Fmc South Nashville

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 33763 Based on policy review, medical record review, and interview, the facility failed to ensure patients’ plans of care were implemented when they failed to assess and monitor patients during hemodialysis treatments and failed to follow physician’s orders for the prescribed dose of dialysis. The findings included: 1. Review of the facility policy titled, “Patient Assessment and Monitoring” dated 5/1/2023 revealed, “...During Treatment... Obtain blood pressure and pulse rate every 30 minutes...” Medical record review revealed facility staff failed to perform and document assessments every 30 minutes during treatment for Patient #1, #2, #3, #4, #5, and #6. During an interview on 8/13/2024 at 4:10 PM, the DO stated, “...blood pressures should be monitored every 30 to 45 minutes...” Review of the physician’s orders dated 6/15/2024 revealed Clonidine HCL [medication used to treat high blood pressure] 0.1 mg should be given by mouth as needed and may be repeated once. Medical record revealed nursing staff failed to follow physician’s orders for hypertension for Patient #3. During an interview on 8/13/2024 at 3:55 PM, the DO verified staff should have notified the RN, and Patient #3’s should have been treated with Clonidine as ordered. Refer to V543. 2. Review of the facility policy titled, “Patient Assessment and Monitoring” dated 5/1/2023 revealed, “...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...” Medical record review revealed facility staff failed to follow physician’s orders for prescribed BFR and/or DFR for Patient #2, #3, #5, #6, and #7. During an interview on 8/13/2024 at 4:10 PM, the DO stated “...the BFR/DFR should be running at the prescribed rate...” Refer to V544”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 33763 Based on policy review, observation and interview, the facility failed to ensure proper hand hygiene to prevent the spread of potentially infectious bacteria was performed by 2 of 2 (RN #1 and #2) nurses observed performing direct patient care. The findings included: 1. Review of the facility policy titled, “Hand Hygiene” dated 11/6/2023 revealed, “...All staff...must follow the same requirements for hand hygiene...Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub...Hands will be...Washed with antimicrobial soap and water When Hands are visibly dirty or contaminated with proteinaceous material, blood, or other body fluids...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...Before and after direct contact with patient...Before performing any invasive procedure such as vascular access cannulation...Immediately after removing gloves...When moving from a contaminated body site to a clean body site of the same patient...” 2. Review of the facility policy titled, “Dialyzing Patients with Positive Hepatitis B” dated 11/6/2023 revealed, “ ...Hand hygiene must be practiced when entering and leaving the isolation area ...” 3. Observations on the treatment floor in the isolation room on 8/12/2024 beginning at 11:20 AM, revealed RN #1 entered the isolation room and discontinued Random Patient #1’s (positive for Hepatitis B), hemodialysis treatment. Prior to leaving the isolation room, RN #1 removed the face shield, donned gloves, and performed hand hygiene. After performing hand hygiene, RN #1 removed the protective gown, then exited the isolation room with Random Patient #1, obtained the patient’s weight, then returned to the isolation room and performed hand hygiene. RN #1 failed to perform hand hygiene after removing the gown with bare hands and before exiting the isolation room. 4. Observations on the treatment floor on 8/12/2024 beginning at 12:06 PM, revealed RN #1 was preparing to administer an IV medication to Random Patient #2. RN #1 performed hand hygiene, obtained the vial of medication and syringe, cleaned the rubber stopper with alcohol, inserted the needle and withdrew the medication. Without performing hand hygiene, RN #1 donned gloves, walked to Station #5, connected the syringe, and administered the medication to Random Patient #2. RN #1 failed to perform hand hygiene before donning gloves. 5. Observations on the treatment floor on 8/12/2024 beginning at 3:08 PM, revealed RN #2 was preparing to administer IV medication to Random Patient #3. RN #2 performed hand hygiene, donned gloves, and took the prepared syringe of medication to Station #4, and entered data on the hemodialysis machine screen. Without removing gloves, performing hand hygiene, or donning new gloves, RN #2 connected the syringe and administered the medication to Random Patient #3. RN #2 failed to remove the gloves, perform hand hygiene, and don new gloves after touching the hemodialysis machine screen and before administering the medication. 6. Observations on the treatment floor on 8/12/2024 beginning at 3:35 PM, revealed RN #2 was preparing to discontinue Patient #2’s hemodialysis treatment via a CVC. RN #2 performed hand hygiene, donned gloves, and assessed Patient #2, then removed the gloves. Without performing hand hygiene, RN #2 donned new gloves and placed the clean barrier under the CVC ports and completed the procedure to discontinue the hemodialysis treatment. RN #2 failed to perform hand hygiene between glove use. 7. During an interview on 8/14/2024 at 9:00 AM, the DO verified hand hygiene should be performed before and after glove use, when moving from a dirty site to a clean site, and before exiting the isolation room.”

“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: 33763 Based on policy review, document review, medical record review and interview, the facility failed to ensure patients undergoing hemodialysis treatments were monitored every 30 minutes per facility policy for 6 of 7 (Patient #1, #2, #3, #4, #5, and #6) sampled patients and failed to follow physician’s orders for hypertension for 1 of 7 (Patient #3) sampled patients. The findings included: 1. Review of the facility policy titled, “Patient Assessment and Monitoring” dated 5/1/2023 revealed, “...During Treatment...Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations...Report to the nurse: Systolic blood pressures greater than 180 mm/Hg...Diastolic blood pressure greater than 100 mm/Hg...Record Pulse...” 2. Medical record review for Patient #1 revealed an admission date of 11/1/2023 with diagnoses which included Type II Diabetes Mellitus and End Stage Renal Disease. Review of the physician’s orders dated 11/1/2023 revealed the Patient’s blood pressure was to be assessed every 30 minutes while receiving hemodialysis. Review of the physician’s orders dated 7/5/2024, 7/19/2024, and 7/31/2024 revealed the Patient was to receive in-center hemodialysis treatments 3 times a week via a CVC. Review of the Treatment Sheet dated 7/17/2024 revealed the treatment was initiated at 12:11 PM and ended at 3:44 PM. There was no documentation facility staff assessed Patient #1’s blood pressure from 2:02 PM until 3:07 PM, a total of 1 hour and 5 minutes later. Review of the Treatment Sheet dated 7/26/2024 revealed a pre-treatment blood pressure was obtained at 10:45 AM. The treatment was initiated at 12:29 PM and ended at 3:42 PM. There was no documentation facility staff assessed Patient #1’s blood pressure until 1:34 PM, a total of 2 hours and 49 minutes after the pre-treatment assessment, and a total of 1 hour and 5 minutes after the treatment was initiated. Further review revealed there was no documentation facility staff assessed Patient #1’s blood pressure from 2:32 PM until 3:40 PM, a total of 1 hour and 8 minutes. Review of the Treatment Sheet dated 7/29/2024 revealed the treatment was initiated at 12:15 PM and ended at 3:43 PM. Facility staff failed to assess Patient #1’s blood pressure from 2:12 PM until 3:05 PM, a total of 53 minutes. Review of the Treatment Sheet dated 8/2/2024 revealed the treatment was initiated at 12:10 PM and ended at 3:28 PM. There was no documentation facility staff assessed Patient #1’s blood pressure from 1:33 PM until 2:32 PM a total of 59 minutes. Review of the Treatment Sheet dated 8/9/2024 revealed the treatment was initiated at 12:13 PM and ended at 3:41 PM. There was no documentation facility staff assessed Patient #1’s blood pressure from 1:31 PM until 3:02 PM, a total of 1 hour and 31 minutes. 3. Medical record review for Patient #2 revealed an admission date of 4/3/2023 with diagnoses which included Acute Renal Failure and End Stage Renal Disease. Review of the physician’s order dated 6/26/2024, revealed the Patient was to receive in-center hemodialysis treatments 3 times a week via an AV fistula. Review of the Treatment Sheet dated 7/8/2024 revealed the treatment was initiated at 11:44 AM and ended at 4:20 PM. There was no documentation facility staff assessed Patient #2’s blood pressure from 1:31 PM until 2:30 PM, a total of 59 minutes. Review of the Treatment Sheet dated 7/22/2024 revealed the treatment was initiated at 11:53 AM and ended at 4:45 PM. There was no documentation facility staff assessed Patient #2’s blood pressure from 11:57 AM until 12:40 PM, a total of 43 minutes. Review of the Treatment Sheet dated 7/26/2024 revealed the treatment was initiated at 11:45 AM and ended at 4:30 PM. There was no documentation facility staff assessed Patient #2’s blood pressure from 2:01 PM until 2:42 PM, a total of 41 minutes. Review of the Treatment Sheet dated 8/7/2024 revealed the treatment was initiated at 11:45 AM and ended at 4:36 PM. There was no documentation facility staff assessed Patient #2’s blood pressure from 2:31 PM until 3:34 PM, a total of 1 hour and 4 minutes. 4. Medical record review for Patient #3 revealed an admission date of 5/14/2024 with diagnoses which included Hypertensive Chronic Kidney Disease and End Stage Renal Disease. Review of the physician’s orders dated 7/11/2024 revealed Patient #3 was to receive in-center hemodialysis treatments three times a week via an AV fistula. Review of the Treatment Sheet dated 7/11/2024 revealed the treatment was initiated at 11:37 AM and ended at 2:37 PM. There was no documentation facility staff assessed Patient #3’s blood pressure from 11:37 AM until 1:05 PM, a total of 1 hour and 28 minutes. Review of the Treatment Sheet dated 7/25/2024 revealed the treatment was initiated at 11:52 AM and ended at 3:02 PM. There was no documentation facility staff assessed Patient #3’s blood pressure from 12:33 PM until 1:33 PM, a total of 1 hour. Review of the Treatment Sheet dated 7/30/2024 revealed the treatment was initiated at 12:00 PM and ended at 3:01 PM. There was no documentation facility staff assessed Patient #3’s blood pressure from 12:34 PM until 1:32 PM, a total of 58 minutes, and from 1:32 PM until 2:31 PM, a total of 59 minutes. Review of the Treatment Sheet dated 8/1/2024 revealed the treatment was initiated at 12:09 PM and ended at 2:37 PM. There was no documentation facility staff assessed Patient #3’s blood pressure from 12:09 PM until 2:06 PM, a total of 1 hour and 57 minutes. Review of the Treatment Sheet dated 8/8/2024 revealed the treatment was initiated at 11:25 AM and ended at 2:29 PM. There was no documentation facility staff assessed Patient #3’s blood pressure from 1:39 PM until 2:29 PM, a total of 50 minutes. Review of the Treatment Sheet dated 8/10/24 revealed the treatment was initiated at 11:47 AM and ended at 2:48 PM. There was no documentation facility staff assessed Patient #3’s blood pressure from 11:59 AM until 1:07 PM, a total of 1 hour and 8 minutes. 5. Review of the facility document titled, “2023...Incenter Standing Orders...” revealed, “... Hypertension... Intradialytic HTN: Clonidine 0.1mg PRN may repeat Q1 hours x 3 for persistent SBP > 180 mm/HG. Patient must remain on the treatment floor for 30 minutes after medication administration...” Review of the physician’s orders for Patient #3 dated 6/15/2024 revealed Clonidine HCL [medication used to treat high blood pressure] 0.1 mg should be given by mouth as needed and may be repeated once. Review of the Treatment Sheet dated 7/16/2024 revealed the following: a pre-treatment blood pressure of 196/104 at 11:46 AM; treatment was initiated at 11:54 and Patient #3’s blood pressure was 183/97; At 12:05 PM, the Patient’s blood pressure was 189/101; At 12:34 PM, the Patient’s blood pressure was 194/100; At 1:05 PM, the Patient’s blood pressure was 169/107; At 1:32 PM, the Patient’s blood pressure was 191/105; At 2:04 PM, the Patient’s blood pressure was 191/95. There was no documentation facility staff assessed Patient #3’s blood pressure from 2:04 PM until 3:01 PM, a total of 57 minutes. At 3:01 PM, the Patient’s blood pressure was 182/101. The treatment ended at 3:11 PM and the Patient’s blood pressure was 179/99. There was no documentation Patient #3’s elevated blood pressure was treated with Clonidine as ordered, and no documentation an RN was notified of the Patient’s blood pressures. During an interview on 8/13/2024 at 3:55 PM, the DO verified staff should have notified the RN and Patient #3’s hypertension should have been treated with Clonidine as ordered. 6. Medical record review for Patient #4 revealed an admission date of 7/16/2024 with diagnoses which included Hypertensive Chronic Kidney Disease and End Stage Renal Disease. Review of the physician’ orders dated 7/16/2024 revealed, “...BP...q30 min while on dialysis and PRN...” Review of the physician’s order dated 7/30/2024 revealed Patient #4 was to receive in-center hemodialysis treatments 3 times a week via an AV graft. Review of the Treatment Sheet dated 7/25/2024 revealed the treatment was initiated at 12:27 PM and ended at 4:48 PM. There was no documentation facility staff assessed Patient #4’s blood pressure from 1:05 PM until 2:03 PM, a total of 58 minutes, and from 3:00 PM until 4:39 PM, a total of 1 hour and 39 minutes. Review of the Treatment Sheet dated 7/30/2024 revealed the treatment was initiated at 11:56 AM and ended at 4:00 PM. There was no documentation facility staff assessed Patient #4’s blood pressure from 12:32 PM until 1:32 PM, a total of 1 hour, and from 2:01 PM until 5:07 PM, a total of 1 hour and 6 minutes. Review of the Treatment Sheet dated 8/1/2024 revealed the treatment was initiated at 10:40 AM and ended at 2:49 PM. There was no documentation facility staff assessed Patient #4’s blood pressure from 12:33 PM until 2:07 PM, a total of 1 hour and 34 minutes. Review of the Treatment Sheet dated 8/6/2024 revealed a pre-treatment blood pressure was obtained at 10:50 AM. The treatment was initiated at 11:09 AM and ended at 3:06 PM. There was no documentation facility staff assessed Patient #4’s blood pressure from 10:50 AM until 12:04 PM, a total of 1 hour and 14 minutes after the pre-treatment assessment and a total of 55 minutes after the treatment was initiated. There was no documentation facility staff assessed Patient #4’s blood pressure from 12:35 PM until 2:02 PM, a total of 1 hour and 27 minutes. Review of the Treatment Sheet dated 8/8/2024 revealed a pre-treatment blood pressure was obtained at 10:31 AM. The treatment was initiated at 10:50 AM and ended at 2:10 PM. There was no documentation facility staff assessed Patient #4’s blood pressure from 10:31 AM until 12:04 PM, a total of 1 hour and 33 minutes after the pre-treatment assessment and a total of 1 hour and 23 minutes after the treatment was initiated. Review of the Treatment Sheet dated 8/10/2024 revealed a pre-treatment blood pressure was obtained at 6:57 AM. The treatment was initiated at 7:17 AM. There was no documentation facility staff assessed Patient #4’s blood pressure from 6:57 AM until 8:34 AM, a total of 1 hour and 37 minutes after the pre-treatment assessment and a total of 1 hour and 27 minutes after the treatment was initiated. 7. Medical record review for Patient #5 revealed an admission date of 6/25/2024 with diagnoses which included Essential (Primary) Hypertension and End Stage Renal Disease. Review of the physician’s orders dated 7/11/2024 and 8/6/2024 revealed the Patient was to receive in-center hemodialysis treatments 3 times a week via an AV graft. Review of the Treatment Sheet dated 7/20/2024 revealed the treatment was initiated at 10:11 AM and ended at 1:16 PM. There was no documentation facility staff assessed Patient #5’s blood pressure from 10:34 AM to 11:32 AM, a total of 58 minutes. Review of the Treatment Sheet dated 8/1/2024 revealed the treatment was initiated at 10:16 PM and ended at 1:29 PM. There was no documentation facility staff assessed Patient #5’s blood pressure from 12:30 PM to 1:25 PM, a total of 55 minutes. 8. Medical record review for Patient #6 revealed an admission date of 12/19/2022 with diagnoses which included Unspecified Injury of unspecified kidney and End Stage Renal Disease. Review of the physician’s orders dated 12/1/2023 revealed the Patient’s blood pressure was to be assessed every 30 minutes while receiving hemodialysis. Review of the physician’s orders dated 6/24/2024, 7/15/2024, 7/17/2024, 7/26/2024, and 8/9/2024 revealed the Patient was to receive in-center hemodialysis treatments 3 times a week via an AV fistula. Review of the Treatment Sheet dated 7/31/2024 revealed the treatment was initiated at 1:57 PM and ended at 6:20 PM. There was no documentation facility staff assessed Patient #6’s blood pressure from 1:57 PM to 3:02 PM, a total of 1 hour and 5 minutes. 9. During an interview on 8/13/2024 at 4:10 PM, the DO was asked how often patient blood pressures should be assessed during treatment. The DO stated, “...the policy says blood pressures should be monitored every 30 to 45 minutes...there is no excuse for it not to be done...” The DO continued and stated, “If it’s not documented, it’s not done.” .”

“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: 33763 Based on policy review, medical record review and interview, the facility failed to ensure physician’s orders for prescribed BFR and/or DFR were followed for 5 of 7 (Patient #2, #3, #5, #6, and #7) sampled hemodialysis patients. The findings included: 1. Review of the facility policy titled, “Patient Assessment and Monitoring” dated 5/1/2023 revealed, “...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...Document any findings and interventions in the medical record...” 2. Medical record review for Patient #2 revealed an admission date of 4/3/2023 with diagnoses which included Acute Kidney Failure and End Stage Renal Disease. Review of the physician’s orders dated 6/26/2024, revealed a BFR of 450 ml/min and a DFR of 800 ml/min. Review of the Treatment Sheet dated 7/8/2024, revealed the BFR was 400 ml/min instead of 450 ml/min as prescribed from 11:45 AM until 4:19 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 7/10/2024, revealed the BFR was 300 ml/min instead of 450 ml/min as prescribed at 4:04 PM and 4:34 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 7/10/2024, revealed the BFR was 400 ml/min instead of 450 ml/min as prescribed from 11:47 AM until 3:04PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 7/12/2024, revealed the BFR was 300 ml/min instead of 450 ml/min as prescribed from 2:34 PM until 3:01 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 7/12/2024, revealed the BFR was 400 ml/min instead of 450 ml/min as prescribed from 12:36 PM until 4:02 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 7/22/2024, revealed the BFR was 400 ml/min instead of 450 ml/min as prescribed from 2:32 PM until 4:35 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 8/2/2024, revealed the BFR was 400 ml/min instead of 450 ml/min as prescribed from 12:41 PM until 4:34 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 8/9/2024, revealed the BFR was 400 ml/min instead of 450 ml/min as prescribed from 11:47 AM until 2:33 PM. There was no documentation why the prescribed BFR was not followed. 3. Medical record review for Patient #3 revealed an admission date of 5/14/2024 with diagnoses which included Hypertensive Chronic Kidney Disease and End Stage Renal Disease. Review of the physician’s orders dated 7/11/2024 revealed a BFR of 400 ml/min and a DFR of 800 ml/min. Review of the Treatment Sheet dated 7/20/2024 revealed the BFR was 450 ml/min instead of 400 ml/min as prescribed from 12:40 PM until 2:02 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 8/1/2024 revealed the BFR was 450 ml/min instead of 400 ml/min as prescribed from 12:09 PM until 2:37 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 8/3/2024 revealed the BFR was 300 ml/min instead of 400 ml/min as prescribed from 12:01 PM until 2:33 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 8/6/2024 revealed the BFR was 450 ml/min instead of 400 ml/min from 1:02 PM until 2:35 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 8/10/2024 revealed the BFR was 450 ml/min instead of 400 ml/min as prescribed from 11:48 AM until 2:46 PM. There was no documentation why the prescribed BFR was not followed. 4. Medical record review for Patient #5 revealed an admission date of 6/25/2024 with diagnoses which included Essential (Primary) Hypertension and End Stage Renal Disease. Review of the physician’s orders dated 7/11/2024 revealed a BFR of 400 ml/min and a DRF of 800 ml/min. Review of the Treatment Sheet dated 8/1/2024 revealed the DFR was 500 ml/min instead of 800 ml/min as prescribed from 12:11 PM until 12:32 PM and again at 1:25 PM. There was no documentation why the prescribed DFR was not followed. 5. Medical record review for Patient #6 revealed an admission date of 12/19/2022 with diagnoses which included Unspecified Injury of unspecified kidney and End Stage Renal Disease. Review of the physician’s orders dated 7/15/2024 revealed a BFR of 450 ml/min and a DFR of 800 ml/min. Review of the Treatment Sheet dated 7/24/2024 revealed the BFR was 400 ml/min instead of 450ml/min as prescribed from 2:05 PM until 6:01 PM. There was no documentation why the prescribed BFR was not followed. Review of the physician’s orders dated 7/26/2024 and 8/9/2024 revealed a BFR of 450 ml/min and a DFR of 800 ml/min. Review of the Treatment Sheet dated 8/7/2024 revealed the BFR was 400 ml/min instead of 450 ml/min as prescribed at 2:34 PM and from 4:04 PM until 6:10 PM. There was no documentation why the prescribed BFR was not followed. 6. Medical record review for Patient #7 revealed an admission date of 2/9/2024 with diagnoses which included Diabetes Mellitus and End Stage Renal Disease. Review of the physician’s orders dated 6/26/2024 revealed a BFR of 400 ml/min and a DFR of 800 ml/min. Review of the Treatment Sheet dated 7/24/2024 revealed the BFR was 300 ml/min instead of 400 ml/min as prescribed from 12:26 PM until 3:45 PM. There was no documentation why the prescribed BFR was not followed. Review of the Treatment Sheet dated 8/5/2024 revealed the BFR was 300 ml/min instead of 400 ml/min as prescribed from 12:44 PM until 1:32 PM. The BFR was 350 ml/min from 2:03 PM until 4:08 PM. There was no documentation why the prescribed BFR was not followed. 7. During an interview on 8/13/2024 at 4:10 PM, the DO stated “...the BFR/DFR should be running at the prescribed rate...if the rate is unable to be obtained, the staff should be documenting why...if this becomes a trend, we need to find out the root cause and treat it...””