Usrc Falls Church Dialysis

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 42929 Based on observations, interviews, and document review, it was determined the facility staff failed to follow standard infection control precautions related to cleaning and disinfection of contaminated surfaces, medical devices, and equipment for six (6) dialysis station disinfections observed. Findings: During the flash tour on 12/11/2023 at 10:49 a.m., the surveyor observed a bleach container at the dirty sink with the lid askew and a labeled dated 10/28/2023, with no time or initials when the bleach was prepared. The bleach container at the clean station near patient station #4 had no date, time, or initials of the staff member (SM) preparing the bleach. On 12/12/2023 at 9:55 a.m. during disinfection of the dialysis station, the staff member did not wipe the inside of the prime waste bucket and did not wipe the hanging card or emergency supply kit hanging from the intravenous (IV) pole. On 12/12/2023 at 10:02 am. during disinfection of the dialysis station, SM14 did not put the chair side tables down to wipe in the crevice between the table and chair, then wiped the blood pressure (BP) cuff and placed it back on the chair that had not been disinfected. The staff member did not wipe the card hanging from the IV pole or the prime waste bucket. On 12/12/2023 at 10:15 a.m. during disinfection of the dialysis station, the staff member did not thoroughly wipe the inside of the prime waste bucket at station #8 and placed the disinfected BP cuff on top of hemostats sitting on top of the dialysis machine that had not been removed after the patient left the station. The staff member did not wipe the counter behind the dialysis station. On 12/12/2023 at 10:19 a.m. during disinfection of the dialysis station, the staff member did not thoroughly wipe the inside of the prime waste bucket at station #3 then placed the disinfected BP cuff on the chair that had not been disinfected. On 12/12/2023 at 10:23 a.m. during disinfection of the dialysis station, the staff member did not wipe the basket on the side of the machine to hold the BP cuff and did not put the chair side tables down to wipe in the crevice between the table and chair. On 12/12/2023 at 10:05 a.m. during disinfection of the dialysis station, the staff member disinfected the chair and dialysis machine, then set up the dialysis machine for the next patient, then disinfected that oxygen machine that was next to the dialysis chair used by the prior patient. The surveyor did not observe the staff disinfecting the tops of the sharps containers during any station disinfection. A review of the facility’s policy titled “Disinfection and Cleaning of Dialysis Machine Equipment” states in part: ... Policy: 1. A 1:100 dilution bleach solution will be made daily or per stricter state regulations and discarded at the end of the day. 2. Label bleach container with concentration, date, time and initials of individual mixing the bleach solution. Both container and lid must be opaque to prevent weakening of the beach solution. Container will remain covered at all times. ... 3.... Clamps will be removed from the IV pole and disinfected even if not used on the patient. 4. Empty the prime container into a designated dirty sink. Do not empty contents of the prime container in the wall box. 5. Remove gloves, perform hand hygiene, don clean gloves. ... 7. Clean all external surfaces of the dialysis machine to include top, sides, front and back, BP cuffs and basket; dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on pole, attached computer monitors and keyboard/mouse. 8. Disinfect all surfaces of the prime waste container, inside and out, with a moistened 1:100 bleach cloth. 9. Clean counter tops behind patient station. 10. Clean ancillary equipment including but not limited to: oxygen concentrator; acid/bicarb jug (if applicable); IV pole/pump (if applicable), emergency cart, AED and suction machine. 11. Clean chair by placing in the reclining position and swing arms out (if applicable) to clean seat, footrest, backrest and sides, armrest, inside of chair arms and chair frame and side tray tables. Return chair to its upright position when cleaning is complete. ... 15. Disinfect non-disposable medical equipment (e.g., scissors, hemostats in open position and clamps), between uses by fully submerging items and soaking in 1:100 bleach solution for at least 5 minutes. ... Procedure for preparing 1:100 bleach solution: ... 3. Label bleach container with concentration, date, time and initials of individual mixing the bleach solution.... The above concerns were discussed with SM1, SM5, SM7, SM8, and SM22 at the exit conference on 12/13/2023 at 4:25 p.m.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 49355 Based on employee interviews, personnel record reviews and facility document review, it was determined the facility staff failed to follow it’s policy for Tuberculosis (TB) Surveillance Testing for Employees for eight (8) out of eighteen (18) personnel. Findings: Upon review of the facility’s “staff tracking” spreadsheet, it was noted by the surveyor that out of eighteen (18) listed active staff, six (6) were noted as having “pending CXR (chest x-ray) results” under the “PPD (purified protein derivative) 2 step or neg CXR” heading. The corresponding box for two (2) other staff members was completely blank, with no entry. After performing a personnel record review on five (5) of the active staff listed, two (2) of those chosen records had no record of a two step Tuberculin Skin Test (TST) ever being performed. Upon interview with Staff Member (SM) 7, SM7 admitted the entry “pending CXR results” noted on the tracking spreadsheet was added after the surveyor’s request for personnel training and vaccination records and was due to lack of documentation present in the personnel record. A review of the facility’s policy titled “TB surveillance Testing - Employee” states, in part: ... 2. Perform two step TST on or within 10 days of hire date, unless employee provides evidence of negative TB.... The findings were discussed with SM1, SM5, SM7, SM8, and SM22 at the exit conference on 12/13/2023 at 4:25 p.m.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 42929 Based on observations, interviews, and document review, it was determined the facility staff failed to ensure aseptic technique when preparing and administering medications and maintaining a safe environment for dialysis patients, staff, and the public by not including all of the necessary components of medication labeling and not removing expired medications and supplies from the treatment floor. Findings: On 12/11/2023 at 10:50 a.m., the surveyor observed two (2) opened heparin vials that were not labeled with the date, time, and initials of the staff member opening the vial. There was one bottle of Nitrostat that expired on 10/2023 in the medication cabinet and one (1) box of Clathflo Activase 2 mg that expired on 8/2023 in the medication refrigerator. On 12/12/2023 at 10:55 a.m., the surveyor observed SM23 draw up a second syringe of heparin without wiping the vial stopper prior to accessing the vial. The surveyor observed the drawn up heparin syringe labels did not contain the time they were drawn up. The opened heparin vial was dated but not initialed. On 12/12/2023 at 1:21 p.m., the surveyor observed a pre-drawn heparin syringe labeled without a time documented on the label. On 12/12/2023 at 1:35 p.m., the surveyor observed SM21 give a patient a small cup with oral medication, but did not ask the patient to confirm their name or date of birth. A review of the facility’s policy titled “Guidelines for Administration of Medication” states in part: ... Check inventory of emergency medications monthly for expiration. ... 14. When administering a medication, the following steps will be followed: ... c. Follow the “5 Rights” to ensure proper administration of the medication; The right: i. Patient; ii. Medication; iii. Dose; iv. Route of administration; v. Time. ... 15. Label pre-drawn medications with the patient’s name, medication name, dose, date, time and preparer’s initials. Pre-drawn medications will not be stored more than four (4) hours prior to the anticipated administration time. ... c. Ensure all supplies, medications and testing strips are checked at least monthly for expiration. Ensure expired items are discarded appropriately. This ensures that medication is replaced prior to the expiration date. ... 17. Multi-dose vials (MDV): a. Multi-dose vials will be discarded within 28 days of opening unless otherwise specified by manufacturer instructions. Unopened vials will be discarded according to the manufacturer’s expiration date. ... b. Open only one vial of any specific multi-dose medication at a time. Date and initial vials when opened as a point of reference for staff utilizing medications. c. Use aseptic techniques when entering a vial.... The above concerns were discussed with SM1, SM5, SM7, SM8, and SM22 at the exit conference on 12/13/2023 at 4:25 p.m.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 42929 Based on observations, interviews, and document review, it was determined that the facility staff failed to ensure they maintained a safe environment by not disposing of used sharps at point of use in three (3) observations conducted of staff members discontinuing dialysis with patients with a fistula or graft. Findings: On 12/11/2023 at 9:42 a.m., Staff Member (SM) 16 removed the needle from a patient’s access site and laid the needle on the chair side table prior to placing the needles in the sharps container at station #8. On 12/12/2023 at 10:10 a.m., SM16 removed the needles from a patient’s access site and laid the needles on the chair side table prior to placing the needles in the sharps container at station #7. On 12/12/2023 at 10:50 a.m., SM16 removed the needles from a patient’s access site and laid the needles on the chair side table prior to placing the needles in the sharps container at station #9. A review of the facility’s policy titled “Infection Control and Precautions for All Patients” states in part: ... 4. Discard used needles and sharps in appropriate containers. The above concerns were discussed with SM1, SM5, SM7, SM8, and SM22 at the exit conference on 12/13/2023 at 4:25 p.m.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 49355 Based medical record review, policy review and staff interview, it was determined the facility staff failed to: document notification to the charge nurse or physician of estimated dry weights (EDW) not being met; blood pressure (BP) measurements outside of facility guidelines; and pulse (heart rate - HR) outside of facility guidelines in five (5) out of six (6) patients reviewed. Findings: The six (6) most recent flow sheets for six (6) in-center hemodialysis patients were reviewed on 12/12/2023 and 12/13/2023. Five (5) of the six (6) patients were missing documentation of notification to the charge nurse concerning discrepancies in target and post weights, blood pressure (BP) readings, and/or heart rate (HR) readings. Patient # 1 11/24/2023 - at 13:45 the patient’s HR was 119; at 18:15 the patient’s HR was 101. No documentation was noted on the flow sheet. 11/27/2023 - at 15:00 the patient’s HR was 113; at 14:30 the patient’s systolic BP was 168; at 16:00 the systolic BP was 163; the patient’s post dialysis weight was 52.6 kg, 1.4 kg less than the EDW of 54 kg. No documentation was noted on the flow sheet. 12/01/2023 - at 14:55 the patient’s HR was 124; at 14:56 the HR was 120; at 15:00 the patient’s HR was 122; at 15:02 the HR was 110; and at 15:03 the heart rate was 107. No documentation was noted on the flow sheet. 12/04/2023 - at 16:30 the patient’s systolic BP was 163; at 17:26 the systolic BP was 161. No documentation was noted on the flow sheet. 12/06/2023 - at 14:29 the patient’s systolic BP was 162. No documentation was noted on the flow sheet. Patient # 2 11/01/2023 - at 18:30 the patient’s HR was 49; at 19:00 the patient’s HR was 47; at 19:36 the patient’s HR was 49; at 19:26 the patient’s systolic BP was 173; at 19:36 the systolic reading was 177. No documentation was noted on the flow sheet. 11/03/2023 - at 18:59 the patient’s systolic BP was 165; at 19:31 the systolic BP was 166; at 19:41 the systolic BP was 170. No documentation was noted on the flow sheet. 11/06/2023 - at 19:00 the patient’s HR was 48; at 16:07 the patient’s systolic BP was 171; at 16:09 the systolic reading was 165; at 16:10 the reading was 165; at 16:13 the systolic reading was 170; at 18:00 the reading was 163; at 19:00 the reading was 162; at 19:30 the systolic reading was 171; at 19:45 the reading was 176; at 20:11 the systolic BP was 186. No documentation was noted on the flow sheet. Patient # 4 11/28/2023 - at 6:27 the patient’s systolic BP was 164; at 6:24 the reading was 170; at 6:33 the reading was 199; at 6:59 the reading was 177; at 7:02 the reading was 165; at 7:33 the systolic BP reading was 162. No documentation was noted on the flow sheet. 11/30/2023 - at 10:02 the patient’s systolic BP was 186; at 10:15 the reading was 184; at 10:29 the systolic BP reading was 177. No documentation was noted on the flow sheet. 12/02/2023 - at 8:02 the patient’s systolic BP was 173; at 8:32 the reading was 172; at 10:39 the systolic BP reading was 161. No documentation was noted on the flow sheet. 12/05/2023 - at 6:43 the patient’s systolic BP was 164; at 6:49 the reading was 179; at 6:50 the reading was 166; at 7:32 the reading was 189; at 8:02 the reading was 169; at 8:32 the reading was 170; at 9:02 the reading was 168; at 10:02 the reading was 164; at 10:20 the systolic BP was 172. No documentation was noted on the flow sheet. 12/07/2023 - at 6:31 the systolic BP was 171; at 6:32 the reading was 177; at 6:34 the reading was 172; at 6:52 the reading was 171; at 7:02 the reading was 165; at 7:32 the systolic BP reading was 170. No documentation was noted on the flow sheet. 12/09/2023 - at 7:02 the patient’s systolic BP was 173; at 8:02 the reading was 163. No documentation was noted on the flow sheet. Patient # 5 11/27/2023 - at 10:55 the patient’s systolic BP was 162; at 10:55 the reading was 171; at 10:57 the reading was 168; at 10:58 the reading was 161; at 11:02 the reading was 182; at 11:32 the reading was 177; at 12:02 the reading was 186; at 12:32 the reading was 195; at 13:02 the reading was 185; at 13:31 the reading 175; a the 14:02 the reading was 171; at 14:09 the reading was 170; at 14:18 the systolic BP reading was 170. No documentation was noted on the flow sheet. 11/29/2023 - at 10:45 the systolic BP reading was 184; at 10:55 the reading was 169; at 10:56 the reading was 165; at 11:02 the reading was 164; at 12:02 the systolic BP reading was 168. No documentation was noted on the flow sheet. 12/01/2023 - at 11:14 the systolic BP reading was 172; at 11:30 the reading was 167; at 12:00 the reading was 165; at 12:30 the reading was 182; at 13:00 the reading was 175; at 13:31 the reading was 174; at 14:01 the reading was 171; at 14:37 the reading was 184; at 14:37 the systolic BP reading was 194. No documentation was noted on the flow sheet. 12/04/2023 - at 11:29 the patient’s systolic BP was 162; at 12:02 the reading was 171; at 12:32 the reading was 184; at 13:32 the reading was 173; at 14:02 the reading was 167; at 14:49 the systolic BP reading was 172. No documentation was noted on the flow sheet. 12/07/2023 - at 14:36 the patient’s systolic BP reading was 177; at 14:39 the reading was 171; at 15:03 the reading was 174; at 15:33 the reading was 169; at 16:03 the reading was 175; at 17:19 the reading was 167; at 17:27 the systolic BP reading was 176; the patient’s post dialysis weight was 71.2 kg, 1.2 kg more than the EDW of 70 kg. No documentation was noted on the flow sheet. Patient # 6 11/27/2023 - at 15:32 the patient’s systolic BP reading was 164; at 15:34 the reading was 186. No documentation was noted on the flow sheet. 11/29/2023 - at 16:07 the patient’s systolic BP reading was 197; at 16:08 the reading was 205. No documentation was noted on the flow sheet. 12/01/2023 - at 15:58 the patient’s systolic BP reading was 175; at 15:59 the reading was 179; at 16:00 the systolic reading was 194. No documentation was noted on the flow sheet. 12/04/2023 - at 15:51 the patient’s systolic BP reading was 161; at 15:56 the reading was 168; at 15:59 the reading was 164; at 16:00 the reading was 178; at 19:30 the reading was 182; at 20:05 the systolic BP reading was 182. No documentation was noted on the flow sheet. 12/06/2023 - at 15:46 the patient’s systolic BP reading was 168; at 15:51 the reading was 171; at 15:52 the reading was 181; at 16:00 the systolic BP reading was 169. No documentation was noted on the flow sheet. 12/08/2023 - at 15:37 the patient’s systolic BP was 178; at 15:39 the reading was 162; at 15:40 the systolic BP reading was 166. No documentation was noted on the flow sheet. A discussion of the above findings was held with SM11, who agreed that notes should be made on the patient’s flow sheet and the charge nurse should be notified whenever any parameters fall out of the guidelines on “C-FORMS-0081-Reportable Parameters to CN.” A review of the facility’s policy for “Intradialytic Monitoring of Patient” states, in part: ... 2. 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. ... 3. Volume status: Indicated by changes in BP and HR parameters... A review of the facility’s policy for “Post Dialysis Assessment of Patient” states, in part: ...f. Weight/volume status i. Evaluate post weight variance from EDW. If post weight +/- 1 kg from EDW, evaluate patient’s condition, document.... A review of the facility’s “C-FORMS-0081-Reportable Parameters to CN” states, in part: ... Pre-Dialysis ... B/P Systolic >160 or <90 ... Pulse <50 or >110 beats per minute ... Intra-Dialysis ... B/P Systolic >160 or <90 ... Pulse <50 or >110 beats per minute ... Post-Dialysis ... Weight > 1 kg above or below EDW ... B/P Systolic >160 or <90 ... Pulse <50 or >110 beats per minute These findings were discussed at the exit conference on 12/13/2023 at 4:25 p.m. with SM1, SM5, SM7, SM8, and SM22.”

“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: 49355 Based on medical record review and policy review, it was determined the facility staff failed to follow the dialysis treatment orders, specifically blood flow rate (BFR) and/or dialysate flow rate (DFR), for four (4) out of six (6) patients reviewed. Findings: The six (6) most recent flowsheets for six (6) in-center hemodialysis patients were reviewed on 12/12/2023 and 12/13/2023. Dialysis orders were not followed in four (4) of the six (6) patients reviewed. There was no documentation to notify the charge nurse of the discrepancy. P1 11/24/2023 - DFR was documented at 500 ML/min for entire 3.5 hour treatment cycle when prescribed rate was 600 ML/min. No documentation was noted on flowsheet. 11/29/2023 - DFR was documented at 500 ML/min for entire 3.5 hour treatment cycle when prescribed rate was 600 ML/min. No documentation was noted on flowsheet. P2 10/27/2023 - DFR was documented at 500 ML/min for the entire 4 hour treatment cycle when prescribed rate was 600 ML/min. No documentation was noted on the flowsheet. 10/30/2023 - DFR was documented at 500 ML/min for the entire 4 hour treatment cycle when prescribed rate was 600 ML/min. No documentation was noted on the flowsheet. 11/01/2023 - DFR was documented at 500 ML/min for the entire 4 hour treatment cycle when prescribed rate was 600 ML/min. No documentation was noted on the flowsheet. 11/03/2023 - DFR was documented at 500 ML/min for the entire 4 hour treatment cycle when prescribed rate was 600 ML/min. No documentation was noted on the flowsheet. P3 11/28/2023 - DFR was documented at 500 ML/min for entire 3.5 hour treatment cycle when prescribed rate was 600 ML/min. BFR was documented at 300 ML/min for the entire 3.5 hour treatment cycle when prescribed rate was 400 ML/min. No documentation was noted on the flowsheet. 12/02/2023 - BFR was documented at 350 ML/min for the entire 3.5 hour treatment cycle when prescribed rate was 400 ML/min. No documentation was noted on the flowsheet. P4 11/28/2023 - BFR was documented at 400 ML/min during the treatment cycle when prescribed rate was 350 ML/min. No documentation was noted on the flowsheet. 12/02/2023 - BFR was documented at 400 ML/min for the entire 3.5 hour treatment cycle when prescribed rate was 350 ML/min. No documentation was noted on the flowsheet. 12/05/2023 - BFR was documented at 400 ML/min for the entire 3.5 hour treatment cycle when prescribed rate was 350 ML/min. No documentation was noted on the flowsheet. A review of the facility’s policy “Intradialytic Monitoring of Patient” states, in part: ... Monitoring: Direct patient care staff will monitor the following parameters during each dialysis treatment: Patient: ... ... 8. Delivery of dialysis prescription. The above findings were discussed at the exit conference on 12/13/2024 at 4:25 pm with SM1, SM5, SM7, SM8, and SM22.”

“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: 42929 Based on observations, interviews, and document review, it was determined that the facility staff failed to follow the facility’s policy related to use of clamps. Findings: On 12/11/2023 at 9:50 a.m., Staff Member (SM) 14 placed two (2) clamps at the same time on the patient’s access site at station #3. Both clamps remained on the patient for over ten (10) minutes. A review of the facility’s policy titled “Clamp Usage” states in part: ... Policy: 1. Clamps are not recommended on hemodialysis accesses due to the risk of damage and/or thrombosis that can occur by applying too much pressure to the access. 2. **Clamps will not be used on new and developing arteriovenous fistula due to the increased risk for hematoma formation, infiltration and bruising.... 4. If clamps are used on a mature fistula or graft, use one clamp at a time to prevent excessive pressure/thrombosis. 5. Ideally, patients and/or family members will be instructed to hold sites and if this is not possible, staff will assist when possible.... The above concerns were discussed with SM1, SM5, SM7, SM8, and SM22 at the exit conference on 12/13/2023 at 4:25 p.m. 49355 Based on medical record review and staff interview, the facility registered nurse failed to perform pre-treatment assessments on patient’s as per the facility’s policy in five (5) out of six (6) patients reviewed. Findings: The six (6) most frequent flowsheets for six (6) in-center hemodialysis patients were reviewed on 12/12/2023 and 12/13/2023. Five (5) out of six (6) patients had late pre-assessment documentation. Patient # 1 12/01/2023 - The pre-treatment assessment was completed over 2 hours after initiation of treatment. 12/04/2023 - The pre-treatment assessment was completed nearly 5 hours after initiation of treatment. Patient # 2 11/03/2023 - The pre-treatment assessment was completed over 2.5 hours after initiation of treatment. Patient # 4 12/02/2023 - The pre-treatment assessment was completed over 1 hour after initiation of treatment. Patient # 5 12/01/2023 - The pre-treatment assessment was completed over 1 hour after initiation of treatment. Patient # 6 12/01/2023 - The pre-treatment assessment was completed over 5 hours after initiation of treatment. 12/06/2023 - The pre-treatment assessment was completed over 1 hour after initiation of treatment. 12/08/2023 - The pre-treatment assessment was completed over 2 hours after initiation of treatment. A review of the facility’s policy “Pre-Treatment Assessment of Patient” states, in part: ... Policy: The patient will receive hemodialysis treatment and nursing care based on data collected and the pre dialysis nursing assessment. Pre dialysis nursing assessment will occur within the first hour of patient contact.... ... Procedure: ... PRE DIALYSIS NURSING ASSESSMENT/EVALUATION OF DATA COLLECTED: Pre dialysis assessments are performed by qualified nursing staff (RN/LPN/LVN)..... The above findings were discussed at the exit conference on 12/13/2023 at 4:25 pm with SM 1, 5, 7, 8 and 22.”

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 42929 Based on observations, interviews, and document review, it was determined that the facility staff failed to ensure that medical record of a discharged patient was completed promptly for one (1) of one (1) involuntary discharged patient reviewed. Findings: At the entrance conference on 12/11/2023 at 11:44 a.m., the surveyor requested all documentation related to the involuntary discharge of Patient (P) 2. On 12/11/2023, the surveyor received: 1) the incident report related to the involuntary discharge of P2; 2) five (5) nurses notes dated 11/7/2023 at 10:44 a.m., 11/7/2023 at 5:08 a.m. with a unsigned verbal order from the medical director, 11/8/2023 at 8:24 a.m., 11/9/2023 at 1:10 p.m. with an unsigned verbal order from the attending physician, and 11/9/2023 at 4:03 p.m.; 3) four (4) social worker’s notes from 11/7/2023 at 9:53 a.m., 11/7/2023 at 3:35 p.m., 11/9/2023 at 2:45 p.m., and 11/9/2023 at 2:45 p.m.; and 4) the facility’s policy titled “Involuntary Discharge or Transfer of a Patient and Checklist.” On 12/12/2023, the surveyor reviewed the facility’s policy “Involuntary Discharge or Transfer of a Patient and Checklist” which states in part “... k ... ii. Document notification and information requested was sent including ... facility discharge summary ...” and reviewed the facility’s “Medical Records” policy which states in part “... 13. Physician Orders ... c. Verbal orders will be received by licensed RNs or LVN/LPNs [licensed vocational nurse/licensed practical nurse] as required by state regulation and must be signed by the physician within [thirty] 30 days or sooner per state requirements ... Closed Records (transferred, transplanted, recovered function, etc). All closed records must include: 1. A discharge summary will be completed within [thirty] 30 days after the patient is inactivated/discharged or as required by state regulations which includes: a. Date of discharge; b. Prognosis and diagnosis at discharge clearly identified by the attending physician; c. Cause and location of death, transplant or relocation information when applicable; i Reason for discharge if not from transplantation or death ...” The surveyor then requested the signed facility discharge summary for P2. During an interview on 12/13/2023 at 4:00 p.m., SM5 stated that when a patient is discharged the electronic medical record generates a discharge summary printout and the doctor normally signs the hardcopy discharge summary. SM5 stated there was no record of a discharge summary for P2 who was discharged as of 11/7/2023. The surveyors exited the survey on 12/13/2023. On 12/14/2023, SM1 emailed the surveyor a scan of the discharge summary signed and dated by the medical director on 12/13/2023. The discharge summary did not contain the “reason for discharge if not from transplantation or death” as per the facility’s policy. The reason for discharge was documented as “transferred”. The above concerns were discussed with SM1, SM5, SM7, SM8, and SM22 at the exit conference on 12/13/2023 at 4:25 p.m.”

“GOV-INVOL DISCHARGE PROCESS REQUIREMENTS CFR(s): 494.180(f)(4) The medical director ensures that no patient is discharged or transferred from the facility unless - (4) The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team- (i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record; (ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge; (iii) Obtains a written physician’s order that must be signed by both the medical director and the patient’s attending physician concurring with the patient’s discharge or transfer from the facility; (iv) Contacts another facility, attempts to place the patient there, and documents that effort; and (v) Notifies the State survey agency of the involuntary transfer or discharge. (5) In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure. This Standard is not met as evidenced by: 42929 Based on observations, interviews, and document review, it was determined that the medical director failed to ensure that all staff follow the facility’s patient discharge and transfer policies and procedures. Specifically, the medical director failed to ensure a written physician’s order was signed by both the medical director and the patient’s attending physician, and that a discharge summary was completed and signed, concurring with the patient’s discharge. Findings: On 12/11/2023 at 11:44 a.m., the surveyor requested all documentation related to the involuntary discharge of Patient (P) 2. On 12/11/2023, the surveyor received: 1) the incident report related to the involuntary discharge of P2; 2) five (5) nurses notes dated 11/7/2023 at 10:44 a.m., 11/7/2023 at 5:08 a.m. with a unsigned verbal discharge order from the medical director, 11/8/2023 at 8:24 a.m., 11/9/2023 at 1:10 p.m. with an unsigned verbal discharge order from the attending physician, and 11/9/2023 at 4:03 p.m.; 3) four (4) social worker’s notes from 11/7/2023 at 9:53 a.m., 11/7/2023 at 3:35 p.m., 11/9/2023 at 2:45 p.m., and 11/9/2023 at 2:45 p.m.; and 4) the facility’s policy titled “Involuntary Discharge or Transfer of a Patient and Checklist.” After review of the facility’s policy “Involuntary Discharge or Transfer of a Patient and Checklist” the surveyor requested the “Involuntary Discharge Checklist for Dialysis Facilities” for P2. The surveyor was later provided with the requested checklist and a form titled “Part III: Patient’s Disposition” and “Part IV: Required Documents” that was signed by a physician on 11/9/2023, but the form contained no patient name, date of birth, or medical record number to identify which patient the form was related to. On 12/13/2023 at 1:37 p.m., SM1 notified the surveyor original discharge summary for P2 had been “misplaced” and that the copy that they could provide would not be signed by the doctor. During an interview on 12/13/2023 at 4:00 p.m., SM1, SM5, and SM7 stated that the medical director and attending physician’s verbal discharge orders were documented in nursing notes, but they did not realize that the electronic note was not sent to the medical director and attending physician to sign electronically. SM5 stated that when a patient is discharged, the electronic medical record generates a discharge summary printout and the doctor normally signs the hardcopy discharge summary, but there was no record of signed discharge orders or a discharge summary for P2 who was discharged as of 11/7/2023. The surveyors exited the survey on 12/13/2023. On 12/14/2023, SM1 emailed the surveyor a scan of a discharge order and a discharge summary signed by the medical director and dated 12/13/2023. There was no signed discharge order by the attending physician provided. The discharge summary did not contain the “reason for discharge if not from transplantation or death” as per the facility’s policy. The reason for discharge was documented as “transferred”. A review of the facility’s policy titled “Medical Records” states in part: ... 13. Physician Orders ... c. Verbal orders will be received by licensed RNs or LVN/LPNs [licensed vocational nurse/licensed practical nurse] as required by state regulation and must be signed by the physician within [thirty] 30 days or sooner per state requirements ... ... Closed Records (transferred, transplanted, recovered function, etc). All closed records must include: 1. A discharge summary will be completed within [thirty] 30 days after the patient is inactivated/discharged or as required by state regulations which includes: a. Date of discharge; b. Prognosis and diagnosis at discharge clearly identified by the attending physician; c. Cause and location of death, transplant or relocation information when applicable; i. Reason for discharge if not from transplantation or death; ... A review of the facility’s policy titled “Involuntary Discharge or Transfer of a Patient and Checklist” states in part: ... i. All dialysis facilities in the following networks are required to complete and submit an Involuntary Discharge Packet to the network when discharging a patient involuntarily. ... i. If all steps have been exhausted with no resolution of issues, the facility will: i. Notify and obtain approval for discharge from Medical Director. ii. Obtain a written order for discharge signed by the patient’s nephrologist and Medical Director. ... ii. Document notification and information requested was sent including discharge order, discharge letter to patient, facility discharge summary, patient rights and responsibilities policy, documentation about incident and police report. The above concerns were discussed with SM1, SM5, SM7, SM8, and SM22 at the exit conference on 12/13/2023 at 4:25 p.m.”