On 06/12/2024 in the afternoon, the NP expressed concern upon learning the RN did not communicate the suspected GI bleed concern to the SNF and did not transcribe the NP’s verbal orders to hold Heparin on 05/21/2024 and the PCT had administered P1’s Heparin bolus on 05/23/2024. The NP indicated an order to refer P1 to the PCP and a GI specialist regarding suspected GI bleed was likewise not communicated to the skilled nursing facility. The NP indicated blood was coming out of P1’s mouth during CPR which possibly pointed to a GI bleed. On 06/12/2024 in the afternoon, a PCT who had assisted in P1’s CPR response recalled the NP initiated a code for P1 when the patient was found unresponsive during treatment on 05/23/2024. The PCT was tasked to terminate P1’s treatment by rinsing back and disconnecting the lines from P1’s central venous catheter (CVC). The PCT recalled seeing blood coming out of P1’s mouth during resuscitation efforts and the PCT constantly wiped the blood off prior to suctioning to allow for efficient Oxygen administration using the Ambu-bag. The Physician Order Documentation policy dated 07/03/2023, documented nurse practice acts required nurses to carry out physician medication administration, laboratory, and treatment services in accordance with physician’s orders. All medical orders were to be entered in the patient’s electronic health record. Verbal orders must be entered in the clinical system by appropriate licensed personnel who received the verbal order as allowed by licensure., scope of practice and federal/state regulations.”

“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: 29141 Based on record review, interview, and document review, the facility failed to ensure: 1) a patient care technician did not initiate a hemodialysis treatment in a patient having abnormal vital signs before nursing assessment and physician approval was obtained, 2) a patient care technician reported abnormal vital signs to the registered nurse before the initiation of a hemodialysis treatment, 3) a registered nurse assessed a patient before the initiation of a hemodialysis treatment, and 4) the attending nephrologist or physician extended was notified about a patient having abnormal vital signs before the initiation of a hemodialysis treatment for 1 of 4 sampled patients (Patient #1). The deficient practice led to a negative outcome as the patient suffered a cardiac arrest resulting in transportation to a hospital, and subsequent death. Findings included: Patient #1 (P1) P1 was admitted on 12/28/2023, with diagnoses including end stage renal disease. Hemodialysis treatment records dated 05/07/2024, 05/09/2024, 05/11/2024, 05/14/2024, 05/16/2024, and 05/18/2024, lacked documented evidence nursing approval was obtained to start the treatments. A hemodialysis treatment record dated 05/21/2024, revealed a patient care technician (PCT) obtained P1’s vital signs at 1:23 PM which included a blood pressure (BP) of 92/52 and heart rate (HR) of 48 beats per minute (bpm). The treatment record lacked documented evidence nursing approval was obtained to start the treatment. The hemodialysis treatment record dated 05/21/2024, revealed P1 was connected to the hemodialysis machine and the treatment started at 1:32 PM with a BP of 88/52 and HR of 45 bpm. The ultrafiltration rate (UFR - amount of fluid removed in milliliters (ml) per minute (min) was running at 70 ml/min. (Ultrafiltration (UF) can lead to decreased blood volume and lower blood pressure). The hemodialysis treatment record dated 05/21/2024, revealed the following intradialytic (during dialysis) monitoring information: 2:00 PM: BP 98/53 HR 47 bpm UF on. UFR 140 ml/min. The pre-treatment assessment performed at 1:35 PM, indicated P1 had low BP with no signs or symptoms. The record indicated 250 ml of normal saline solution (intravenous fluid) were administered at the end of the hemodialysis treatment. The record lacked documented evidence the vital signs were verified and re-checked by the RN during the pre-treatment assessment and reported to the attending nephrologist or physician extender. A hemodialysis treatment record dated 05/23/2024, revealed a patient care technician (PCT) obtained P1’s vital signs at 1:20 PM which included a BP of 93/47 and HR of 40 bpm. The treatment record lacked documented evidence nursing approval was obtained to start the treatment. The hemodialysis treatment record dated 05/23/2024, revealed P1 was connected to the hemodialysis machine and the treatment started at 1:30 PM with a BP of 92/42 and HR of 43 bpm. The UFR was running at 140 ml/min. The hemodialysis treatment record dated 05/23/2024, revealed the following intradialytic monitoring information: 2:00 PM: BP 97/52 HR 48 bpm UF on. UFR 70 ml/min. The hemodialysis treatment record dated 05/23/2024, lacked documented evidence the vital signs were verified, re-checked, reported by the PCT to the RN, the patient was assessed by the RN, and the ultrafiltration was reduced or turned off. The hemodialysis treatment record dated 05/23/2024, revealed the following intradialytic monitoring information: 2:15 PM: BP 85/52 HR 49 bpm Treatment discontinued. P1 unresponsive. 250 ml. normal saline given. 2:16 PM: BP 100/52 HR 49 bpm Carotid pulse weak. Cardiopulmonary resuscitation (CPR) started. The hemodialysis treatment record dated 05/23/2024, revealed P1 received hemodialysis treatment for a period of 45 minutes while having low BP and low HR. A Nurse Practitioner (NP) progress note dated 05/23/2024, revealed the NP was making rounds and found P1 unresponsive, with agonal breathing (gasping), BP 95/48 and HR of 44 bpm. The progress note documented P1 was not receiving medications that decrease HR (beta blocker medications) when the list of medications was checked. The NP tried to wake up the patient unsuccessfully and CPR maneuvers were initiated. A nursing clinical note dated 05/23/2024, confirmed the RN was aware of P1’s low BP and HR before the treatment was started. On 06/12/2024 at 11:43 AM, the RN indicated being assigned to P1 on 05/21/2024 and 05/23/2024 and described P1 as having baseline hypotensive (low BP) and bradycardic (low HR) and had undergone a recent thyroidectomy (surgical removal of all or part of thyroid gland). The RN recalled P1 reporting to the RN the skilled nursing facility had administered Nifedipine (hypertensive medication) prior to transport to dialysis clinic. The RN indicated the PCT should have reported P1’s low BP and low HR in order to manually confirm the automated readings performed by the hemodialysis machine. According to the RN, the PCT did not report abnormal findings and started the treatment without nursing approval. The RN explained nursing assessments should be performed before the initiation of the treatment which did not occur in the case of P1 because the RN became busy with another patients. The RN stressed the significance of the pre-treatment assessment in order to verify patient’s condition, identify and address abnormalities and to inform the attending nephrologist for further guidance. The medical record revealed a general assessment dated 05/23/2024 documented at 6:51 PM. The note was a late entry since P1’s hemodialysis treatment started at 1:30 PM and patient was transported to a hospital at 2:37 PM. This assessment did not include the verification of the vital signs. On 06/12/2024 at 1:10 PM, the physician indicated being the primary nephrologist for P1. The physician indicated receiving a page from the facility after the incident but did not get notified of any abnormal findings pre-treatment. The physician indicated it would be difficult to comment on what the physician might have done if the physician was informed of the abnormal findings because the physician would have asked more questions from the RN in order to make an informed medical decision on whether to approve P1’s initiation of treatment or transfer to the hospital. On 06/12/2024 at 1:46 PM, the Facility Administrator (FA) indicated conducting an investigation into P1’s incident the following morning on 05/24/2024. Based on the facility’s investigation, the FA acknowledged, 1) the PCT initiated P1’s dialysis treatment without informing the RN of P1’s low BP and low HR, 2) the RN did not conduct a pre-dialysis nursing assessment, and 3) the RN did not notify the nephrologist regarding P1’s hypotension and bradycardia. The FA verbalized this failure resulted in P1 to become unresponsive with unsuccessful resuscitation and eventual pronouncement of death at the hospital at 3:02 PM. On 06/12/2024 at 1:54 PM, the Charge Nurse and the FA indicated even if the patient was baseline hypotensive and bradycardic, it did not eliminate the requirement to notify the RN and the nephrologist of abnormal data collected. On 06/12/2024, the NP explained that on 05/23/2024 while rounding the patients, noticed P1 in an uncomfortable position and called their name. The NP assessed P1’s blood pressure and heart rate, which were low, and a hypotension protocol was initiated. The NP indicated after finding P1 having weak pulse and agonal breathing, CPR maneuvers were started. The NP expected all abnormal findings identified before, during, and after treatment should have been reported to the attending nephrologist or extenders. The NP stated would never allow a patient with a low heart rate to start dialysis until being medically cleared. The facility policy titled Patient Assessment and Monitoring dated 05/01/2023, documented if abnormal findings were identified by the PCT, or patient was hospitalized, the RN must assess the patient. The RN will notify patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgement for additional instruction. The policy provided instructions for the RN to assess and/or reassess any findings addressed pre or during treatment as needed, including Systolic BP less than or equal to 100 mmHg during treatment, and to verify pulse manually if automated readings display below 60 BPM. The facility policy titled Hypotension dated 05/06/2024, revealed the PCT must immediately report signs and symptoms of low blood pressure to the RN. The RN would assume care of the patient, recheck the BP and compare to previous BP. If the BP was verified low, the patient would be positioned with trunk and head horizontally, and legs elevated 30 to 45 degrees, reduce ultrafiltration, or turned off, notify the treating physician for additional orders, administer normal saline solution as ordered by the physician, and monitor and document BP every 5 minutes until patient returned to base line or as ordered by the treating physician.”

“PQ-PCT-TRAINING PROGRAM CONTENT CFR(s): 494.140(e)(3) The training program must include the following subjects: (i) Principles of dialysis. (ii) Care of patients with kidney failure, including interpersonal skills. (iii) Dialysis procedures and documentation, including initiation, proper cannulation techniques, monitoring, and termination of dialysis. (iv) Possible complications of dialysis. (v) Water treatment and dialysate preparation. (vi) Infection control. (vii) Safety. (viii) Dialyzer reprocessing, if applicable. This Standard is not met as evidenced by: 40142 Based on interview, record review and document review the facility failed to ensure updated competencies were completed and maintained for a Registered Nurse (RN1). The deficient practice resulted in failure of the RN to follow pre-treatment assessment protocols which may have resulted in a patient’s hypotensive episode leading to cardio-pulmonary arrest during dialysis. Findings include: Patient #1 (P1) P1 was admitted on 12/28/2023, with diagnoses including end stage renal disease. A Clinical Note dated 05/23/2024, revealed at approximately 2:15 PM, the nurse practitioner (NP) alerted RN1 regarding P1’s level of alertness. Blood pressure (BP) rechecked 85/52 millimeters of mercury (mmHg) and heart rate (HR) 48 beats per minute (bpm). Attempted to arouse patient to no avail. Code status confirmed in chairside. Carotid pulse weak with agonal (gasping for air) breathing noted. P1 placed in modified Trendelenburg, back board placed, compression started. Emergency services arrived 2:30 PM, paramedics took over code, left clinic 2:37 PM with CPR ongoing. A Clinical note dated 05/23/2024, revealed the hospital called dialysis clinic to inform P1’s death was pronounced at 3:02 PM. On 06/12/2024 at 1:46 PM, the Facility Administrator (FA) indicated conducting an investigation into P1’s incident the following morning on 05/22/2024. Based on the facility’s investigation, the FA acknowledged, RN1 did not conduct a pre-dialysis nursing assessment and did not notify the nephrologist regarding P1’s hypotension and bradycardia (low HR). The FA verbalized this failure resulted in P1 to become unresponsive with unsuccessful resuscitation. On 06/12/2024 at 11:43 AM, RN1 indicated being employed for one year and three months with date of hire 02/06/2024. RN1’s Education Transcript revealed the RN was provided new hire training beginning 02/07/2023. On 06/12/2024 at 1:54 PM, the initial and annual clinical skills checklists for RN1 was requested from the charge nurse. On 06/13/2024, the RN’s skills validation checklist was provided and was dated 06/12/2024. The RN 1’s Direct Patient Care Skills Validation (Initial) was completed on 03/30/2023. Topics included pre-dialysis, post-dialysis and intradialytic (during dialysis) assessment and monitoring, ultrafiltration (fluid removal) goal calculation, safety checks, vascular access, cannulation and responding to alarms. The Compliance Training policy dated 01/01/2014, documented compliance training was mandatory and was required to be done upon hire and after the first year of employment. The Clinical Manager was responsible for ensuring that direct reports complete all compliance training in a timely manner, monitor and follow up with overdue training.”