Fkc Liberty Dialysis Washington

“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: 46886 Based on observations of the facility ’ s clinic area (OBS) and employee interviews (EMP) the facility failed to monitor the supplies designated for emergency use during one (1) of three (3) clinic observations (OBS2). Findings include: During an observation (OBS2) performed on 6/25/24 at approximately 9:30 am of the clinic floor the following expired supplies were found in the Emergency Evacuation Box: Six (6) Disposable 16-gauge 25 mm A.V. Fistula Needle sets Lot # 2102010765, expiration date 3/23/2024 Two (2) Sterile Medline Suture removal trays Lot # (10)16LB8439, expiration date 7/31/2019 Four (4) BD 10 mL LuerLok tip Syringes Lot # 727589041, expiration date 9/30/2022 The finding was reported to EMP1 (Clinical Manager) and EMP2 (Director of Operations) on 6/25/24 and reviewed during a survey exit conference on 6/27/24 at approximately 3:00 pm.”

“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: 46886 Based on interviews with staff (EMP), medical record (MR) reviews, and policy reviews, the facility staff failed to follow policies created to provide the necessary care and services to manage a patient ’ s volume status for four (4) of five (5) medical records reviewed. (MRs 1-4) Findings include: A review of facility policy Patient Assessment and Monitoring on 6/27/28 revealed: “ Purpose: ...to provide guidance to FKC direct patient care staff on assessment and monitoring patients ...Data Collection ... Machine Parameters and Extracorporeal Circuit ...Check prescribed blood flow (BFR) is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate (DFR) setting is correct, and the prescribed flow is being delivered. “ A review of agency policy Pre-Pump Arterial Pressure Monitoring Guidelines on 6/27/28 revealed: “ ...to provide guidance on pre-pump arterial pressure (PPAP) monitoring ...All FKC Direct Care Patient Care Staff ...Monitor the PPAP with each hemodialysis treatment parameter check. Interventions to reduce pre-pump arterial pressure will be attempted when the pre-pump pressure is more negative than -250mmHg ...Hemolysis..If the PPAP is more negative than -250 mmHg, the blood pump speed should be reduced ...Documentation ...Document all findings in the patient ’ s FKC medical record.” A medical record review conducted on 6/27/24 between approximately 11:00 am to 2:30 pm revealed: MR1: Admission Date: 8/1/23. A Treatment Sheet for 6/24/24 noted dialysis prescriptions with an ordered Dialysate Flow Rate (DFR) of 500 mL/min. Treatment Data on 6/24/24 recorded DFRs of 100 mL/min for the entirety of the treatment from 11:44 to 14:31 by EMP7 and EMP8. The DFR recorded did not match the prescribed order, facility staff failed to monitor that the prescribed flow was being delivered. MR2: Admission Date: 1/26/2015. Treatment Sheets for 6/14/24 and 6/21/24 noted dialysis prescriptions with an ordered blood flow rate (BFR) of 400 mL/min. Treatment data on 6/14/24 recorded BFR adjustments between to 350 mL/min to 300 mL/min by EMP8 and EMP9. Treatment data on 6/21/24 recorded a BFR adjustment to 300 mL/min by EMP9. The reason that the prescribed flow rate was unable to be maintained in each instance was not documented as per facility policy. MR3: Admission Date: 5/13/24. Treatment Sheets for 6/17/24 and 6/19/24 noted dialysis prescriptions with an ordered BFR of 400 mL/min. Treatment data on 6/17/24 recorded a BFR decrease to 260 mL/min by EMP10. Treatment data on 6/19/24 recorded a BFR decrease to 290 mL/min by EMP11. The reason that the prescribed flow rate was unable to be maintained in each instance was not documented as per facility policy. MR4: Admission Date: 10/19/11. A Treatment Sheet for 6/3/24 noted a dialysis prescription with an ordered BFR of 500 mL/min. Treatment data on 6/3/24 recorded a BFR decrease to 300 mL/min by EMP12. The reason that the prescribed flow rate was unable to be maintained was not documented as per facility policy. The findings were reviewed with EMP1 (Clinical Manager) and EMP2 (Director of Operations) during an exit interview on 6/27/24 at approximately 2:30 pm. An action plan started on 4/25/24 was presented for surveyor review. The action plan had reassessment dates of 5/29/24 and 6/26/24 but failed to provide quantifiable indicators or goals demonstrating process improvement.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 46886 Based on interviews with staff (EMP), medical record (MR) reviews, and policy reviews, the facility medical director failed to ensure that all staff adhered to policies and procedures related to patient assessment and monitoring for four (4) out of five (5) MRs reviewed. (MRs 1,2,4 and 5) Findings include: A review of facility policy Patient Assessment and Monitoring on 6/27/28 revealed: “ Purpose: ...to provide guidance to FKC direct patient care staff on assessment and monitoring patients ...Data Collection ...If the PCT/LPN note any changes or abnormal findings in the patient ’ s condition or vascular access are observed ...the registered nurse must assess the patient.... During treatment ...Report to the nurse: Systolic blood pressures greater than 180 mmHg ...Blood Pressure less than or equal to 100 mm/hg systolic ...Pulse ...Verify pulses manually if automated readings display below 60 ...Report to the nurse patients whose heart rates have dropped below 60 ... “ A medical record review conducted on 6/27/24 between approximately 11:00 am to 2:30 pm revealed: MR1: Admission Date: 8/1/23. 6/10/24 Treatment Sheet documented intradialytic (during dialysis) heart rates (HR) between 55-59 beats per minute (bpm) by EMP8 (PCT) and EMP10(PCT). 6/24/24 Treatment Sheet documented intradialytic HRs between 56-57 bpm by EMP7 (PCT) and EMP8 (PCT). 6/26/24 Treatment Sheet documented intradialytic HRs between 54-58 bpm by EMP7 (PCT), EMP8 (PCT), EMP10 (PCT), and EMP12 (LPN). RN notification and manual pulse verification for HRs less than 60 were not documented as per facility policy on 6/10/24, 6/24/24, and 6/26/24. 6/19/24 Treatment Sheet documented intradialytic HRs between 53-57 bpm by EMP7 (PCT), EMP8 (PCT), EMP9 (RN), EMP11 (RN), and EMP13 (PCT). Manual pulse verification for HRs less than 60 were not documented as per facility policy. MR2: Admission Date: 1/26/15. 6/14/24 Treatment Sheet documented an intradialytic systolic blood pressure of 88 by EMP8 (PCT). 6/21/24 Treatment Sheet documented intradialytic SBPs between 79 - 89 by EMP8 (PCT), EMP10 (PCT), and EMP13 (PCT). RN notification for a SBP less than 100 was not documented as per facility policy for each of MR2 ’ s identified treatment sheets. MR4: Admission Date: 10/19/11. 5/29/24 Treatment Sheet documented intradialytic (during dialysis) SBPs between 73 - 89 mmHg by EMP12 (LPN). 6/3/24 Treatment Sheet documented intradialytic SBPs between 67 - 91 mmHg by EMP12 (LPN) and EMP13 (PCT). 6/5/24 Treatment Sheet documented intradialytic SBPs between 82 - 88 mmHg by EMP8 (PCT) and EMP12 (LPN). 6/7/24 Treatment Sheet documented intradialytic SBPs between 64 - 86 mmHg by EMP12 (LPN) and EMP13 (PCT). RN notification for a SBP less than 100 was not documented as per facility policy for each of MR4 ’ s identified treatment sheets. A review of MR5 ’ s treatment sheets on 6/27/24 at approximately 2:00 pm revealed MR5: Admission Date: 4/22/24. 6/12/24 Treatment Sheet documented intradialytic SBPs between 188 -191 mmHg by EMP8 (PCT) and EMP13 (PCT). 6/14/24 Treatment Sheet documented an intradialytic SBP of 183 by EMP15 (PCT). RN notification for SBP greater than 180 mmHg was not documented as per facility policy in each of MR5 ’ s identified treatment sheets. The finding was reviewed with EMP1 (Clinical Manager) and EMP2 (Director of Operations) on 6/27/24 at approximately 2:30 pm. An action plan started on 4/25/24 was presented for surveyor review. The action plan had reassessment dates of 5/29/24 and 6/26/24 but failed to provide quantifiable indicators or goals demonstrating process improvement.”