Fresenius Medical Care Graham

“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: 50181 Based on record review and interview, the Medical Director failed to ensure that policies and procedures related to patient care were adhered to by non physician providers, in that the Registered Nurse (RN) instructed the direct patient care (DPC) staff to administer boluses of 100mL of normal saline for tachycardia without a specific physician order or standing order providing this guidance. Findings included: In review of Patient #1 treatment record from 05/08/2024 the following is noted: Pre-treatment the patient’s heart rate is recorded as 103 beats per minute (BPM) and regular with the following note entered, “asymptomatic tachycardia noted, pulse 103, will continue to monitor, educate staff to notify RN for change in condition or pulse greater than 110.”There is no evidence the physician was notified prior to treatment start and the order to allow the heart rate reportable parameter to be increased to 110 was provided. 05:36 treatment record entry reveals the heart rate is 92Comments entered by patient care technician at 05:36: “UF on, Resting Comfortably; access visible; green AMP Light, Denies complaints; 100 ns given as ordered.” There is no evidence the physician ordered to administer 100ml normal saline bolus for tachycardia. 07:21 treatment record entry reveals the heart rate is 119Comments entered by RN at 07:21, “UF on; access visible; Green AMP light; Patient alert; tachycardia noted, regular rate, states feels a little pressure on heart extra 100ml ns given was under EDW, then pressure eased, pulse 124, on monitor oxygen sat 93, Dr. Patel notified, observe.”There is no evidence the physician ordered to administer 100ml normal saline bolus for tachycardia. 08:02 treatment record entry reveals the heart rate is 100 and blood pressure is 164/85Comments entered by patient care technician at 08:02, “UF on; resting comfortably; access visible; green AMP light, denies complaints; 100ns given as ordered.”There is no evidence of why the 100 NS bolus was administered 09:03 treatment record entry reveals the heart rate is 94 and the blood pressure is 192/90Comments entered by the patient care technician at 09:03, “UF on; resting comfortably; access visible; green AMP light; denies complaints, 100ns given as ordered, RN aware of BP.”No follow-up by the RN regarding the administration of the normal saline bolus or why the bolus was administered. In an interview on 05/22/2024 with the Physician (Personnel #1) and the Director of Operations (Personnel #2) the above findings were confirmed. The facility’s policy titled, “Determination of Pulse Rate (published date: 02/07/2022, version 4),” provides the following guidance: “...Consider verifying a pulse manually if a digital pulse reads below 60 or greater than 100 beats per minute and the Medical Director in conjunction with the Clinical Manager will determine what the upper and lower range parameters will be for the facility. The parameters can also be modified by the nephrologist for individual patients that may require modifications based on their comorbid conditions.” The facility’s policy titled, “Nursing Supervision and Delegation (published date: 11/06/2023, version 6),” provides the following guidance: “...Delegation: Allowing a delegatee to perform a specific patient care task, activity, or procedure that is within the nurse’s scope of practice and the delegatee’s routine role function and/or job description, supported by policy and procedure...””