Davita West Plano Dialysis

“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: 30377 Based on review of hemodialysis flow sheets 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. The findings included: Review of hemodialysis flow sheets dated 7/26/24 and 8/13/24 in the facility conference room revealed an example of the following discrepancies: Patient # 1 Flow Sheet Dated: 7/26/24 - Initiation of treatment: 0515 AM Termination of treatment: 0800 AM. Pre-Vitals: 162/93 heart rate 89. During treatment blood pressure recorded from 128/71 to 69/48 with heart rate recorded from 79-94. Post Vitals: 99/71 heart rate 100. The Following vitals were recorded: 06:31 AM: Blood Pressure: 90/62 with heart rate 94: RN documents: “BP is dropping asymptomatic: patient has a history of low BP. Has a special BP parameter order by MD. OK to continue HD if systolic blood pressure >65 and asymptomatic. Patient is stable. 07:01 AM: Blood Pressure recorded 74/52 with heart rate 90. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 07:12 AM: Blood Pressure recorded 79/52 with heart rate 92. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 07:16 AM: Blood Pressure recorded 78/54 with heart rate 89. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 07:31 AM: Blood Pressure recorded 72/48 with heart rate 90. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 07:32 AM: Blood Pressure recorded 78/50 with heart rate 92. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 07:46 AM: Blood Pressure recorded 71/50 with heart rate 91. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 07:47 AM: Blood Pressure recorded 69/48 with heart rate 89. UF TURNED OFF. No documentation found that the patient care technician notified the registered nurse of the severe hypotension and UF Turned off. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. Treatment termed at 0800 AM. Flow Sheet Dated: 8/07/24: Initiation of treatment: 05:51 AM Termination of treatment: 08:41 AM. Pre-Vitals: 143/86 heart rate 90. During treatment blood pressure recorded from 108/70 to 57/41 with heart rate recorded from 79-94. Post Vitals: 97/68 heart rate 99. The Following vitals were recorded: 06:31 AM: Blood Pressure recorded 82/56 with heart rate 81. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 06:33 AM: Blood Pressure recorded 78/51 with heart rate 85. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 07:01 AM: Blood Pressure recorded 78/57 with heart rate 83. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 07:31 AM: Blood Pressure recorded 71/48 with heart rate 94. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 08:01 AM: Blood Pressure recorded 52/34 with heart rate 90. No documentation found that the patient care technician notified the registered nurse of the severe hypotension. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 08:02 AM: Blood Pressure recorded 57/41 with heart rate 89. Patient care technician documented: UF off and RN notified. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 08:15 AM: Blood Pressure recorded 59/38 with heart rate 88. Patient care technician documented: UF Remains off, Patient refused normal saline, registered nurse notified. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. 08:31 AM: Blood Pressure recorded 58/40 with heart rate 84. No documentation found that the registered nurse addressed the severe hypotension at time of occurrence. Treatment termed at 08:41 AM. An interview conducted with (Staff #2) on 8/14/24 following her own review of the findings revealed she was unaware of the discrepancies found in the flow sheets. Staff #2 stated that the attending physician has provided an order that allows the patient to continue with hemodialysis treatment if systolic blood pressure remains greater than 65 and patient is asymptomatic. Staff #2 stated that Midodrine (to support blood pressure) has been ordered and patient will pick up prescription this afternoon.”