Fmc Redmond

“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: 31224 Based on observation, interview and review of documentation, it was determined the facility failed to ensure that emergency drugs and equipment remained immediately available for use and secured in a locked cart. Findings: Observation of the in-center emergency code cart on 04/01/2024 at 1330 revealed the emergency code cart was unsecured. The breakaway lock was placed in a manner which did not prevent the opening of the drawers and accessing the emergency medications and equipment contained therein. During interview on 04/01/2024 at 1330, an RN confirmed the emergency code cart was not secured and the contents were accessible.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 47148 Based on interview and review of documentation, it was determined that the facility had failed to ensure that staff members that were not immune to Hepatitis B were offered Hepatitis B vaccination. Findings: Review of the “Redmond Clinic #3908 Oregon Employee Files Workbook” completed by the FA revealed that Employees #8 and #9 lacked documentation that these employees had received or declined the Hepatitis B vaccine. An interview with the FA on 04/03/2024 at 1000 confirmed these personnel files lacked documentation that Employees #8 (hire date 11/13/2023) and #9 (hire date 11/13/2023) had received or declined the Hepatitis B vaccine and further documentation of Hepatitis vaccination was not available. CDC requirements incorporated by reference require all staff to be offered Hepatitis B vaccination and documentation of vaccination or declination of the vaccine be maintained.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 31224 Based on observation, it was determined that the water purification and storage system were not secured or restricted to prevent access by unauthorized users. Findings: Observation of the facility on 04/01/2024 beginning at 1305 revealed the water purification and storage system was located in a space within the supply room. The supply area had an entrance door off of a general access hallway and an entrance door off of the treatment floor. Both were accessible with a keyless entry lock which utilized a security door code. This door code was the same code for all other secured areas and could be entered by anyone with the door code, including those not trained in water monitoring and maintenance. During interview on 04/01/2024 at 1420, an RN reported the security door code was the same for all doors in the dialysis facility, but that there was a line on the floor to indicate where only trained staff were allowed to cross. During interview on 04/01/2024 at 1620, the FA confirmed the door code was the same and that unauthorized individuals could access this equipment.”

“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: 31224 Based on interview, review of patient medical records and review of documentation, it was determined that the facility failed to ensure that patients received appropriate and timely hemodialysis monitoring or that the dialysis prescription was followed for 5 of 5 patients (Patients #s 1-5). Findings: 1. Review of Patient #1’s dialysis orders and treatment sheets dated 02/27/2024 through 03/30/2024 (15 hemodialysis treatments) reflected the following: * The treatment flowsheets reflected vital signs and access checks were missed: - On 03/14/2024, the PCT documented a VS and access check at 1400. At 1414, the PCT documented a set of identical vital signs, but no patient safety or access checks. The next VS and access check was documented 61 minutes later at 1501. - On 03/23/2024, the PCT documented a VS and access check at 1233. The next VS and access check was documented 59 minutes later at 1332. - On 03/26/2024, the PCT documented a VS and access check at 1205. The PCT documented a VS and access check 59 minutes later at 1304. The PCT next documented a VS and access check 56 minutes later at 1400. The PCT then documented the next VS and access check 58 minutes later at 1458. - On 03/30/2024, the PCT documented a VS and access check at 1137. The next VS and access check was documented 56 minutes later at 1233. * The treatment flowsheets reflected the physician order for BFR was 450 mL/min. The BFR was set by the PCT and verified by a second PCT at 400 mL/min on 02/27/2024, 03/05/2024, 03/09/2024, 03/12/2024, 03/21/2024, and 03/23/2024. PCT documentation and RN evaluation did not note why the physician orders were not followed. 2. Review of Patient #3’s dialysis orders and treatment sheets dated 03/09/2024 through 03/30/2024 (13 hemodialysis treatments) reflected the following: * The treatment flowsheets reflected vital signs and access checks were missed on 03/09/2024, 03/11/2024, 03/14/2024, 03/21/2024, 03/28/2024, and 03/30/2024. Examples included: - On 03/09/2024, the PCT documented a VS and access check at 1004. The next VS and access check was documented 57 minutes later at 1101. The PCT next documented a VS and access check 63 minutes later at 1204. - On 03/14/2024, the PCT documented a VS and access check at 1035. The next VS and access check was documented 124 minutes later at 1239. - On 03/21/2024, the PCT documented a VS and access check at 1004. The next VS and access check was documented 153 minutes later at 1247. * The treatment flowsheets reflected the physician orders for BFR was 350 mL/min and DFR was “Autoflow 2.0,” which meant the DFR would run at 700 mL/min. - On 03/11/2024, the PCT set the DFR at 800 mL/min with no documentation by the PCT or RN to indicate why the physician order was not followed. - On 03/12/2024, the PCT set the BFR at 300 mL/min with no documentation by the PCT or RN to indicate why the physician order was not followed. This resulted in the DFR running at 600 mL/min. - On 03/14/2024 at 1239, the PCT documented increasing the DFR to 800 mL/min with no documentation by the PCT or RN to indicate why the physician order was not followed. - On 03/28/2024 at 0934, the PCT documented decreasing the BFR to 300 mL/min with no documentation by the PCT or RN to indicate why the physician order was not followed. This resulted in the DFR running at 600 mL/min. 3. Similar findings were noted for Patient #2, Patient #4, and Patient #5. 4. Review of facility policy titled,”Patient Assessment and Monitoring,” dated 05/01/2023, stipulated: * “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 [min] or more often as needed but not to exceed 45 minutes or per state regulations.” * “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow.” * “Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” During interview on 04/02/2024 at 1520, the CM and FA confirmed the above findings.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 47148 Based on interview and review of documentation, it was determined that the facility failed to offer pneumococcal vaccination to patients based on assessment of status as required by facility policy and CDC guidelines for 5 of 49 patients (Patient #s 6-10). Findings: Review of the “Pneumonia Vaccination Report,” printed on 04/01/2024 revealed 5 of 49 patients had “04/01/2024” entered in the “Next Due Date” column. The “Suggested Action(s)” column for all 5 patients advised administration of the appropriate pneumococcal vaccine product specific to each patient based upon age and current vaccination status per facility policy. Documentation failed to reflect that the vaccination had been offered to those patients. Examples include but are not limited to: * Patient #6 had documentation of receiving PPSV23 on 10/17/2018. No other documentation as to subsequent pneumococcal vaccine given, offered or refused was noted. * Patient #7,with an age <65 years old, had documentation of receiving the PCV13 on 02/14/2023. According to facility policy, as well as CDC guidelines, this patient should have received a pneumococcal vaccine in 02/2024. * Patient #8 had documentation of receiving PPSV23 on 07/18/2018. According to facility policy, as well as CDC guidelines, this patient should have received a pneumococcal vaccine in 2023. Similar findings for Patient #9 and #10. Review of the facility policy titled, “Pneumococcal Vaccine for Adults,” dated “02/05/2024 Version: 6” stipulated, “Patients should receive vaccines based on the administration frequencies outlined below.” The policy provided guidelines for offering pneumococcal vaccines to patients based on age and vaccination history as recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices in September 2023. During interview with the FA on 04/01/2024 at 1630, the above findings were presented. The FA agreed that the system that generated this report defaulted to the current date under “Next Due Date” when a suggested action is overdue and confirmed the above findings.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 31224 Based on interviews, review of facility policy, and review of patient clinical records, it was determined the facility failed to ensure a plan of care developed by the IDT was specific to meet the identified individual care needs of the patient for 1 of 5 patients (Patient #1). Findings: Review of Patient #1’s clinical records revealed the following: - Patient #1 began dialysis in 01/2024. - Clinical Notes from 01/2024 through 03/2024 documented Patient #1 frequently missed treatments and canceled appointments related to transitioning to home PD. - The RN comprehensive assessment dated 02/22/2024 reflected Patient #1 continued to miss ICHD treatments. Review of Patient #1’s POC dated 02/24/2024 found: * It did not address treatment adherence as an issue and therefore no interventions or goals were developed. * “Emotional/Mental Health ...”Patient scored 0 on PHQ and is doing well.” Met Goal: Continue to monitor patient.” * “Coping/Adjusting to Dialysis Issues ...”Patient will verbalize or indicate feelings of adjustment to dialysis ...”Patient is doing well on dialysis and would like to start home dialysis.”... Assist patient in adjusting to dialysis.” Review of facility policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” and dated 07/03/2023 stipulated: * “The patient’s Plan of Care will be guided and developed based on the findings identified in the Comprehensive Interdisciplinary Assessment.” * “The IDT members are expected to interact and share information from the comprehensive assessment to facilitate the development of the plan of care.” During interview on 04/02/2024 at 1520, the FA disclosed Patient #1 faced challenges due to a recent change in health status, including loss of ability to provide one’s own transportation and general frustrations related to the loss of independence and decline in health requiring dialysis. The CM and FA confirmed the above findings.”