Kaiser Sunnybrook Peritoneal Dialysis Facility

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(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:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 37898 Based on observation, interview and review of documentation, it was determined that the facility failed to implement procedures to ensure that emergency equipment necessary to meet the needs of the patients in the event of evacuation was monitored and maintained according to facility policy. Findings: Observation of the emergency evacuation kit located in the medication room on 11/08/2023 at 1000 revealed: * 7 of 7 “stay safe Cap” closure caps expired 08/31/2023; and * 2 of 3 IV start sets expired 07/31/2023. Review of “SYB Peritoneal Dialysis Emergency Evacuation Kit” monthly check documentation revealed that the last evacuation kit check documented was dated “Aug ‘23.” Further review of documentation revealed that the monthly check signed off on “8/4/23” noted the “IV Start Kit” expiration date of “7/31/23.” Review of the facility policy titled “MERBs (Adult and Peds), AED Equipment, Broselow and Emergency Medication Checks,” with a last revision date of 12/15/2022, stipulated “Procedures ... Perform and document the following monthly checks by utilizing the standardized checklist for your level of response ... Open MERB and check entire contents of bag for expiration dates; completeness of supplies and operational flashlight batteries ... Remove and replace any items within a month of expiration.” During interview with the Facility Manager on 11/08/2023 at 1455, they confirmed the findings.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 37898 Based on interview and review of documentation, it was determined that the facility failed to implement procedures to maintain all equipment in accordance with facility policy as required to ensure a safe and functional environment was provided. Findings: Review of “Emergency Eyewash Station Weekly Inspection Checklist” documentation revealed that weekly inspection of the facility’s 6 eyewash stations (Treatment Rooms #1 - 4, Medication Room, Dirty Utility) was performed inconsistently throughout 2023. Findings include, but are not limited to: * Treatment Room #1: A check was documented on “5/10/23,” the next check was documented 26 days later on “6/5/23,” and the next check was documented 38 days later on “7/13/23.” * Treatment Room #2: A check was documented on “5/10/23,” and the next check was documented 64 days later on “7/13/23.” Similar findings were noted on documentation for the 4 remaining eyewash stations. Review of the facility policy titled “Emergency Eyewash and Deluge Shower Program” with a last reviewed date of “11/18” stipulated “1. Department Manager or Supervisors are responsible for: ... e. Weekly testing of eyewashes and showers and documentation.” During interview with the Facility Manager on 11/08/2023 at 1447, they confirmed “It was missed.””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 37898 Based on interview, medical record review, and review of documentation, it was determined that the facility failed to ensure that the patient plan of care was signed by the patient, or the patient’s designee, in a timely manner for 2 of 5 patient records reviewed (Patients #3 and 5). Findings: Patient #3 Review of the medical record revealed an Interdisciplinary Team Meeting and patient Plan of Care were completed on 06/22/2023. The plan of care was signed by the patient on 10/10/2023. Patient #5 Review of the medical record revealed an Interdisciplinary Team Meeting and patient Plan of Care were completed on 09/28/2023. As of the review on 11/09/2023, “Signature pending” was listed for the patient participation section. Review of the facility policy titled “Comprehensive Patient Assessment and Plan of Care,” with a last revision date of 01/24/2022, revealed that the “Interdisciplinary team (IDT)” consisted of “at a minimum, the patient or the patient’s personal representative (caregiver), a Registered Nurse (RN), a Nephrology Clinician treating the patient for End Stage Renal Disease (ESRD), a Social Worker (SW), and a Registered Dietician (RD).” The policy stipulated that the “Interdisciplinary team develops and implements a written, individualized, comprehensive POC on all new patients or patients that transfer into the facility.” Further review of the facilty policy stipulated “Documentation ... Minimum Documentation Standards for Registered Nurse Encounters ... Implement and communicate POC changes within the IDT ... Sign the POC and CPA - if a signature is withheld, it should be documented by whom and why.” During interview with the Facility Manager and the Facility Manager of a sister facility on 11/09/2023 at 1045, the above findings were acknowledged and they agreed that the POC should be signed by the patient in a more timely manner.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 37898 Based on interview and medical record review, it was determined that the facility failed to ensure that care plans were updated monthly for 1 of 2 patients assessed as unstable (Patient #2). Findings: Patient #2 Review of the Plan of Care dated 09/27/2023 revealed Patient #4 was listed as “unstable due to unmanaged anemia, unmet adequacy, unmet nutrition goal.” As of 11/09/2023, the medical record lacked documentation of the required monthly POC update. Review of the facility policy titled “Comprehensive Patient Assessment and Plan of Care,” with a last revision date of 01/24/2022, stipulated “Revision of the POC with a comprehensive re-assessment of each patient: ... At least monthly for unstable patients.” During interview with the Facility Manager and the Facility Manager of a sister facility on 11/09/2023 at 1045, they confirmed the findings.”