Davita Cypress Woods Northwest Dialysis

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 30124 The facility failed to ensure that nursing staff were notified of patient specific paramaters pre, during and post treatment that were out of the patient’s paramaters and failed to ensure that nursing staff assessed or reassessed and took action to address those values in 2 of 7 selected patient records reviewed (Patient ID#’s 5,7). The facility has a current census of 58 hemodialysis patients. 1. Conduct pre-nursing assessment within the first hour of initiation of hemodialysis treatment for 2 of 7 current sampled patient records. (Patient ID #s 5, 7). 2. Conduct assessments on patients who have abnormal findings outside of any patient specific physician ordered parameter or change in condition in 2 of 7 current sampled patients records. (Patient ID #s 5, 7). 3. Report abnormal findings or findings outside the patient specific physician ordered parameters to the nurse in 2 of 7 records reviewed (Patient ID #s 2, 7). 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 October 2, 2024, of the facility’s current policy and procedure on pre- intra and post assessment; Policy # 1-03-08, revised April 2024 directs staff as follows: 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment with one (1) hour of dialysis treatment initiation or sooner as required by law. 11. “Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record.” Document titled “Patient Parameters”, reportable by direct patient care team to the charge nurse: Pre pulse greater than 100 or less than 50, post treatment pulse greater than 120 or less than 50. Pre or post Blood Pressure: Systolic greater than 180 or less than 90, diastolic greater than 100. Records Reviewed on 10/02/2024 along with facility staff ID #B the following was identified: Patient ID #5 09/30/2024 hemodialysis treatment record documents treatment was initiated at 10:15 AM; pre-nursing assessment completed at 11:30 AM. 09/27/2024 hemodialysis pre-treatment pulse documented as 105 beats per minute standing and 112 beat per minute sitting. There was no documentation the nurse was notified pre-initiation of treatment of the elevated heart rate pretreatment. Hemodialysis was initiated at 09:50 AM with BP 121/65 and pulse rate 96. Patient care technician note, “Treatment started without complications; HR elevated pre; asymptomatic; CN (charge nurse) notified. Patient ID #7 09/30/2024 hemodialysis treatment record documents treatment was initiated at 09:50 AM; pre-nursing assessment completed at 11:10 AM. 09/27/2024 hemodialysis treatment record documents treatment was initiated at 10:00 AM; pre-nursing assessment completed at 11:12 AM. 09/20/2024 hemodialysis treatment record documents pre sitting blood pressure at 190/104, pulse 81. Hemodialysis treatment was initiated by patient care technician at 10:11 AM with BP 173/103 with patient care technician note, “Treatment started without complications”. There was no documentation the nurse was notified pre-initiation of treatment of the elevated blood pressure. 10:32 AM PB 170/102, pulse 78 with patient care technician note, “Patient awake; alert; and states no complaints at this time”. There was no documentation the nurse was notified pre-initiation of treatment of the elevated blood pressure. The above was confirmed during and interview with staff ID #B om 10/02/2024.”