Bay City Regional Dialysis Center

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 37322 Based on observation, record review and interview the facility failed to ensure the AED was maintained and operating in accordance with the manufactures recommendations. Finding Include: Based on observation and record review on 03/11/2025 at 1357 of the Emergency Equipment & Medication Checklist, the AED had not checked since 03/03/2025. Record review of the facility policy “Crash Cart” dated 08/2017 stated: Emergency equipment, such as the AED, suction machine and portable oxygen are to be checked weekly to ensure that they are working properly and ready to use. Interview with on 03/11/2025 at 1400 staff (ID#C) who stated “the AED should be checked every week. We usually check it on Mondays”.”

“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 medical record review, policy review and staff interview the medical dirictor failed to ensure that staff followed the facility’s policy and procedures in that a Registered nurse completed pre-assessments, intradialytic intervention assessments, and post dialysis assessments of patients receiving hemodialysis and 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: Policies Reviewed Review of the facility’s current policy on 03/11/2025 titled: “Policy Number IC08 Monitoring and Documentation of Patient Care During Treatment”; Last Revision Date: 11/29/2022. Purpose: To Ensure: “ That patients are monitored to ensure safety during the hemodialysis treatment. “ Proper documentation of all patient care activities before, during and after hemodialysis treatment. “ That all data collected and documented accurately reflects what occurred during each hemodialysis treatment. 6. Patient pre-assessment must be performed by the nurse prior to initiation or at the beginning of treatment and documented with in on hour of treatment initiation. 17. Patient post assessments must be performed by the nurse once the treatment has ended, and the patient’s blood has been rinsed back. Policy Reviewed: Review of the facility’s current policy on 03/11/2025 titled: “Policy Number IC07 Patient Assessment: Pre & Post Dialysis”; Last Revision Date: 6/20/2024. Purpose: “ To establish the patient’s baseline status at the beginning of treatment. “ To ensure that the patient is stable enough at the end of the treatment to be released from the center. “ To provide information necessary to individualize the treatment to meet identified patient outcomes. “ To evaluate the effectiveness of the dialysis treatment by comparing per and post assessment findings. “ 4. Pre and post dialysis assessments will be done on each patient by: Registered Nurse (RN) Licensed Practical/Vocational Nurse (LPN/LVN) as allowed by specific state regulations and state Nurse Practice Act. 6. The pre-dialysis assessment will be done by an RN or LPN/LVN as allowed by state regulations before initiation of or at the beginning of treatment. 8. The post-dialysis assessment will be done before discharge of the patient from the center, but after the treatment has ended and the patient’s blood has been rinsed back. Review on 03/11/2025 of the Texas Board of Registered Nurse 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. Review on 03/11/2025 of the Texas Board of Licensed Vocational Nurse Scope of Practice. Rule 15.27. Assessment The LVN assists in determining the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families based on interpretation of health-related data. The LVN collects data and information, recognizes changes in conditions and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and formulation of goals, outcomes and patient-centered plans of care that are developed in collaboration with patients, their families, and the interdisciplinary health care team. The LVN cannot perform independent assessments as the LVN has a directed scope of practice under supervision. The LVN participates in the nursing process by appraising the individual patient’s status or situation at hand. This represents a focused assessment and may be considered a component of a more comprehensive assessment performed by a RN or another appropriate clinical supervisor. For example, a RN may utilize the data and information collected and reported by the LVN in the formation of the nursing plan of care; however, the RN’s comprehensive assessment lays the foundation for the nursing process. The LVN reports the data and information collected either verbally or in writing. The LVN must also document this data and information, the written documentation must be accurate and complete, and according to policies, procedures, and guidelines for the employment setting. Policy Reviewed: Review of the facility’s current policy on 03/11/2025 titled: “ Procedure Number: IC07A Charge Nurse Notification; Last Revision Date: 01/13/2025. Events Reportable to the Nurse by Direct Patient Care Staff: Pre-Treatment Weight - No weight gain or weight gain > 3.0 KG Temperature - > 100° Blood Pressure - Systolic > 180 or <90 Diastolic - > 100 or <50 Pulse - >110 or < 55, or irregular rhythm noted. Intradialytic Blood Pressure - Systolic > 180 or <90 or any significant change in pressure. Temperature - Increase of 2 degrees over incoming temp or c/o shaking chills. Cardiac - Pulse > 110 or < 50, any significant change in rate or rhythm. An c/0 chest pain or discomfort. Post Treatment Weight - KG < or > EDW (estimated dry weight) post treatment. Blood Pressure - Systolic > 180 or < 110, Diastolic - > 90 or <50. Orthostatic BP changes - drop of SBP or > 25 pts or drops in DBP of > 15 points. Temperature - - > 100° or increase of 2 degrees over incoming temperature. Cardiac - Pulse > 110 or < 50, any significant change in rate or rhythm. Any c/o chest pain or discomfort. Records reviewed on 03/11/2025 along with the Facility Administrator, Staff ID #G revealed the following: Patient ID #2 02/26/2025 Post nursing assessment completed by a Licensed Vocational Nurse not the required Registered Nurse. 03/05/2025 Post nursing assessment completed by a Licensed Vocational Nurse not the required Registered Nurse. 12:05 PM - Blood pressure 208/91, Note by Patient Care Technician “Treatment started, lines secured and access visible. Blood flow at prescribed rate”. No documentation indicating registered nurse notified of blood pressure above parameters. 12:10 PM Blood pressure 198/99, Note by Licensed Vocational Nurse, “Unable to increase prescription rate r/t venous pressure marginally elevated, Will allow BLE (bilateral lower extremities to remain dependent r/t HTN”. No documentation indicating registered nurse notified of blood pressure above parameters. 12:15 PM Blood pressure 217/106 Note by Patient Care Technician, “Blood pressure High, patient denies complaints”. No documentation indicating register nurse notified of blood pressure above parameters. 13:00 PM Blood pressure 184/93, Note by Licensed Vocation Nurse, “BP continues elevated. Denies distress or discomfort Informed CN (charge nurse)”. No documentation was found where the registered nurse re-assessed or intervened concerning elevated blood pressure of the patient. Patient ID #11 02/25/2025 Pre-assessment and post nursing assessment was completed by a Licensed Vocational Nurse and not by the required Registered Nurse. 02/27/2025 Pre-nursing assessment was completed by a Licensed Vocational Nurse. Patient ID #13 02/25/2025 Pre-assessment and post nursing assessment was completed by a Licensed Vocational Nurse and not by the required Registered Nurse. 02/27/2025 Pre-assessment and post nursing assessment was completed by a Licensed Vocational Nurse and not by the required Registered Nurse. 03/01/2025 Pre-assessment and post nursing assessment was completed by a Licensed Vocational Nurse and not by the required Registered Nurse. 03/08/2025 Pre-assessment and post nursing assessment was completed by a Licensed Vocational Nurse and not by the required Registered Nurse. Pre-assessment noted heart rate of 118, with no documentation the charge nurse was notified of heart rate above parameters. Patient ID #14 02/25/2025 Pre-nursing assessment nursing was completed by a Licensed Vocational Nurse and not by the required Registered Nurse. Pre-treatment blood pressure documented as 183/84. No documentation as found where the registered nurse was notified of increased blood pressure out of parameters. 03/01/2025 Pre- nursing assessment was completed by a Licensed Vocational Nurse and not by the required Registered Nurse. Pre-treatment blood pressure documented as 182/79. No documentation as found where the registered nurse was notified of increased blood pressure out of parameters. Hemodialysis treatment was initiated by Patient Care Technician with the following blood pressures documented: 10:09 AM Blood pressure 197/83. Note “Treatment started, line secure and access visible”. No documentation as found where the registered nurse was notified of increased blood pressure out of parameters. 10:12 AM Blood pressure 188/74. Note “Blood pressure high, patient denies complaints”. No documentation indicating register nurse notified of blood pressure above parameters. 11:16 AM Blood pressure 182/81. Note “F/U (follow-up) BP”. No documentation indicating register nurse notified of blood pressure above parameters. 13:01 AM Blood pressure 173/81. Note “ BP high/informed CN”. No documentation was found where the registered nurse reassessed or intervened concerning elevated blood pressure of the patient. 03/08/2025 Pre-nursing assessment was completed by a Licensed Vocational Nurse and not by the required Registered Nurse. Interview: On 03/11/2025, an interview with the Facility Administrator, Staff ID #G confirmed the facility’s reportable parameters and documentation required for out of parameter findings by the DPC staff were not reported to the registered nurse. Staff ID #G also acknowledged that the register nurse did not complete all the pre or post assessments on the patients. Staff ID #G stated they has received a new policy from corporate that instructed the facility that a Licensed Vocational Nurse could complete patients’ assessments.”