Dominion Dialysis Center

“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: 34452 Based on document review and interview, it was determined that the facility failed to obtain and document standing blood pressures (BP) for one (1) of six (6) In Center Hemodiaylsis (ICHD) Patients (P), P # 2; have an Registered Nurse (RN) verify the treatment prescription for four (4) of six (6) ICHD Patients, P # 1, # 2, # 4 and # 6; and assess and document at least every 45 minutes treatment data to include blood pressures for two (2) of six (6) ICHD Patients, P # 1 and # 2. The findings include: On January 3, 2024 between 11:00 a.m. and 12:30 p.m. during clinical record reviews, the following was revealed: P # 1- The flowsheet dated December 18, 2023 revealed there was no Registered Nurse (RN) of verification of the treatment prescription. The flowsheet dated December 22, 2023 revealed there was no documentation of treatment data to include Blood Pressure (BP) between 6:00 a.m. and 7:01 a.m. (more than 45 minutes). The flowsheet dated December 27, 2023 revealed there was no RN of verification of the treatment prescription. The flowsheet dated December 29, 2023 revealed there was no RN documentation of verification of the treatment prescription. There was no documentation of treatment data to include BP between 7:02 a.m. and 8:01 a.m. (more than 45 minutes). P # 2- The flowsheet dated December 24, 2023 revealed there was no documentation of treatment data to include BP between 2:29 p.m. and 3:33 p.m. (more than 45 minutes). The pre treatment standing BP was documented as 138/72. The post treatment standing BP was documented as “Cannot Assess”. The nursing evaluation at 3:08 p.m. revealed ambulation status “ambulates without assistance”. The flowsheet dated December 27, 2023 revealed there was no RN documentation of verification of the treatment prescription. The flowsheet dated December 29, 2023 revealed there was no documentation of treatment data to include BP between 2:01 p.m. and 3:01 p.m. (more than 45 minutes). P # 4- The flowsheet dated December 27, 2023 revealed there was no RN documentation of verification of the treatment prescription. P # 6- The flowsheet dated December 22, 2023 revealed there was no RN documentation of verification of the treatment prescription. The facility policy provided by Staff Member # 3 on January 3, 2024 at 1:00 p.m. titled “Pre-intra-post treatment data collection, monitoring and nursing assessment” reads in part “The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. Standing BP and weight are obtained pre and post dialysis by the licensed nurse or PCT (Patient Care Technician). Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes.” On January 3, 2024, the findings were discussed with Staff Members # 3 and # 9 during the exit interview.”

“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: 34452 Based on document review and interview, it was determined that the facility failed to have signed Plan of Care by the interdisciplinary team (IDT) including the Patient for three (3) of six (6) Patients (Patients # 3, # 4 and # 5). The findings include: On January 3, 2024 between 11:00 a.m. and 12:30 p.m., Clinical Record review revealed the following: Patient # 3- The Patient’s Plan of Care meeting was documented as August 23, 2023. There was no signature or date for the Physician (attended remotely). No signature to reflect participation in the Plan of Care meeting. Patient # 4- The Patient’s annual Plan of Care meeting was documented as September 21, 2023. There was no signature or date for the Physician (attended remotely) or Social Worker (SW) (attended remotely). No signatures to reflect participation in the Plan of Care meeting. Patient # 5- The Patient’s annual Plan of Care meeting was documented as June 15, 2023. There was no signature or date for the Physician (attended remotely). No signature to reflect participation in the Plan of Care meeting. The facility policy provided by Staff Member # 3 on January 3, 2024 at 1:00 p.m. titled “Comprehensive Interdisciplinary Assessment an Plan of Care” reads in part “The Comprehensive Interdisciplinary Assessment and Plan of Care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the Patient or Patient’s designee ... The Plan of Care must be signed at the time of the interdisciplinary team meeting for those attending in person. If unable to sign at the time of the meeting or if attending remotely, the care plan must be signed by the IDP member within 30 days of the interdisciplinary team meeting.” On January 3, 2024, the findings were discussed with Staff Members # 3 and # 9 during the exit interview.”