Hope Kidney Clinic

“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: 39425 Based on review of hemodialysis flow sheets, reportable parameters, and staff interview the facility failed to ensure that direct patient care staff reported significant changes in patient health status while receiving hemodialysis to the charge nurse and or the charge nurse failed to reassess the patient when significant changes occurred during treatment and notify the physician when appropriate. The findings included: Facility reportable parameters PCT to RN Reporting During Dialysis B/P: Systolic >180 or Diastolic >110 Report to the RN and Document Review of hemodialysis flow sheets dated 5/31/24 through 5/17/24 at approximately 10:00 AM in the facility conference room revealed the following discrepancies: Patient # 1 Flowsheet Dated: 5/06/24. Dialysis initiated at 9:55 AM and terminated at 13:40 PM. At 9:55 AM the blood pressure was recorded as 185/90 by the PCT. The PCT documented “nurse vg notified.” At 10:25 AM the blood pressure was recorded as 189/92 by the PCT. No documentation of PCT notifiying nurse. At 10:42 AM the blood pressure was recorded as 195/93 by the PCT. No documentation of PCT notifying nurse. At 11:24 AM the blood pressure was recorded as 186/87 by the PCT. No documentation of PCT notifying nurse. At 11:28 AM the blood pressure was recorded as 186/87 by the PCT. No documentation of PCT notifying nurse. At 13:08 PM the blood pressure was recorded as 189/91 by the PCT. No documentation of PCT notifying nurse. At 13:38 PM the blood pressure was recorded as 185/86 by the PCT. No documentation of PCT notifying nurse. No documentation by the RN regarding patient blood pressures during dialysis. Flowsheet Dated: 5/08/24. Dialysis initiated at 10:14 AM and terminated at 13:50 PM. At 10:42 AM the blood pressure was recorded as 189/99 by the PCT. The PCT documented “pt continued with high b/p, RN aware.” At 11:10 AM the blood pressure was recorded as 190/81 by the PCT. The PCT documented “high b/p, RN aware.” At 11:30 AM the blood pressure was recorded as 191/75 by the PCT. No documentation of PCT notifying nurse. At 11:58 AM the blood pressure was recorded as 187/84 by the PCT. No documentation of PCT notifying nurse. No documentation by the RN regarding patient blood pressures during dialysis. Flowsheet Dated: 5/10/24. Dialysis initiated at 10:17 AM and terminated at 13:13 PM. At 10:42 AM the blood pressure was recorded as 204/97 by the PCT. The PCT documented “RN notified” At 11:10 AM the blood pressure was recorded as 196/98 by the PCT. No documentation of PCT notifying nurse. No documentation by the RN regarding patient blood pressures during dialysis. Flowsheet Dated: 5/13/24. Dialysis initiated at 9:51 AM and terminated at 13:36 PM At 9:51 AM the blood pressure was recorded as 183/97 by the PCT. PCT documented “RN aware.” At 10:14 AM the blood pressure was recorded as 198/97 by the PCT. No documentation of PCT notfying nurse. At 10:38 AM the blood pressure was recorded as 209/96 by the PCT. No documentation of PCT notifying nurse. At 10:52 AM the blood pressure was recorded as 187/95 by the PCT. No documentation of PCT notifying nurse. At 13:00 AM the blood pressure was recorded as 208/88 by the PCT. No documentation of PCT notifying nurse. No documentation by the RN regarding patient blood pressures during dialysis. Flowsheet Dated: 5/15/24. Dialysis initiated at 10:06 AM and terminated at 12:10 PM At 10:06 AM the blood pressure was recorded as 211/93 by the PCT. No documentation of PCT notifying nurse. At 10:36 AM the blood pressure was recorded as 207/85 by the PCT. No documentation of PT notifying nurse. At 10:51 AM the blood pressure was recorded as 209/92 by the PCT. PCT documented “RN aware.” At 11:06 RN documented “BP 209/85 pt denies chest pain and wants to recline back on her seat, goal increased to 4.4L as tolerated.” At 11:20 AM the blood pressure was recorded as 196/98 by the PCT. No documentation of PCT notifying nurse. At 11:43 AM the blood pressure was recorded as 196/86 by the PCT. No documentation of PCT notifying nurse. At 11:52 AM the blood pressure was recorded as 196/86 by the PCT. PCT documented “UF Off.” No documentation of PCT notifying nurse. At 12:09 AM the blood pressure was recorded as 206/98 by the PCT. PCT documented “UF on.” No documentation of PCT notifying nurse. At 12:10 AM the blood pressure was recorded as 196/86 by the PCT. PCT documented “tx ended as per pt request, RN aware.” At 12:43 RN Documented “1215--Late entry-206/98 denies chest pain-adm Clonidine 0.1mg PO” Flowsheet Dated: 5/17/24 Dialysis initiated at 9:51 AM and terminated at 13:36 PM At 10:21 AM the blood pressure was recorded as 188/102 by the PCT. PCT documented “RN aware.” At 10:36 AM the blood pressure was recorded as 199/81 by the PCT. No documentation of PCT notifying nurse. At 10:48 AM the blood pressure was recorded as 199/86 by the PCT. No documentation of PCT notifying nurse. At 11:46 AM the blood pressure was recorded as 183/80 by the PCT. No documentation of PCT notifying nurse. No documentation by the RN regarding patient blood pressures during dialysis. Findings reviewed during preliminary exit conference on 6/5/24 with the Clinical Manager. Surveyors asked if there was flowsheet tracking for the month of May, the Clinical Manager on 6/5/24 at 11:00 AM stated “No Ma’am.””