Rai - Goode Way-Portsmouth

“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: 45736 Based on medical record review, facility document review and interview, the facility failed to monitor two (2) of five (5) patients (Patient #2 and #5) during their dialysis treatment per facility policy. The facility also failed to ensure one (1) of five (5) patients (Patient #5) had an assessment completed by a Registered Nurse (RN) within one (1) hour of dialysis treatment initiation. The findings include: Patient #2’s treatment record on June 27, 2024, indicated that vital signs were assessed at 11:40 AM and were not assessed again until 12:46 PM. Patient #5’s treatment record on June 24, 2024, indicated that vital signs were assessed at 1:03 PM and were not assessed again until treatment ended at 3:30 PM. Review of record for June 21, 2024 treatment revealed that an RN assessment was not completed for Patient #5. Staff Member #1 reviewed Patient #5’s medical record on July 2, 2024, and determined the nursing assessment was not completed. A facility policy, “Patient Assessment and Monitoring,” dated May, 1, 2023, revealed, in part, “...During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations...” A facility policy, “Nursing Supervision and Delegation,” dated November 1, 2021, revealed, in part, “...Policy: The registered nurse must evaluate each patient preferably within an hour or according to state requirements...””

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- (1) At least annually for stable patients; This Standard is not met as evidenced by: 45736 Based on medical record review, facility policy review and interview, the facility failed to complete a revised Plan of Care (POC) at least annually for one (1) of five (5) stable patients (Patient #5), who have been receiving treatment at the facility for at least one (1) year. The findings include: Medical records for five (5) patients included in the survey sample were reviewed on July 2, 2024. Patient #5 was admitted to this facility on May, 13, 2022. Their last POC was completed on June 28, 2023. The surveyor requested an updated POC for the patient; however, the staff were unable to locate one. Staff Member #1 indicated during an interview on July 2, 2024, that the facility is currently behind on POCs due to staffing issues and that the Governing Body is aware. Staff Member #1 confirmed that Patient #5 didn’t have an updated POC. A facility policy, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated July 3, 2023, revealed, in part, “... CIA/POC for Stable Patients... Comprehensive interdisciplinary assessments and modifications to the Plan of Care must be conducted 12 months after the completion of the 3 month assessment and then reassessed annually thereafter on all stable patients. The Plan of Care must be implemented within 15 days of the reassessment...”.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 19883 Based on medical record and facility document review, the facility staff failed to follow physician’s orders for the prescribed dose of dialysis DFR (dialysate flow rate) for one (1) of five (5) in-center dialysis patients included in the survey sample. The findings include: Patient #1 The surveyor reviewed six (6) dialysis treatment records covering a time period of June 19, 2024 through July 1, 2024. The treatment sheets evidenced an order for a DFR for 500. The treatment records evidenced the following: On June 28, 2024 , the DFR was documented as 800. Patient #1’s clinical record failed to contain evidence of documentation explaining why the DFR was not administered as prescribed. Review of the facility’s policy titled “Patient Assessment and Monitoring” (published 05/01/2023) reads in part: “Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 45736 Based on medical record review and facility document review, it was determined that the facility failed to ensure the Plan of Care (POC) was signed by the patient for two (2) of five (5) patients included in the survey sample (Patient #2 and #4). The findings include: Patient #2’s POC was dated June 6, 2024 and did not include Patient #2’s signature, or the patient’s refusal to sign. Patient #4’s POC was dated April 24, 2024 and did not include Patient #4’s signature, or the patient’s refusal to sign. On July 2, 2024, Staff Member #1 confirmed that a signed copy of Patient #2 and #4’s signed POC could not be found. A review of the facility’s policy “Comprehensive Interdisciplinary Assessment and Plan of Care”, published 7/3/23, stated in part: “...Comprehensive Assessment Participation and Plan of Care Review...- The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for the refusal must be documented in the patient’s medical record...”.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 45736 Based on medical record review, facility document review and interview, it was determined that the facility failed to complete the initial plan of care (POC) within 30 calendar days or 13 treatments for one (1) of one (1) patients included in the survey sample, (Patient #3) The findings include: Patient #3 was a new admission to this facility on May 14, 2024. At the time of the survey, Patient #3 did not have a completed POC. In an interview with Staff Member #1 on July 2, 2024, they indicated that it is the expectation that the POC for new admission would be completed within thirty (30) days or thirteen (13) treatment and that Patient #3’s was not completed. Staff Member #1 indicated that the facility is currently behind on POCs due to staffing issues and that the Governing Body is aware. A facility policy, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated July 3, 2023, revealed, in part, “...An initial comprehensive interdisciplinary assessment (CIA) and plan of care (POC) must be completed on all patients new to dialysis within the later of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session...””