Usrc Keller

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review, the facility failed to ensure the patient’s mask was covering his/her nose during the initiation of dialysis via a Central Venous Catheter (CVC) (thin, flexible tube is inserted into a vein, usually below the collarbone. It is guided (threaded) into a large vein above the right side of the heart) for one of two observations. The failure to ensure the mask was covering the nose as required in policy, had the potential for contamination of the CVC increased the risk of infections, and could affect 39 of 69 patients that have CVCs in the facility. Findings include: During an observation on 02/05/23 at 11:30 AM Charge Nurse (CN) 1 was at Station #6 initiating the treatment for Patient (P) 23 via a CVC. CN1 completed CVC care and initiated the dialysis treatment via the CVC, however, the P23’s mask remained below his/her nose the entire time CN1 performed CVC exit site care and dialysis initiation. During an interview on 02/05/24 at 11:45 AM CN1 confirmed P23’s mask was not covering his/her nose as required to prevent contamination. During an interview on 02/07/24 at 3:25 PM the Facility Administrator confirmed it was part of the facility policy for the patient to wear a mask covering the mouth and nose during CVC care and initiation of dialysis via a CVC to prevent contamination of the CVC. A review of the facility’s policy titled, “Accessing and De-accessing the Dialysis Catheter,” revised 02/2023, revealed “ ...Procedure: Don full PPE (Personal Protective Equipment) including mask; assist patient to don mask ...””

“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: 28297 Based on interviews, medical record review, and review of policies the facility failed to ensure one of 23 sampled patients (P) (P13) was assessed and treated for low blood pressure (BP) in a timely manner. The failure to properly monitor and assess the patient had the potential for worsening patient conditions without a timely intervention that could affect 69 in-center patients. Finding include: A review of the “End Stage Renal Disease Incident Report” provided by the facility for P13 revealed the facility admitted the patient on 01/13/23 with a diagnosis including Acute Kidney Failure. The patient was transferred to the hospital due to low blood sugar and low blood pressure during treatment on 03/10/23. A review of P13’s Hemodialysis Treatment Flowsheet in the electronic medical record (EMR) for the date of incident 03/10/23 provided by the facility revealed the following: P13’s dry weight was 106.5 kg (kilograms). P13’s pre-weight was 113.6 kg, and the pre-blood pressure was 135/60 millimeters of mercury (mm/Hg) at 11:00 AM. The patient fluid removal goal was set to 4700 milliliters/kilogram (ml/kg). P13’s blood pressure (BP) was monitored every 30 minutes with abnormal findings as follows: At 11:27 AM P13’s had a drop in systolic pressure of 26 mm/Hg and a drop in diastolic pressure of 17 mm/HG and was recorded as 109/43 mm/Hg. There was no documentation that the Charge Nurse (CN) was notified. Thirty minutes later at 11:57 AM, the BP dropped to 91/47 mm/Hg. There was no documentation that the Charge Nurse (CN) was notified. At 12:21 PM the BP dropped to 83/48 mm/Hg. Certified Clinical Hemodialysis Technician (CCHT) 7 documented “possible error in blood pressure, cuff readjusted and retaking”. There was no documentation that the Charge Nurse (CN) was notified of the below normal BP reading for P13. At 12:23 the BP was 95/51 mm/Hg. There was no documentation that the Charge Nurse (CN) was notified. At 12:27 PM, Patient Care Technician (PCT) 9 checked and documented the BP as 81/42 mm/Hg, and the PCT9 documented “possible error in blood pressure, cuff readjusted and retaking”. There was no documentation that the CN was notified of the below-normal BP for P13. At 12:30 PM P13’s BP was documented as 85/40 mm/Hg and PCT9 again documented “possible error in blood pressure, cuff readjusted and retaking.” There was no documentation that the CN was notified of P13’s below-normal BP. At 12:32 PM the BP was 78/32 mm/Hg and PCT9 documented that he/she “administered 100 ml saline and decreased goal to 4200 and notified the Charge Nurse.” At 12:38 PM, one hour and 11 minutes after the first abnormal BP was recorded, Registered Nurse (RN) 10 checked P13’s BP and recorded the BP as 96/48 mm/Hg, RN10 re-checked P13’s BP at 12:39 PM and recorded the BP as 83/44 mm/Hg. RN10 documented “blood pressure cuff readjusted, and blood pressure rechecked.” At 12:40 PM the BP was 82/44 mm/Hg. RN10 documented “blood pressure cuff readjusted, and blood pressure rechecked.” At 12:41 PM RN10 documented that the “goal decreased, saline 100 cc [cubic centimeters] is administered, Patient denies problem.” Blood pressure was rechecked and was 117/39 mm/Hg. At 1:27 PM the BP was 93/48 mm/Hg, retaken, and was 86/49 mm/Hg. PCT9 documented a “possible error in bp cuff readjusted and retaking.” There was no documentation that the CN was notified, and the next blood pressure was not taken until 1:57 PM (30 minutes later). At 1:57 PM the BP was 88/48 mm/Hg then retaken immediately and recorded as 82/56 mm/Hg. PCT9 documented that he/she “administered 100 ml of normal saline to help support blood pressure. Charge Nurse informed.” At 2:00 PM the BP was 104/59 mm/Hg. At 2:11 PM the BP was 108/54 mm/Hg, and the treatment was terminated. RN10 documented “blood pressure is within normal limits, but the patient is lethargic, blood glucose checked 64. Oral glucose gel was administered, and the patient responded to command. Able to swallow glucose gel. EMT [Emergency Medical Technicians] were called and blood sugar is 40 per EMT [Emergency Medical Technicians] then went up to 80. Per the facility documentation in the EMR, the [family] stated he/she made a mistake in insulin administration. Sent to medical center alliance hospital.” The dialysis post-assessment documented that P13’s fluid removal was 4008 ml/kg and post-treatment weight was 110.6 kg. There was no documentation that the Physician was notified by the Charge Nurse during P13’s dialysis treatment related to low blood pressure. The Physician was not notified until the end of the treatment at 2:11 PM and ordered the patient to go to the hospital. During an interview on 02/07/24 at 3:25 PM the Facility Administrator confirmed that RN10 and PCT9 no longer work at this facility and could not be reached for interviews and that CCHT7 was still working at this facility but unavailable to conduct an interview related to this complaint and the concerns identified related to P13. The Facility Administrator confirmed that if the patient’s blood pressure was greater than 170 systolic or less than 100 systolic the staff could readjust the blood pressure cuff however, they should have notified the Charge Nurse, and the Charge Nurse should have notified the Physician when P13’s blood pressure was consistently running low on 03/10/23. The Facility Administrator confirmed CCHT 7, and PCT9 did not document that the Charge Nurse was notified of the low BPs on 03/10/23 and should have. The Facility Administrator also confirmed that RN10 did not document that he/she notified the Physician until the end of the treatment on 03/10/23 at 2:11 PM. A review of the facility’s policy titled, “Intradialytic Patient Monitoring,” revised 09/20 revealed, “Purpose: The patient will receive a safe, effective and comfortable treatment. Monitoring: Direct Patient Care Staff will monitor the following parameters during each dialysis treatment ...Vital signs: Obtained and documented at least every 30 minutes and reported to charge nurse if outside of standing orders and/or reportable parameters, refer to C-FORMS- 0081 Reportable Parameters to CN [Charge Nurse] ...” A review of the facility’s policy titled, “Reportable Parameters to the CN (Charge Nurse),” effective 01/20 revealed, “ ...PCT/CCHT/LPN [Licensed Practical Nurse] report to Charge Nurse intra-dialysis ...Systolic >170 or >90, diastolic >100 or <50 ...””

“MD RESP-STAFF ED, TRAINING & PERFORM CFR(s): 494.150(b) Medical director responsibilities include, but are not limited to, the following: (b) Staff education, training, and performance. This Standard is not met as evidenced by: 28297 Based on interviews, review of the Incident Report, medical records, and policies the facility failed to ensure staff were trained or in-serviced after an adverse event in a timely manner for one of 22 complaints reviewed during the survey. The failure of the facility to train staff in a timely manner had the potential for the same events to reoccur without intervention and could affect all 69 in-center patients. Findings include: A review of the “End Stage Renal Disease Facility Incident Report,” provided by the facility revealed the facility reported a “Hospital Transfer” report for Patient (P) 13 dated 03/10/23. The Facility Administrator documented and reported the following: “Patient’s blood pressure was low for most of the dialysis treatment requiring multiple saline boluses during treatment and reduction in UF [ultrafiltration] goal to support blood pressure. Treatment was completed and the PCT (Patient Care Technician) noted the patient was sweaty and lethargic, notifying the CN (Charge Nurse). Additional saline bolus was given by CN with blood pressure stable in 100s/50s. Patient continues to appear sweaty and lethargic. Blood glucose taken showing 64 and patient is diabetic. Oral Glucose Gel is administered to prevent blood sugar to drop (sic) more. EMS [Emergency Medical Services] called for transfer to hospital for hypoglycemia. Patient remains lethargic but responds to inquiry. Blood sugar taken by EMS on arrival and is 40. Dextrose administered by EMS with blood glucose improving to 80. [Family] notified and reported to CN that he/she may have made a mistake in insulin administration and given too much insulin. Patient is sent to Medical City Alliance per [family members] request. NP [Nurse Practitioner] is notified.” Under the section: “How the incident was handled and what actions will be taken to reduce the potential of similar incidents in the future?” The Facility Administrator documented, “Review of medical records reveals lack of immediate intervention of symptoms during treatment despite reporting to CN. A review of treatment records reveals an opportunity for improvement in documentation and timely intervention of symptoms. Staff to receive education in proper documentation and timely response. Incident to be reviewed in QAPI [Quality Assessment and Performance Improvement] and Governing Body.” “Action to Take as a result of this incident: Education of Staff, Education of Caregiver, Measure, analyze and track in QAPI ...” A review of the facility’s “Policy-: Education In-Service Tracking Form” dated 01/20 revealed, that the training and in-service were not completed until 07/26/23, four months and 16 days after the date of the incident on 03/10/23 for P13 and that the Facility Administrator and the Group Facility Administrator conducted the training. During an interview on 02/07/24 at 3:25 PM the Facility Administrator stated he/she will look at the adverse events and look at the treatment flowsheet regarding the adverse event and if there are educational needs they will be done as soon as possible. The Facility Administrator confirmed that 4 months was too long to wait to do an in-service after an adverse event. The Facility Administrator confirmed there was no documentation but stated he/she had talked to staff before the date of in-service but just put it all together on 07/26/23. During an interview on 02/06/24 at 10:41 AM the Medical Director stated he/she expected the facility to conduct training and in-services to staff to ensure they are educated on policies and procedures. A review of the facility’s policy titled, “Occurrences/Incident Reports Including Close Calls/Near Misses,” revised 10/20 revealed, “ ...me FA [Facility Administrator] or designee or the medical director will review and document an analysis of patient history and specific circumstances to identify potential interventions to prevent recurrence.””