Farmers Branch Dialysis Center

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 50181 Based on observation and interview, the facility staff failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the dialysis center. This practice had the potential for creating an environment that risks contamination of equipment and supplies used for patient care, which placed all facility patients in the facility at risk. Findings Include: During a tour of the facility on 04/02/2024 with Personnel #1 and Personnel #5 the floor in the water room and warehouse has multiple areas of damaged epoxy flooring in need of repair. A review of the facility’s Governing Body meeting minutes for September, October, November, and December 2023 revealed the following: “Physical Environment Issues Floor in the water room, and the warehouse needs to be refinished. A vendor was approved but has been unable to provide a start date. Another vendor will be contacted by the Area Technical Operations Manager (ATOM) as the approved vendor has been unable to provide a start time.” On 04/02/24, an interview with the CM confirmed the floor damage was identified by the facility staff and has been reported in Governing Body with no definitive date of resolution.”

“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 the facility dialysis assessment parameters includes the following guidance: “Fluid Status Any weight gains greater than 4kg pre- treatment. Any swelling in the facial area and lower extremity edema. Any post treatment weight with a variance from the estimated dry weight (EDW) of 0.5kg. Any weight loss or no change in weight from a patient’s last treatment post weight.” “Blood Pressure (BP) Systolic blood pressure greater than 180mm/Hg and/or diastolic blood pressure greater than 100 at any time before during or after treatment. A systolic blood pressure less than 100mm/Hg post treatment when standing. A drop in systolic blood pressure of 20mm/Hg between sitting & standing.” “Cardiac A pulse greater than 100 or less than 60 beats per minute, irregular, or weak. Any signs of cyanosis or chest pain. Any patient reported irregular heartbeat, use of Nitroglycerin, or change in activity level” Patient #4 treatment record dated 04/01/2024 reveals the following: 07:25 Treatment initiation, BP: 196/80, HR: 59 07:35 BP: 187/81 HR: 58 08:06 BP: 196/82 HR: 58 08:30 BP: 188/82 HR: 57 09:02 BP: 189/92 HR: 56 10:03 HR: 55 10:30 HR: 54 11:00 HR: 57 11:16 HR: 57 11:23 BP: 185/86 HR:57 There is no documentation noted for the above entries on the treatment sheet acknowledging the systolic BP and heart rate was a reportable finding and was reported to the RN by the DPC staff. Patient #5 treatment record dated 04/01/2024 reveals the following: 13:37 BP:92/54 HR:55 DPC staff documents RN notified; no follow-up noted by RN 14:03 BP:77/47 HR: 56 “Patient alert, bp is low, pt asymptomatic, NS flush 100 given, RN notified” No RN follow-up noted, no re-evaluation of BP and HR after 100 NS given until 14:30. 14:30 BP: 103/50 HR: 57 There is no documentation acknowledging the HR was a reportable finding and was reported to the RN by the DPC staff. Patient #10 treatment record dated 04/01/2024 reveals the following: 18:01 HR: 58 There is no documentation acknowledging the HR was a reportable finding and was reported to the RN by the DPC staff. 19:30 BP: 152/105 There is no documentation acknowledging the diastolic BP was a reportable finding and was reported to the RN by the DPC staff. On 04/02/2024, an interview with the CM and CC confirmed the facility’s reportable parameters and documentation required for out of parameter findings pre/intra/post dialysis treatment by the DPC staff and registered nurse providing care to the patient.”

“GOV-INVOL DISCHARGE PROCESS REQUIREMENTS CFR(s): 494.180(f)(4) The medical director ensures that no patient is discharged or transferred from the facility unless - (4) The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team- (i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record; (ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge; (iii) Obtains a written physician’s order that must be signed by both the medical director and the patient’s attending physician concurring with the patient’s discharge or transfer from the facility; (iv) Contacts another facility, attempts to place the patient there, and documents that effort; and (v) Notifies the State survey agency of the involuntary transfer or discharge. (5) In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure. This Standard is not met as evidenced by: 50181 Based on medical record review, policy review, and staff interview the medical director failed to ensure that the facility staff followed their policies and procedures related to involuntary patient discharge. The facility failed to provide the patient with a 30-day notice prior to discharge from the facility. A review of facility policy titled, “Routine and Involuntary Patient Discharge,” published: 09/04/2019, version 4 includes the following guidance: “A 30-day notice is not required when a patient’s behavior is a severe and immediate threat to the health and safety of others. After following the steps on the procedure related to notifications contact the State agency and Network to inform them of the immediate discharge. CMS has defined “immediate severe threat” to be a threat of physical harm. For example, if a patient has a gun or knife or is making credible threats of physical harm, this would be considered an “immediate severe threat.” “If a patient’s medical condition is deemed to require non-routine, extensive monitoring, or other interventions that are not available in the facility, transfer or discharge of the patient may be necessary ...Involuntary discharge of a medically or cognitively compromised patient should be the option of last resort.” “A written order, signed by the attending physician and the medical director, must be in the patient’s medical record for the facility to involuntarily discharge or transfer a patient.” Review of Patient #1 medical records revealed the following: Patient #1 was immediately discharged from the facility on 11/16/2023 with his last treatment in the facility being 11/15/2023. Personnel #2 psychosocial progress note dated 11/16/2023 details the conversation had with patient #1 son who is his primary caregiver. “It was explained to the pts. Son that pt. will be immediately discharged from FKC Farmers Branch due to the inability to meet the pts. Medical needs.” The attending physician, personnel #3, discharge order, dated 11/28/23, in patient #1 medical record reads, “IVD 2/2 to inability to meet pt medical needs.” On 04/02/2024, an interview with the CM confirmed the patient was immediately discharged from the facility due to the facility’s inability to meet the patient’s medical needs. He indicated it was deemed immediate due to the patient grabbing the nurse and leaving a bruise when she attempted to calm him during his last treatment on 11/15/2023.”