Rcg Madison

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 46831 Based on policy review, medical record review and interview, the facility failed to ensure 4 of 7 (Patient #1, #3, #4 and #5) sampled patients received the prescribed dialysis prescription for BFR and or DFR and failed to ensure the prescribed dialysis treatment time was met and AMA forms were completed for 2 of 7 (Patient #4 and 7) sampled patients receiving in-center hemodialysis. The findings included: 1. Review of the “Unable to Achieve Prescribed Blood Flow Rate” policy published 11/01/2021, revealed, “...Achieving prescribed BFR is a critical parameter in achieving adequate treatment Kt/V...Notify physician/extender if unable to achieve prescribed blood flow rate...Document in patient’s treatment record what action taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physician orders...” Review of the “Patient Assessment and Monitoring” policy published 05/01/2023, revealed, “...Machine Parameters and Extracorporeal Circuit...Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow...Check dialysate flow rate setting is correct, and the prescribed flow is being delivered...” Review of the “Early Termination or arriving late for treatment” policy published 11/07/2022, revealed, “Purpose The purpose of this policy is to provide guidelines for staff when patients...request early termination of treatment...Treatment duration and frequency is prescribed by a patient’s physician and the facility expects that all patients will adhere to their prescribed treatment time and schedule. Serious health related consequences may result from...terminating earlier than prescribed...If a patient insists on terminating early and this has not been previously approved by the patient’s physician, the patient must take full responsibility for consequences of the missed or shortened treatment...If a patient requests to leave treatment early...The RN is responsible to notify the physician and document on the “AMA” or against medical advice form...” 2. Medical record review for Patient #1 revealed an admission date of 10/25/2024 with diagnoses that included AKI and ESRD. A physician’s order dated 12/2/2024 revealed dialysis 3 times per week for 3 hours with a BFR of 350 and a DFR of 500. Review of the 11/24/2024 Hemodialysis Flowsheet revealed the DFR was 800 from 11:31 AM to 3:15 PM at the end of treatment. There was no documentation for the reason the DFR was not administered as prescribed. There was no documentation the physician was notified of the DFR not being administered at the prescribed rate. Review of the 12/2/2024 Hemodialysis Flowsheet revealed the BFR was 300 from 11:21 AM to 12:30 PM. The DFR was 800 from 11:14 AM to 11:35 AM and 12:30 PM. There was no documentation for the reason the BFR/DFR was not administered as prescribed. There was no documentation the physician was notified of the BFR/DFR not being administered at the prescribed rate. Review of the 12/6/2024 Hemodialysis Flowsheet revealed the BFR was 310 at 11:04 AM and 300 from 11:30 AM to 1:47 PM. The DFR was 800 from 11:04 AM to 1:51 PM until the end of treatment. There was no documentation for the reason the BFR/DFR was not administered as prescribed. There was no documentation the physician was notified of the BFR/DFR not being administered at the prescribed rate. Review of the 12/11/2024 Hemodialysis Flowsheet revealed the DFR was 800 from 11:21 AM to 2:02 PM. There was no documentation for the reason the DFR was not administered as prescribed. There was no documentation the physician was notified of the DFR not being administered at the prescribed rate. Review of the 12/24/2024 Hemodialysis Flowsheet revealed the BFR was 400 from 11:19 AM to 11:32 AM and 12:34 PM to 1:34 PM. The DFR was 800 from 11:19 AM to 11:35 AM and 2:21 PM. There was no documentation for the reason the BFR/DFR was not administered as prescribed. There was no documentation the physician was notified of the BFR/DFR not being administered at the prescribed rate. 3. Medical record review for Patient #3 revealed an admission date of 6/8/2017 with diagnoses that included Biological Substances and ESRD. A physician’s order dated 1/7/2025 revealed dialysis 3 times per week for 4 hours with a BFR of 400 and a DFR of 500. Review of the 1/14/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 11:42 AM to 1:01 PM. The DFR was 800 from 11:42 AM to 1:01 PM. There was no documentation for the reason the BFR/DFR was not administered as prescribed. There was no documentation the physician was notified of the BFR/DFR not being administered at the prescribed rate. Review of the 1/25/2025 Hemodialysis Flowsheet revealed the DFR was 800 from 11:30 AM to 3:31 PM. There was no documentation for the reason the DFR was not administered as prescribed. There was no documentation the physician was notified of the DFR not being administered at the prescribed rate. Review of the 1/28/2024 Hemodialysis Flowsheet revealed the DFR was 800 from 11:27 AM to 3:29 PM. There was no documentation for the reason the DFR was not administered as prescribed. There was no documentation the physician was notified of the DFR not being administered at the prescribed rate. 4. Medical record for Patient #4 revealed an admission date of 3/27/2020 with diagnoses that included HTN and ESRD. A physician’s order dated 8/17/2024 revealed dialysis 3 times per week for 3 hours with a BFR of 350 and a DFR of 500. Review of the 12/30/2024 Hemodialysis Flowsheet revealed Patient #4 shortened his treatment to 45 minutes. There was no AMA form documented. Review of the 1/14/2025 Hemodialysis Flowsheet revealed Patient #4 shortened his treatment to 58 minutes. There was no AMA form documented. The BFR was 300 from 1:55 PM to 2:53 PM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 1/21/2025 Hemodialysis Flowsheet revealed Patient #4 shortened his treatment to 53 minutes. There was no AMA form documented. The BFR was 300 from 1:40 PM to 2:33 PM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 1/23/2025 Hemodialysis Flowsheet revealed Patient #4 shortened his treatment to 55 minutes. There was no AMA form documented. The BFR was 300, and the DFR was 800 from 1:30 PM to 2:25 PM. There was no documentation for the reason the BFR/DFR was not administered as prescribed. There was no documentation the physician was notified of the BFR/DFR not being administered at the prescribed rate. Review of the 1/28/2025 Hemodialysis Flowsheet revealed Patient #4 shortened his treatment to 33 minutes. There was no AMA form documented. The BFR was 300, and the DFR was 800 from 1:27 PM to 2:00 PM. There was no documentation for the reason the BFR/DFR was not administered as prescribed. There was no documentation the physician was notified of the BFR/DFR not being administered at the prescribed rate. Review of the 2/2/2025 Hemodialysis Flowsheet revealed Patient #4 shortened his treatment to 54 minutes. There was no AMA form documented. The BFR was 300 from 1:40 PM until 2:04 PM, and the BFR was 200 from 2:04 PM to 2:33 PM. There was no documentation for the reason the BFR/DFR was not administered as prescribed. There was no documentation the physician was notified of the BFR/DFR not being administered at the prescribed rate. 5. Medical record review for Patient #5 revealed an admission date of 11/21/2020 with diagnoses that included Type 2 DM with Diabetic Chronic Kidney Disease and ESRD. A physician’s order dated 1/16/2025 revealed dialysis 3 times per week for 4 hours and 30 minutes with a BFR of 550 and a DFR of 800. Review of the 1/7/2025 Hemodialysis Flowsheet revealed the BFR was 500 from 9:31 AM to 10:12 AM and 450 from 10:34 to 11:33 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 1/11/2025 Hemodialysis Flowsheet revealed the BFR was 500 from 6:30 AM to 8:13 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 1/16/2025 Hemodialysis Flowsheet revealed the BFR was 500 from 6:38 AM to 10:03 AM. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 1/17/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 8:40 AM to 9:03 AM and 500 from 9:32 AM to 11:32 AM at the end of treatment. There was no documentation for the reason the BFR was not administered as prescribed. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. 6. Medical record for Patient #6 revealed an admission date of 8/2/2024 with diagnoses that included DM and ESRD. A physician’s order dated 12/18/2024 revealed dialysis 3 times per week for 4 hours. Review of the 1/22/2025 Hemodialysis Flowsheet revealed Patient #6 shortened his treatment to 3 hours and 47 minutes. There was no AMA form documented. Review of the 1/24/2025 Hemodialysis Flowsheet revealed Patient #6 shortened his treatment to 3 hours and 40 minutes. There was no AMA form documented. Review of the 1/27/2025 Hemodialysis Flowsheet revealed Patient #6 shortened his treatment to 3 hours and 43 minutes. There was no AMA form documented. Review of the 1/29/2025 Hemodialysis Flowsheet revealed Patient #6 shortened his treatment to 3 hours and 8 minutes. There was no AMA form documented. 7. During an interview on 2/4/2025 at 10:30 AM, CN #2 stated staff should document the reason BFR or DFR is not delivered at the prescribed rate on the hemodialysis flowsheets. During an interview on 2/5/2025 at 8:40 AM, CN #2 verified the nursing staff should get an AMA form signed with each shortened treatment per facility policy.”