Fkc Latrobe

“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: 42178 Based on review of facility policies/procedure, medical records (MR), hemodialysis (HD) treatment records, and employee interviews, the facility failed to follow its policy for monitoring vital signs, reporting and/or documenting abnormal findings for four (4) of seven (7) MR reviewed (MR#3-#5, & #7). Findings included: Review of agency Policy on 8/28/24 at approximately 3:00pm revealed: “Patient Assessment and Monitoring...Pre-Treatment...Blood Pressure, Record blood pressure. Verify: Systolic blood pressures greater than 180mm/Hg and/or diastolic blood pressures greater than 100mm/Hg, Systolic blood pressures less than or equal to 100mm/Hg systolic during treatment...During Treatment...Blood Pressure...Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to nurse: Systolic blood pressures greater than 180mm/Hg, Diastolic blood pressures greater than 100mm/Hg, Blood pressures greater than or equal to 100mm/Hg systolic...Post-Treatment...Blood Pressure...Ensure vital signs and overall condition are stable or discharge...” A review of medical records took place on 8/27/24 from approximately 2:00pm-3:15pm and 8/28/24 from approximately 12:00pm-1:30pm and revealed the following: MR #3, Start of Care at facility: 6/28/24, dates reviewed: 8/12/24-8/23/24. Treatment record dated 8/12/24: included pre-treatment blood pressure reading of 167/112 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of blood pressure greater than 100mm/Hg diastolic. Treatment record dated 8/14/24: included blood pressure reading during treatment at 10:04am of 164/110 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of blood pressure greater than 100mm/Hg diastolic. Treatment record dated 8/16/24: included blood pressure reading during treatment at 1:31pm of 167/105 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of blood pressure greater than 100mm/Hg diastolic. Treatment record dated 8/21/24: included blood pressure reading during treatment at 10:00am of 163/109, at 11:04am of 15/101, at 11:31am of 169/105, and at 12:37pm of 178/106. No documentation of recheck or nurse notification of blood pressure greater than 100mm/Hg diastolic. MR#4, Start of Care at facility: 9/6/19, dates reviewed: 8/12/24-8/23/24. Treatment record dated 8/12/24: included pre-treatment blood pressure reading of 209/114 and a blood pressure during treatment at 9:52am of 212/108 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of systolic blood pressure greater than 180mm/Hg or diastolic blood pressure greater than 100mm/Hg. Treatment record dated 8/19/24: included pre-treatment blood pressure reading of 202/97 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of systolic blood pressure greater than 180mm/Hg. Treatment record dated 8/23/24: included pre-treatment blood pressure reading of 184/109 and a blood pressure during treatment at 9:43am of 210/110 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of systolic blood pressure greater than 180mm/Hg or diastolic blood pressure greater than 100mm/Hg. MR#5, Start of Care at facility: 6/18/24, dates reviewed: 8/13/24-8/22/24. Treatment record dated 8/13/24: included a blood pressure during treatment at 10:02am of 140/109 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of diastolic blood pressure greater than 100mm/Hg. MR#7, Start of Care at facility: 3/11/24, dates reviewed: 8/12/24-8/23/24. Treatment record dated 8/12/24: included a blood pressure during treatment at 1:02pm of 91/66 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of systolic blood pressures less than or equal to 100mm/Hg. Treatment record dated 8/16/24: included pre-treatment blood pressure reading of 89/58 and a post-treatment blood pressure of 98/60 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of systolic blood pressure less than or equal to 100mm/Hg. Treatment record dated 8/19/24: included a blood pressure during treatment at 10:33am of 92/56, at 11:33am of 93/50, at 12:02pm of 93/54, at 12:32pm of 91/57, and at 1:04pm of 89/56 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of systolic blood pressures less than or equal to 100mm/Hg. Treatment record dated 8/21/24: included a blood pressure during treatment at 11:01am of 91/64 and at 11:31am of 92/63 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of systolic blood pressures less than or equal to 100mm/Hg. Treatment record dated 8/23/24: included a blood pressure during treatment at 11:35am of 88/55, at 12:31pm of 99/54, at 1:09pm of 98/59, and at1:35pm of 96/58 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of systolic blood pressures less than or equal to 100mm/Hg. An interview conducted with Center Manager and Director of Operations on 8/28/24 at approximately 2:00pm confirmed the above findings.”