Dci Dickson

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 46831 Based on policy review and interview, the facility failed to ensure the Emergency Preparedness (EP) plan was reviewed and/or revised every 2 years by Administration. The findings included: 1. Review of the facility’s “Emergency Preparedness Plan” revealed, “...INTRODUCTION TO THE PLAN...this plan will be reviewed and updated annually and after incidents or planned exercises...effective November 15, 2016...Purpose...To describe the actions to be taken in an emergency or exercise to make sure that the patients, staff and visitors of this facility are kept safe from harm...” There was no documentation the Emergency Preparedness Plan had been reviewed, revised and/or signed since March of 2022. 2. During an interview on 1/29/2025 at 8:55 AM, when asked if the Emergency Preparedness plan had been reviewed and/or revised since 2022, the NM stated, “I noticed that everyone had not signed since 2022. I can’t find where the Emergency Preparedness had been updated, signed or even discussed in a Governing Body meeting.” The NM then stated she was aware the EP book needed to be updated every 2 years.”

“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: 19001 Based on policy review, medical record review and interview, the facility failed to ensure nursing staff was notified and failed to follow facility policy for 1 of 5 (Patient #4) incenter sampled hemodialysis patients who experienced complications during treatment. The findings included: 1. Review of the facility policy “Management of Cramping during Hemodialysis” issued 11/17/2020 revealed, “PURPOSE: To provide guidelines for the management of cramps in the hemodialysis patient... POLICY: 1. Notify the charge nurse immediately if patient complains of cramping...PROCEDURE: 1. Assess patient for signs and symptoms of cramping. 2. If it is determined that cramping is due to volume depletion or hypotension, administer normal saline bolus of 100-200 mL. Repeat NS bolus as needed to resolve cramping...” 2. Medical record review for patient #4 revealed an 80-year-old female with diagnoses that included DM and ESRD, admitted to the clinic on 11/26/2024. Patient #4 received hemodialysis 3 times per week for 3 hours and 30 minutes. Review of the Hemodialysis flowsheet dated 1/11/2025 revealed at 1:32 PM, Patient #4 reported cramping and was administered 200 mL bolus saline by LPN #1. There was no documentation LPN #1 notified the charge nurse about Patient #4’s complications during the treatment. Review of the Hemodialysis flowsheet dated 1/14/2025 revealed at 12:26 PM, Patient #4 reported cramping to PCT #1. PCT #1 turned down the ultrafiltration rate and administered 200 mL of bolus saline. At 12:55 PM, PCT #2 administered another 300 mL of normal saline to Patient #4. There was no documentation the PCTs notified the charge nurse about Patient #4’s complications during the treatment. 3. During an interview on 1/28/2025 at 10:06 AM, the NM verified that PCTs were not allowed to administer saline for cramping. The NM stated the nursing staff should have been notified of the cramping and administered the normal saline for Patient #4. During an interview on 1/28/2025 at 10:09 AM, the NM verified there was no documentation the charge nurse was notified of Patient #4’s cramping complications on 1/11/2025 and 1/14/2025.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 19001 Based on policy review, Quality Assessment Performance Improvement (QAPI) review, and interview, the facility failed to conduct analysis of individual patient deaths to recognize trends, causes and contributory factors for 1 of 2 (November 2024) months reviewed. The findings included: 1. Review of the facility policy “Quality Assessment Performance Improvement (QAPI)” with no documented issue or revision date, revealed, “...PUPRPOSE: To provide guidance on the development and maintenance of an effective QAPI program in accordance with CMS ESRD Conditions for Coverage ...The dialysis facility must measure analyze and track quality indicators and other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations...” 2. Review of the November QAPI minutes for October data revealed the facility had one death in October. There was no documentation the QAPI members completed a mortality review or discussed the death in the QAPI meeting. 3. During an interview on 1/29/2025 at 9:35 AM, the NM verified there had been one death recorded for October for the in-center hemodialysis patients’ census. The NM stated she had not performed a mortality review, but stated the SW conducted the death reviews. The NM stated she documented in the chart the patient died and discharged the patient from the facility. During an interview on 1/29/2025 at 10:15 AM, the SW stated she completed the CMS death notification form but had not conducted a mortality review.”