Fresenius Kidney Care Mt Rainier

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 45888 . Based on document review, observation, and interview, the facility failed to ensure that staff maintained patients in view during hemodialysis treatments to ensure patient safety. Failure to maintain patients in view of staff during hemodialysis treatments places patients at risk for harm from unobserved urgent and emergent needs including needle dislodgement, exsanguination, and hypotensive emergencies. Findings included: 1. Document review of the facility policy titled, “Patient Assessment and Monitoring,” dated 05/23, showed that clinical staff must maintain patients under visual observation during in-center hemodialysis treatments. 2. On 04/11/25 at 9:00 AM, Investigators #1 and #3 observed patient care on the dialysis treatment floor. The observation showed that a Licensed Practical Nurse (LPN) (Staff #302) provided care to Patients #313, #314, #316, #317, #318, #319, and #320 independently without other clinical staff assistance from 9:04 AM to 9:40 AM. Staff #302 was unable to maintain all 7 patients and patient dialysis stations within view while providing care due to the configuration and location of the stations. 3. On 04/11/25 at 9:32 AM, Investigator #3 interviewed the only Registered Nurse (Staff #305) present on the dialysis treatment floor regarding patient observation. Staff #305 stated that facility staff maintained at least 2 clinical staff members per 8 treatment stations in order to maintain all patients in view of staff. Staff #305 stated that they were unaware that an LPN (Staff #302) provided care to 7 patients independently without other clinical staff assistance for 36 minutes or that Staff #302 could not maintain all 7 patients within their view. .”

“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: 45888 . Based on document review, observation, and interview, the facility failed to provide the necessary care and services to manage patients’ volume status and blood pressure (BP). Failure to provide the necessary care and services to manage patients’ dose of dialysis and BP places patients at risk for undetected complications and unsafe dialysis treatment. Findings included: 1. Document review of the facility policy titled, “Patient Assessment and Monitoring,” dated 05/23, showed that patients must be assessed for safety and vital signs, including BP status and changes, at least every 30 to 45 minutes, and any observed aberrant vital signs, patient concerns, or status changes must be addressed. 2. Document review of patient plans of care showed the following: - Patient #313’s plan of care (POC), completed on 01/13/25, showed BP and fluid management as a clinical focus area and that Patient #313 had a history of hypotension. - Patient #314’s POC, completed on 01/13/25, showed BP and fluid management as a clinical focus area and that Patient #314 had a history of BP abnormalities and difficulty removing fluid during dialysis treatment. - Patient #315’s POC, completed on 02/20/25, showed BP and fluid management as a clinical focus area and that Patient #315 had a history of hypertension. 3. On 04/11/25 from 9:00 AM to 10:14 AM, Investigators #1 and #3 observed patient care on the dialysis treatment floor. The observation showed the following: - Patient #313’s flowsheet viewable on Patient #313’s dialysis machine showed that Patient #313 was assessed for safety and vital signs at 8:30 AM. Patient #313’s machine alarmed with a BP reading at 9:00 AM. The Licensed Practical Nurse (Staff #302) responsible for Patient #313’s dialysis station did not respond to the BP alarm until 9:17 AM. Patient #313 reported feeling unwell and required administration of Normal Saline and for the dialysis machine’s ultrafiltration to be turned off. - Patient #314’s flowsheet viewable on Patient #314’s dialysis machine showed that Patient #314 was assessed for safety and vital signs at 8:47 AM. Patient #314’s machine alarmed with a low diastolic BP alert at 9:17 AM. The Patient Care Technician (PCT) (Staff #303) responsible for Patient #314’s dialysis station did not respond to the BP alarm until 9:45 AM. Patient #314’s BP reading was 126/45 millimeters of mercury (m/Hg). Patient #314 had a physician order that Patient #314’s diastolic BP needed to be maintained above 60 mm/Hg during dialysis treatment. - Patient #315’s flowsheet viewable on Patient #315’s dialysis machine showed that Patient #315 was assessed for safety and vital signs at 8:59 AM. Patient #315’s machine alarmed with a low diastolic BP alert at 9:29 AM. The PCT responsible for Patient #315’s dialysis station did not respond to the BP alarm until 9:35 AM. Patient #315’s BP reading was 126/50 mm/Hg, with the diastolic BP 15 mm/Hg less than Patient 315’s prior treatment BP reading. 4. On 04/11/25 at 11:08 AM, Investigator #3 interviewed the covering Facility Administrator (Staff #301) regarding patient BP assessment. Staff #301 acknowledged the observations of prolonged BP alert periods without staff response and patient assessment for patients with BP and fluid management POC focus areas, and confirmed that facility policy required patient assessment for safety and vital signs at least every 30 to 45 minutes. .”