Fkc Schnecksville

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 36372 Based on a review of facility policy, a review of medical records, and an interview with the facility Administrator, the facility failed to ensure patient assessments, including but not limited to blood pressure monitoring, were documented per facility policy while receiving dialysis treatment, for two (2) of five (5) hemodialysis medical records (MR) reviewed (MR#2, MR#3). Findings include: A review was conducted of facility policy on March 6, 2025 at approximately 11:15 a.m. Policy ‘Patient Assessment and Monitoring’ ‘Policy’ ‘Patient monitoring and safety check guidelines: ..... ‘Patient Monitoring’ “Monitor and document every 30 minutes or more frequently as needed but not to exceed 45 minutes ......” Patient monitoring includes: Changes in the patients status, Blood pressure, pulse, respirations ....” A review of medical records completed on March 6, 2025 at approximately 11:15 a.m. revealed the following: MR#2, Date of admission 11/15/23: On 02/26/25 the post treatment flow sheet contained documentation of an assessment obtaining vital signs at 8:38 a.m. The next assessment obtaining vital signs did not occur until 9:30 a.m. (52 minutes between assessments). MR#3, Date of admission 11/17/23: On 02/19/25 the post treatment flow sheet contained documentation of an assessment obtaining vital signs at 2:40 p.m. The next assessment obtaining vital signs did not occur until 3:34 p.m. (54 minutes between assessments). On 02/24/25 the post treatment flow sheet contained documentation of an assessment obtaining vital signs at 2:09 p.m. The next assessment obtaining vital signs did not occur until 3:03 p.m. (53 minutes between assessments). On 02/26/25 the post treatment flow sheet contained documentation of an assessment obtaining vital signs at 2:37 p.m. The next assessment obtaining vital signs did not occur until 3:32 p.m. (55 minutes between assessments). On 02/28/25 the post treatment flow sheet contained documentation of an assessment obtaining vital signs at 12:34 p.m. The next assessment obtaining vital signs did not occur until 1:34 p.m. (60 minutes between assessments). An interview with the facility Administrator on March 6, 2025 at approximately 11:30 a.m. confirmed the above findings.”

“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: 36372 Based on a review of facility policy, a review of the adverse events report, a review of medical records, and an interview with the facility Administrator; the facility failed to ensure the staff followed facility policy for reporting a medication error to the physician for one (1) out of one (1) medical records (MR) reviewed (MR #6). Findings include: A review was conducted of facility policy on March 6, 2025 at approximately 11:15 a.m. Policy ‘Medication Preparation and Administration’ (Setting IC, HT) ‘Documentation’ “..... Medication reactions and errors must be documented appropriately and reviewed by the clinical manager, charge nurse or team leader and reported to the physician to ensure appropriate follow-up and/or intervention.” The facility ‘Adverse Event Report’ reviewed on March 4, 2025 at approximately 11:30 a.m. included but was not limited to the following report: ‘Patient Name’ “(MR #6)”, ‘Event Type’ “Medication Error-Wrong Dose (HD)”, ‘Event Date’ “05/27/2024”. MR #6: Physician Order: ‘Treatment Medications’ ‘Heparin Sodium (Porcine) 1,000 Units/mL Systemic Admin Method: Bolus 8,000 units IVP.’ ’’Heparin Sodium (Porcine) 1,000 Units/mL Systemic Admin Method: Intermittent 1500 units IVP.’ Treatment flowsheet dated 05/27/24 reviewed. Section ‘Anticoagulation’ ‘Bolus/Intermittent’ ‘Description’ ‘Heparin Sodium (Porcine) 1,000 Units/mL Systemic’ ‘Ordered Dose/Route’ “8,000.000/Bolus’’ ‘Administered Dose (Units)’ “8,000.0”. ‘1,500.000/Intermittent” ‘Administered Dose (Units)’ “15,000.0”. (Administered by employee #3). No documentation provided of the facility reporting the medication error (heparin intermittent dosage) to the physician, as per policy. An interview with the facility Administrator on March 6, 2025 at approximately 11:30 a.m. confirmed the above findings.”