Davita the Woodlands Dialysis Center

“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: 30124 Based on record review and interview the facility’s medical director failed to ensure nursing staff followed the facility’s policy and procedures to prevent or reduce complications pre, during or post treatment in that the nursing staff did not: 1. Complete the initial nursing assessment within the first hour of treatment in 4 of 6 records reviewed. (Patient ID #2, 3, 4, 5). 2. Staff failed to notify the charge nurse of specific patient parameters that were identified to be out of range and nursing staff failed address abnormal finding by reassessment of patients in 2 of 6 records reviewed. (Patient ID #s 2, 5). The facility currently has a census of 64 hemodialysis patients that could be affected by the nursing staff failing to complete the initial nursing assessment within the first hour of hemodialysis treatment. Findings: Review of Texas Board of Nursing RN Scope of practice. Rule 15.28. Assessment. The comprehensive assessment is the first step and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis, and interpretation of data. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence- based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed. Patient Diagnosis/Problem Identification/Planning The second step in the nursing process is analyzing data gathered during the assessment and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary health care team, as appropriate for their educational background and scope. The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, participate in the patient diagnoses, and to formulate goals, teaching plans and outcomes. A nursing plan of care for patients is developed by the RN, who has the overall responsibility to coordinate nursing care for patients. Teaching plans address health promotion, maintenance, restoration, and prevention of risk factors. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary health care team during the planning process. Implementation Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate certain nursing tasks within the plan of care for patients within legal, ethical, and regulatory parameters and in consideration of health restoration, disease prevention, patient independence, wellness, and promotion of healthy lifestyles. The RN ’ s duty to patient safety when making assignments to other nurses or when delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN scope of practice may include the supervision of LVNs or other RNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual ’ s performance and activity. 5 The RN may have to directly observe and evaluate the nursing care provided depending on the LVN ’ s skills and competence, patient conditions, and level of urgency in emergent situations. The RN may determine when it is appropriate to delegate tasks to unlicensed personnel and maintains accountability for how the unlicensed personnel perform the tasks. The RN is responsible for supervising the unlicensed personnel when tasks are delegated. The proximity of supervision is dependent upon patient conditions and skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process. Evaluation and Re-assessment A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary. Policy Reviewed: Review on 12/03/2024 of the facility’s current policy titled: “Pre-Inter-Post Treatment Data Collection, Monitoring and Nursing Assessment”; Policy: 1-03-08; Latest Revision: April 2024. Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Pre-Treatment Data Collection/Assessment 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. 7. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated. Intradialytic Data Collection/Assessment 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law. Review on 12/03/2024 of facility specific parameters titled; “Reportable (to RN) Patient Date Collection/Observations” reads: Weight: gain > 6 kg, post-treatment > or < 1.o KG from EDW (estimated dry weight). Temperature - > 100.5 F (37 C). Heart Rate: > 115 or < 55, irregular rhythm. Respirations/Breath Sounds: Respirations < 8 BPM ( breaths per minute), >28 BPM, SOB (shortness of breath), crackles, wheezing, rhonchi, absent sounds. Blood pressure: > 180 SBP (systolic blood pressure), > 90 DBY (diastolic blood pressure). Records Reviewed: Review on 12/03/2024 of selected patient records identified the following: Patient ID #2’s hemodialysis treatment sheet reviewed: 11/30/2024 pre-treatment blood pressure documented as a standing BP (blood pressure) of 170/80, pulse 72. At 11:33 AM blood pressure documented by Patient Care Technician, staff ID #J, BP 194/83. No documentation was found that Patient Care Technician (PCT), staff ID #J notified the nurse of BP that was out of parameters. No documentation was found of reassessment of the patient with abnormal blood pressure out of parameters by the nurse. 11//27/2024 pre-treatment blood pressure documented as a sitting BP 127/66, pulse 78. Blood pressure documented by Patient Care Technician, staff ID #K, as 186/88 at 13:23 PM, at 14:53 BP documented as 189/88, at 14:55 BP documented as190/100. No documentation was found that Patient Care Technician (PCT), staff ID #J notified the nurse of BP that was out of parameters. Initial Nursing Assessment of Patient ID #2 was not found to be completed within the first hour of treatment: 12/03/2024 treatment initiated at 11:22 AM, pre-nursing assessment completed at 13:42 PM. 11/27/2024 treatment initiated at 11:11 AM, pre-nursing assessment completed at 12:13 PM. 11/25/2024 treatment initiated at 11:26 AM, pre-nursing assessment completed at 12:35 PM. Patient ID #3’s hemodialysis treatment sheet reviewed: Initial Nursing Assessment of Patient ID #2 was not found to be completed within the first hour of treatment: 12/03/2024 hemodialysis treatment initiated 11:46 AM, pre-nursing assessment completed at 13:40 PM. 11/25/2024 hemodialysis treatment initiated 11:20 AM, pre-nursing assessment completed at 12:39 PM. Patient ID #4’s hemodialysis treatment sheet reviewed: Initial Nursing Assessment of Patient ID #4 was not found to be completed within the first hour of treatment: 12/03/2024 hemodialysis treatment initiated 11:31 AM, pre-nursing assessment completed at 13:27 PM. 11/25/2024 hemodialysis treatment initiated 11:24 AM, pre-nursing assessment completed at 12:31 PM. 11/21/2024 hemodialysis treatment initiated 11:11 AM, pre-nursing assessment completed at 15:52 PM. Patient ID #5’s hemodialysis treatment sheet reviewed: 12/03/2024 pre-treatment blood pressure documented as sitting BP (blood pressure) of 157/84, pulse 60. At 10:54 AM blood pressure and heart rate documented by registered nurse, staff ID # as 135/62, pulse 54. Patient Care Technician, staff ID # M documented BP 166/89, pulse 51, at 12:31 PM staff ID #M documented pulse 54, at 13:05 staff ID #M documented pulse 51. No documentation was found that Patient Care Technician (PCT), staff ID #M notified the nurse of BP and heart rate that was out of parameters. BP documented as 196/92, pulse 51 at 13:05 with note by staff ID #M “Patient awake; alert; and states no complaints at this time. At 13:32 PM staff ID #M documents BP 192/94, pulse 54 with note as “”BP high; patient no complaints; patient watching TV; patient asymptomatic; RN notified. BP noted at 14:03 192/94, pulse 54 by staff ID #M with note “Patient monitored, watching TV no complaints. At 14:31 note by staff ID #M BP 185/100, pulse 51 note, “ Patient cramping: UF off and 150 mls NS given”. At 14:55 note by staff ID #M BP 206/105, pulse 55 note, “BP high; patient no complaints; patient asymptomatic; CN notified”. A nursing note was not documented till 15:10 my nurse ID #L with BP 199/75, pulse 78 “Manual Entry: Treatment terminated; BP remains elevated; patient will take his home BP meds”. 11/30/2024 - pre-treatment BP 180/87, pulse 52, treatment initiated by nurse, staff ID #I at 11:01 AM with BP 168/99, pulse 54. At 11:33 AM Patient Care Technician, staff ID #M documents BP 186/106, pulse 48, 12:02 BP 195/98, pulse 50, 13:32 BP 186/96, pulse 54. 15:05 note from nurse, staff ID #I, treatment terminated BP 144/83, pulse 68. No documentation was found of reassessment of the patient with abnormal blood pressure and heart rate out of parameters by the nurse during the hemodialysis treatment. Initial Nursing Assessment of Patient ID #5 was not found to be completed within the first hour of treatment: 12/03/2024 hemodialysis treatment initiated 10:53 AM, pre-nursing assessment completed at 12:12 PM. 11/25/2024 hemodialysis treatment initiated 10:07 AM, pre-nursing assessment completed at 12:42 PM. Interview at 17:45 PM on 10/30/2024 with staff ID #E confirmed the above finding and stated the assessment by the nurse should be done within the first hour of hemodialysis and nurse should be notified of abnormal findings and assess the patient.”