Usrc Akron Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 29732 Based on policy review, observation, and staff interview, the facility failed to ensure staff wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station for two patients observed receiving care on the treatment floor (Patient #2 and #3). This could affect all patients receiving services from the facility. The census was 24. Findings include: Review of the facility policy titled, “Personal Protective Equipment (PPE),” effective 01/2020, revealed all staff must wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Clean gloves will be worn when documenting on keyboard integrated/combined with dialysis machine. Observations were made on the treatment floor on 02/21/24 from 7:43 AM to 9:00 AM. 1. At 8:10 AM Staff I was observed to touch the machine at station #10. Staff I then continued to put a clean dressing on Patient #2’s central venous catheter (CVC) while wearing the same gloves. Interview with Staff I at 8:56 AM revealed gloves should be changed when going from a dirty site to a clean site. 2. At 8:20 AM Staff H was observed to touch the machine in the isolation room without gloves on, then touch Patient #3’s arm and assess the patient’s access site without gloves on. Staff H then used hand sanitizer and touched the patient’s machine without gloves on. Interview with Staff H at 8:30 AM confirmed she was not wearing gloves when she touched Patient #3’s dialysis machine and then Patient #3. Staff H stated, “but it’s not an isolation room” and “I used hand sanitizer.” Staff H asked if gloves were needed because it was an isolation room. 3. At 8:40 AM Staff H was observed touching the keyboard on the dialysis machine at station #12 without wearing gloves. Interview with Staff H at 8:40 AM revealed, “we don’t need gloves when we type.” Interview on 02/21/24 at 8:55 AM with Staff I confirmed the keyboard on the dialysis machine was considered dirty and gloves should be worn when typing on it. This deficiency represents non-compliance investigated under Substantial Allegation OH00149794.”

“GOV-INVOL DISCHARGE PROCESS REQUIREMENTS CFR(s): 494.180(f)(4) The medical director ensures that no patient is discharged or transferred from the facility unless - (4) The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team- (i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record; (ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge; (iii) Obtains a written physician’s order that must be signed by both the medical director and the patient’s attending physician concurring with the patient’s discharge or transfer from the facility; (iv) Contacts another facility, attempts to place the patient there, and documents that effort; and (v) Notifies the State survey agency of the involuntary transfer or discharge. (5) In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure. This Standard is not met as evidenced by: 29732 Based on medical record review, document review, policy review and staff interview, the medical director failed to ensure patients were not discharged or transferred unless the facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record; and provides the patient and the local End-Stage Renal Disease (ESRD) Network with a 30-day notice of the planned discharge for one of three discharged patients reviewed (Patient #7). This could affect all patients receiving services from the facility. The census was 24. Findings include: Review of the discharged patient list revealed Patient #7 was admitted on 04/27/23 and discharged on 10/10/23 with the reason listed as lost to follow up. Review of Patient #7’s medical record revealed a start of care at this facility on 04/27/23. The patient had a dual lumen temporary catheter. The patient was to come for dialysis treatments three times a week for treatments lasting three hours and 45 minutes. Review of a Comprehensive Hemodialysis Note dated 05/11/23 by Staff O revealed the physician had an extensive discussion with the patient’s mother per the patient’s request. The physician explained the importance of completing prescribed treatments and the importance of medications to improve high blood pressure as the patient had had multiple strokes and a heart attack. The physician was highly worried about the uncontrolled blood pressure and the potential for an adverse outcome. Review of a Comprehensive Hemodialysis Note dated 08/17/23 by Staff O revealed the physician had explained to the patient the importance of completing prescribed treatments. The patient was a high cerebral vascular risk. The patient needs better management of her blood pressure. Non-compliance and distrust play a big role in the patient’s poor outcomes. The patient has not changed any of the medications that were changed. Drug therapy is unreasonable and all attempts to change or counsel seem to be failing. There was no documentation of any disruptive behaviors in the patient’s medical record. Review of a Dietitian Progress Note dated 09/14/23 revealed the patient had not attended dialysis treatments at this facility in the month of September due to a combination of missed treatments and hospitalization. Review of a Nurse’s Note dated 09/29/23 by the facility administrator (FA) revealed the patient had not had dialysis treatments at this facility for 30 days. The FA spoke with the physician and Regional Director, and it was OK to discharge the patient. Review of a physician order dated 09/29/23 revealed an order to discharge the patient due to no treatments in the facility for 30 days. Review of handwritten documentation of the patient’s “no shows” revealed from 09/01/23-09/10/23 the patient was admitted to the hospital, 09/11/23, 09/13/23, 09/16/23, 09/18/23 the patient was a No call/No show/No contact, and from 09/20/23 to 09/30/23 the patient was hospitalized. Review of the Discharge Summary revealed the discharge date as 08/31/23 due to absence greater than 30 days. Her last in facility treatment was 08/30/23. Review of a letter dated 10/02/23 revealed the letter was to inform the patient, in accordance with the facility’s policy, the patient had been discharged from this facility due to missed treatments lasting greater than 30 days. This was not a 30 day discharge notice. Interview on 02/21/24 at 10:00 AM with Staff D revealed Patient #7 was discharged after more than 30 days of absence from the facility. Staff D stated the patient stated they were only doing two hours of dialysis and would sign off Against Medical Advice (AMA) nearly every treatment. Staff D stated the patient was non-compliant with medications and would not try new medications for high blood pressures. The patient did not think she had a problem with her blood pressure. The patient lived with her parents. The mother did not believe that a change in diet, blood pressure medications, or dialysis was really needed. The mother was hostile, confrontational, and not doing the best for the patient. Staff D stated the mother was not willing to learn or listen to the staff and was very aggressive. Interview on 02/21/24 at 11:08 AM with Staff B revealed the patient was in the hospital from 09/01/23 to 09/10/23 and from 09/20/23 to 09/30/23. Staff B stated the patient’s mother would come to the facility and was verbally abusive, aggressive, and harassing and would talk over you and not listen. The police had been called twice because the mother would not leave, and a restraining order was considered. Staff B confirmed this was not documented and an incident report had not been filled out. Staff B stated the patient was discharged on 10/10/23 but it was retro-active to 08/31/23 because the patient’s last treatment was 08/30/23. The patient had gone 30 days with no contact. Interview on 02/21/24 at 2:25 PM with Staff A revealed the patient was in and out of many hospitals and frequently was a no show for dialysis treatments. Interview on 02/22/24 at 10:57 AM with Staff B revealed the hospital case manager called this facility and asked if the patient had dialyzed here. The case manager was told yes but the patient had been discharged due to not being at the facility for over 30 days. Staff B stated in January there was a conference call with the Renal Network, Medical Director, Director of Clinical Services, Regional Director, and Staff B. The Medical Director had stated that the patient had yelled at and thrown the Nephrologist, Medical Director, out of the hospital room. Staff B stated the Renal Network informed the facility that this was an Involuntary discharge. Staff B stated the Involuntary Discharge policy was not followed. Review of the facility’s policy titled, “Admission/Discharge of Patients and End of Treatment Day Discharge,” effective 01/2020, revealed discharge reasons may include Involuntary discharge and Lost to follow-up for patients who stopped attending dialysis and their whereabouts are unknown; facility should make every effort to locate the patient; and this discharge reason may only be used in conjunction with Network approval and patient is out of the facility >30 days. Discharge steps include discussion with the patient’s physician to determine the extent of the absence and likelihood of return based on patient’s condition. It is at the discretion of the facility to manually hold the patients’ normal, scheduled day and time slot beyond 30 days. NOTE: If the patients’ normal, scheduled day and time slot will be released after absence from the facility >30 days, notify patient and/or family of the decision. A physician order for the discharge will be obtained and placed in the patient’s medical record. A discharge summary will be completed. Discharge date will be the day after the last dialysis session. The patient’s whereabouts were not unknown. Although the patient was out of the facility for 30 days, the lost to follow up reason for discharge was not used in conjunction with Network approval. Review of the facility policy titled, “Involuntary Discharge or Transfer of a Patient and Checklist,” revised 04/2023, revealed patients may be transferred or discharged from the facility with appropriate documentation and approvals for the following reasons: patient’s behavior is disruptive, threatening or violent to the degree that delivery of care and/or facility operations is seriously impaired. The facility’s first priority is the safety and security of patients, staff and visitors. No threats or acts of aggression/violence will be tolerated against any patient, staff or visitor. Any violation of this policy will result in an assessment by the Facility Administrator (FA), Social Worker (SW) and Medical Director to determine the extent of the threatening situation and the actions to address the behavior. All facilities must notify their network of potential involuntary discharge (IVD) to assist with intervention. Attempts to resolve issues will be thoroughly documented and include: Documentation of medical need(s) and why the facility can no longer meet the specific need(s); Any and all steps taken to resolve behavioral issues including an agreement of expectations, if utilized, as part of an action plan. If all steps have been exhausted with no resolution of issues, the facility will: Notify and obtain approval for discharge from Medical Director. Obtain a written order for discharge signed by the patient’s nephrologist and Medical Director. Provide the patient (in-person and/or certified mail) and local ESRD Network a 30-day notice of discharge letter [specific to the incident(s)] with Medical Director’s signature via overnight service and certified mail (not applicable for immediate IVD for threats/violent behavior). The letter will include a list of facilities to assist in finding another outpatient facility. Always keep copies of all documentation sent to the patient; scan into the electronic medical record. Assist with placement in another dialysis facility. The patient’s medical record lacked documentation of disruptive behavior or documentation why the facility could no longer meet the patient’s needs. The Network was not notified of a potential IVD to assist with intervention. The patient was not issued a 30-day notice of discharge letter. This deficiency represents non-compliance investigated under Substantial Allegation OH00149794.”