Fkc East Fort Worth

“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: 50181 Based on observation and interview, the facility’s staff failed to ensure the emergency patient contact list and dialysis orders were updated monthly in the emergency evacuation box and that there were no expired supplies in the evacuation box. Findings included: During a tour of the facility with personnel #2 on 06/05/2024, it was observed that the emergency evacuation box had tongue depressors with an expiration date of 05/2023 and the emergency disaster patient contact list and dialysis orders had not been updated since 11/28/2023. The daily AED log had missing entries for the following days in May 2024: 23,27,28 and 31”

“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: 50181 Based on observation and interview, the facility staff failed to ensure gloves were worn appropriately when caring for the patient or touching the patient’s equipment at the dialysis station and wash their hands or use hand sanitizer after removing gloves and between each patient and station. This deficient practice had the likelihood to cause cross contamination between the patients. Findings included: During observation of the treatment area on 06/05/2024 staff member #10 was observed resetting a machine with a glove wrapped around her finger on three separate occasions. Staff member #11 was observed removing his gloves and not washing or sanitizing his hands on two separate occasions.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 50181 Based on review of the ancillary equipment logs and interview, the facility failed to ensure the logs were completed per policy and procedure. Ancillary equipment may include, but is not limited to: functional and clean patient scales, centrifuge, refrigerators, incubators for in-house performance of water/dialysate cultures, emergency generators, blood pressure monitoring equipment, infusion pumps, patient thermometers, eye wash stations, conductivity and pH meters, Hoyer lifts, and equipment required to provide in-house laboratory testing (e.g. blood glucose meters, heat blocks, equipment for activated clotting times [ACT], supplies for testing for occult blood and hematocrit levels). Maintenance of refrigerators should include the monitoring of temperatures to assure these are appropriate for the items stored. Findings: Helmer Medication Refrigerator log did not have an entry noted for Tuesday, April 4th, 2024Daily AED Log did not have entries noted for May 23, 27, 28 and 31 for year 2024. The above were reviewed and confirmed by the Director of Operations and Area Technical Operations Manager.”

“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: 50181 Based on medical record review, policy review and staff interview the facility failed to ensure the direct patient care (DPC) staff reported patient status changes during treatment to the Registered Nurse (RN) to ensure a reassessment was performed and documented with appropriate interventions and/or physician notification, if required. Findings included: A review of facility policy titled, “Nursing Supervision and Delegation,” with a published date of 11/06/2023, version 6, includes the following guidance: “The following criteria can be used as a guideline to identify when a PCT/LPN/LVN or RN shall refer a patient to the Team Leader/Charge Nurse for further assessment pre, during or post treatment. The Team Leader/Charge Nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. *Fluid Status Any weight gains greater than 4 kg pre-treatment. Any post treatment weight with of variance from the estimated dry weight of 1.0 kg *Blood Pressure A systolic blood pressure greater than 180mm/Hg and or diastolic blood pressure greater than 100mm/Hg at any time before, during or after treatment. If blood pressure is less than or equal to 100mm/Hg systolic during treatment. *Heart Rate A heart rate that is a new onset and is below 60 beats per minute or greater than 100 beats per minute or an irregular heart rate that is a new onset.” Patient #1 treatment record dated 05/22/2024 indicates the following: 11:31 Heart Rate: 104 There is no documentation acknowledging this heart rate was a reportable finding and was reported to the RN by the DPC staff. Patient #1 treatment record dated 05/29/2024 indicates the following: 17:04: Blood Pressure (BP): 98/60 There is no documentation acknowledging this BP was a reportable finding and was reported to the RN by the DPC staff. Patient #1 treatment record dated 05/31/2024 indicates the following: 11:08: Blood Pressure (BP): 97/52 There is no documentation acknowledging this BP was a reportable finding and was reported to the RN by the DPC staff. Patient #5 treatment record dated 05/14/2024 indicates the following: 12:02: Blood Pressure: 182/83 Heart Rate: 53 There is no documentation acknowledging this BP and heart rate were reportable findings and was reported to the RN by the DPC staff. 14:31: Blood Pressure: 196/61 Heart Rate: 56 There is no documentation acknowledging this BP and heart rate were reportable findings and was reported to the RN by the DPC staff. Patient #5 treatment record dated 05/07/2024 indicates the following: 12:31 Heart Rate: 56 13:01 Heart Rate: 59 14:04 Heart Rate: 59 14:31 Heart Rate: 59 There is no documentation acknowledging this heart rate was a reportable finding and was reported to the RN by the DPC staff. Patient #5 treatment record dated 04/23/2024 indicates the following: 11:15 Heart Rate: 58 11:33 Heart Rate: 57 12:02 Heart Rate: 56 12:39 Heart Rate: 55 13:02 Heart Rate: 56 13:32 Heart Rate: 55 14:06 Heart Rate: 55 There is no documentation acknowledging this heart rate was a reportable finding and was reported to the RN by the DPC staff.”

“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: 50181 Based on record review, the facility failed to follow the patient’s ordered plan of care by not following the ordered blood flow rate (BFR) and/or dialysate flow rate (DFR) for one or more treatment records reviewed. The specific BFR is needed to ensure that the blood pump is at constant speed to push the patient’s blood through the dialyzer and back into the patient’s body and is a part the patient’s dialysis prescription. Review of Patient #3 treatment record for 05/06/2024 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ran at 300 mL/min from the start of treatment at 11:52 to 12:33 with no documentation reporting the change to the charge nurse by the direct patient care staff and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #3 treatment record for 05/08/2024 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR ran at 350 mL/min for the duration of treatment with no documentation reporting the change to the charge nurse by the direct patient care staff and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #5 treatment record for 05/07/2024 revealed the BFR was ordered to run at 450mL/min. Review of the intradialytic records revealed the BFR ran at 410 mL/min for the duration of treatment with no documentation reporting the change to the charge nurse by the direct patient care staff and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 50181 Based on record review and interview, the facility failed to ensure the interdisciplinary team completed the plan of care assessment prior to the plan of care meeting date. Findings include: Patient # 5 Plan of Care meeting date: 05/29/2024 Social Worker Assessment Completion Date: 08/17/2023 Registered Nurse has not signed off the plan of care as of 06/05/2024 Patient #3Plan of Care meeting date: 04/24/2024Registered Nurse assessment date: 04/11/2024Social Worker assessment date: 04/23/2024Dietician assessment date: 04/22/2024 Registered Nurse plan of care completion date: 05/20/2024 Social Worker plan of care completion date: 04/24/2024 Dietician plan of care date: 04/24/2024 Patient #1Plan of Care meeting date: 12/19/2023 Registered Nurse assessment date: 12/19/2023 Social Worker assessment date: 12/16/2023 Dietician assessment date: 12/19/2023 Registered Nurse plan of care completion date: 02/16/2024 The above findings were discussed with personnel #1 and personnel #2 both confirmed and acknowledged the above findings.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 34839 Based on observation, interview and record review the Facility’s Governing Body failed implement its policy and procedure to ensure a grievance reported to the facility was investigated and resolution documented in 1 of 1 grievances reviewed. Patient #1 Findings: Review of the facility Grievance log revealed: 1. Grievance Details. Patient #1 submitted a formal grievance to the facility, grievance details read as follows “ pts BP declining, complaints of SOB during treatment staff followed policy by administering O2, decreasing UF goal, reclining head of chair, uf off pt upset due to having SOB pt called EMS services to intervene. Pt refused to leave with EMS and decided to wait for transportation pt contacted the ESRD network to complain that he expressed not feeling safe in the facility under the supervision of the current staff. 2. Resolution/Corrective actions. Blank 3. Follow Up with Patient/ Legal Guardian. Blank 4. Service Recovery Comments. Blank Interview on 11/7/2023 at 1:30 p.m. with the Facility’s Administrator (FA ) revealed, that the previous FA did not complete the grievance process per policy and procedure, and did not discuss the grievance in the facility Quality Assessment and Performance Improvement ( QAI ) nor did the Governing Body review the grievance. Reviewed facility’s Patient Grievance Policy and Procedure published 04/04/2014 version 3 Section: Responding to Grievances: Facility Level page 2 of 4 Step 1. FKC staff promptly acknowledge and report all patient grievances to the charge nurse or team lead as soon as possible. 2. The nurse in charge meets with the patient to gather information and complete as many fields as possible on the patient grievance status report within 72 hours of being notified. and inform the CM 3. The CM reviews the patient grievance status report daily for any new grievances. CM meets with the patient within 5 business days to acknowledge, investigate and address the grievance. NOTE: MSW or other staff may also assist in assessing and resolving patient grievances as appropriate. 4. CM reports back to the patient when a resolution is attained or considered attained by the facility. NOTE: when the grievance cannot be immediately resolved, the CM must provide the patient/ representative with updates periodically on progress. 5 The CM ensures the following details are completed in the QAI . Date of grievance . Mode of grievance . Intake person . Patient Initials . Nature of the grievance . Findings of the investigation . Grievance referred to . resolution and any corrective actions taken . Any follow up related to the grievance NOTE: Even if the patients grievance is resolved quickly, the CM must document the complaint and actions taken to resolve.”