Fmc - Montgomery

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 19883 Based on staff interview, clinical record review and facility document review, facility staff failed to develop a treatment plan with individualized measurable goals for blood pressure management for five (5) of six (6) patients included in the survey sample (Patients # 1, 2, 3, 5, and 6). The findings are: The clinical records for the six (6) patients included in the sample were reviewed during the survey. The clinical record for Patients #1, 2, 3, 5, and 6 were reviewed on the afternoon of 3/5/2024 with the assistance of Staff Member (SM) #1. Review of the Plan of Care for Patients # 1, 2, 3, 5, and 6 revealed the following documented goal: “Achieve BP control as specified by the patient’s physician.” Further review of the patient’s clinical records failed to provide evidence that the physician had specified a desired blood pressure reading for the patients. The lack of a definitive goals for blood pressure was discussed with SM #1. SM #1 agreed the plans of care did not have measurable blood pressure goal for Patients # 1, 2, 3, 5, and 6. Facility policy “ Comprehensive Interdisciplinary Assessment and Plan of Care” published 07/03/2023, reads in part as follows: “Plan of Care Requirements--the Plan of Care must include measurable and expected outcomes and an estimated timetable to achieve these outcomes.” The failure to develop individualized, measurable Plan of Care goals for the patients documented above was discussed with the facility management staff at the time of discovery, and again prior to exit. 33906”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 33906 Based on interview, clinical record review and document review, facility staff failed to ensure medication orders were complete for 2 (two) of 6 (six) patients included in the sample. (Patient #1 and Patient #4) The findings include: Surveyor review of medical records was conducted the afternoon March 5, 2024 with the assistance of Staff Member (SM) #1. Review of the medical record for Patient #1 found the following order: “Clonidine 0.2mg oral PRN- may repeat x1”. (clonidine is a medication commonly given for hypertension) The order was entered on 2/16/24, with a stop date of 2/14/25. The surveyor asked SM #1 if there are guidelines in the medical record as to when to give the clonidine, what blood pressure would be considered hypertensive for the patient and what the time frame would be to administer the repeat dose. SM #1 was unable to locate the requested information in the medical record. Surveyor review of the medical record for Patient #4 found the following order: “Clonidine HCL 0.2 mg oral PRN elevated BP” entered on 8/11/23 with a stop date of 8/9/24”. The surveyor asked SM #1 if there are guidelines in the medical record as to when to give the clonidine, what blood pressure would be considered “elevated” for the patient. SM #1 was unable to locate the requested information in the medical record. Facility policy “Medical Record Guidelines” published 5/1/23 found the following: “The dialysis facility must maintain complete, accurate and accessible records on all patients.” The surveyor discussed with SM #1 the lack of parameters or guidelines in the orders for the administration or re-administration of clonidine. SM #1 agreed with the surveyor that the order failed to provide the details necessary for a complete order. The above findings were reviewed with the management team prior to exit on 3/6/24.”