Lubbock Dialysis Center-Redbud

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 43999 Based on observation, interviews and documentation reviewed, the facility is not in compliance with applicable State regulations pertaining to licensure and any other relevant health and safety requirements.the facility is not in compliance with applicable State regulatory licensing requirements. A. The Charge Nurse(CN) provided direct patient care duties contrary to Texas ESRD Rules and Regulations. B. The facility failed to report hosptial transfers to the Texas Department of Health as required within ten working days. Findings: A. During review of patient/staff assignments for patient care on the following Tuesday & Thursday February 25 & 27, 2025 it was found there were two nurses assigned to provide patient care with no CN (charge nurse) scheduled . In an interview with the nurse (staff # 2) on 2/25/25 during observation of the treatment floor, she said “ On TTS (Tuesday, Thursday, Saturday) shifts there is no CN scheduled . Sometimes there is another nurse scheduled but they are assigned to direct patient care. The two-team lead RN’s provide patient care to all patients that have a CVC(Central venous catheter) administer medications, perform patient assessments, and supervise patient care for 12 patients, if an emergency arises the two team lead nurses provide care and other CN (charge nurse) duties. The new FA (Facility Administrator) sometimes assist with patient care but is not scheduled. The FA might be in the facility one or two days a week, but we do not know when she will be here routinely.” Additional review of the facility’s January 2025 patient/staff assignments for TTS schedule revealed two nurses (team leads )were scheduled with no CN scheduled on these dates. In an interview on 2/25/25 with DO (Director of Operations) , staff #1 and the FA, staff #4 confirmed the TTS schedule with no CN scheduled. B. Review of the facility ambulance transfer log and treatment sheets reflected that 4 of 4 patients (patients #2 , #8, #10 and #12) were not reported as TDH ( Texas Department of Health) within ten working days. Patient # 2 was transferred to the hospital 1/14/2025 for hypertension. The patient was not recorded on the ambulance transfer log with no TDH (Texas Department of Health) Incident report completed. Patient #8 was transferred to the hospital 11/09/24 for syncope. There was no TDH (Texas Department of Health) Incident report completed. Patient #10 was transferred to the hospital 02/22/25 for chest pain. There was no TDH (Texas Department of Health) Incident report completed. Patient #12 was transferred to the hospital 02/10/25 for syncope. There was no TDH (Texas Department of Health) Incident report completed. During an interview on the afternoon of 2/26/25, the facility administrator stated she did not think an incident report had to be submitted for patient hospital transfers to TDH.”

“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: 43999 Based on facility documentation, observation and staff interviews, the facility failed to get patient signature ,or the patient’s designee, for the plan of care 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. Findings: Review of 5 of 5 patient’s (Patient’s 1, 2, 9, 13, 19 ) annual plan of care (POC) documents did not provide documentation the patient (or patient’s legal representative’s) participation or input when completed by the interdisciplinary team. There was no signature on the POC that the information was reviewed with the patient (or patient’s legal representative’s) for the 5 patients completed in January 2025. Facility Administrator, staff #, confirmed 2/26/25 the five POC’s completed in January 2025 for (Patient’s 1, 2, 9, 13, 19 ) had not be discussed with the patient or patient’s legal representative by a member of the interdisciplinary team.”

“PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This Standard is not met as evidenced by: 43999 Based on observations, personnel record review, facility document review and staff interviews, the facility failed to employ and designate a qualified full time registered nurse as the nurse manager of this facility. This finding had potential to negatively impact the functioning of the facility and to adversely affect the outcomes of all patients. Findings: Staff #5 is the interim supervising nurse in the facility 1-2 days a week and the Facility Administrator of the facility as well as the full time Facility Administrator in a sister facility greater than two and a half hours away. Staff #5 stated during the interview 2/26/25 she was assisting the previous supervising nurse and when that nurse resigned in late October, she agreed to be the interim supervising nurse two days a week until a new supervising nurse could be hired. In an interview with the Director of Operations on 2/26/25 she confirmed the facility did not currently have a full time nurse manager of the facility. She stated they were beginning interviews for the position. She further confirmed the current interim supervising nurse is only at the facility maybe 2 days a week and also supervises another facility that is greater than two and a half hours away.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 43999 Based on record reviews, and interviews, the medical director did not demonstrate responsibility in ensuring that the facility staff adhered to facility policy. The facility staff (staff # 11, 16,17 &18) did not follow the facility policies for assessment and monitoring during treatment and the Nurse did not access patient on 1 of 1 patient(patient #1). Findings : Review of Clinical Services Policy , version 4 , reference 45284, dated 05/01/2023- titled “Patient Assessment and Monitoring” partly stated: “If the PCT/LPN note any changes or abnormal findings in the patient ’ s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. The RN will notify the patient ’ s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed.” Review of Clinical Services Policy , version 6, reference 45265, dated 11/06/2023- titled- “Nursing Supervision and Delegation “, partly stated: “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. · Blood Pressure- A Systolic blood pressure greater than 180 mm/Hg and / or diastolic blood pressure greater than 100 mm/Hg at any time before, during or after the treatment. If B/P less than or equal to 100 mm/hg systolic during treatment. A systolic blood pressure less than 100 mm/Hg post treatment when standing. A drop in systolic BP of 20 mmHg between sitting and standing.” Review of patient (pt) #1 treatment sheets revealed the following: 12/14/24 : 1302 - B/P (blood pressure) 184/102 by PCT #11 “no RN assessment “ 1332 - B/P 200/104 by PCT #11, “ no RN assessment” 1403 - B/P 200/104 by PCT #16, “ no RN assessment” 1434 - B/P 200/104 by PCT #16, “ no RN assessment” 1503 - B/P 192/107 by PCT #11, “no RN assessment” 1607 - B/P 204/118 by PCT #11, “no RN assessment” 12/18/24 : 1405 - B/P 205/117 by PCT #17 , “no RN assessment” 1437 - B/P 186/113 by PCT #17, “ no RN assessment” 1534 - B/P 163/103 by PCT #17, “no RN assessment” 1619 - B/P 194/114 by RN #18, treatment discontinued by RN, comments partly stated, “ pt denies complaints, patient alert, discharged home, stable “ 12/23/24 : 1335 - B/P 184/112 by PCT #4, “no RN assessment” 1402 - B/P 190/115 by PCT #4, “no RN assessment” 1434 - B/P 174/111 by PCT #4, “ no RN assessment” 1619 - B/P 194/114 by RN #18 treatment discontinued by RN, comments, “ pt denies complaints, patient alert “ In an interview on 2/26/25 with Staff #1 and Staff #5 the above findings were confirmed.”