QA Investigation Results

Pennsylvania Department of Health
ERIE DIALYSIS
Health Inspection Results
ERIE DIALYSIS
Health Inspection Results For:


There are  15 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey completed on 7/11/18, Erie Dialysis was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services - Emergency Preparedness.


Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey completed 7/11/18, Erie Dialysis was identified to have the following standard level deficiencies. The facility was determined to be in substantial compliance with the requirements of 42 CFR, Part 494, Subparts A, B, C, and D: Conditions for Coverage for End-Stage Renal Disease Facilities (ESRD).


Plan of Correction:




494.90(a)(1) STANDARD
POC-MANAGE VOLUME STATUS

Name - Component - 00
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;


Observations:


Based on review of facility policy and procedure and medical records (MR) and staff (EMP) interview, the facility failed to assess and/or manage patient's blood pressure and follow agency procedure and physician order for four (4) of six (6) incenter hemodialysis MR reviewed (MR1, MR3, MR4, MR6).

Findings Included:

A review of facility policy and procedure on 7/10/18 at approximately 1:10 pm. revealed "... Policy: 1-03-18 ... TITLE: PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT ... Page 4 of 7 ... POST TREATMENT DATA COLLECTION/ASSESSMENT 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. Licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician (or AHP as applicable) is necessary prior to discharge of the patient from the facility. ... ."

A review of facility policy and procedure on 7/10/18 at approximately 12 pm revealed:

" ... Hypertension [elevate blood pressure] Protocol ... Call physician who covered that shift rounds for the month, if not response call Medical Director ... 2. Post dialysis treatments SBP > or = 180 and/or DBP > or = 100 [systolic blood presure greater than or equal to 180 and/or diastolic blood pressure greater or equal to 100]. ... Document Falcon [facility electronic documentation system] not [sic]/Flowsheet note of physician notification and follow up. No Clonidine [medication to treat elevated blood pressure] given without specific physician order. ... ."

"...HYPOTENSION...Take vital signs. Place patient in a flat supine position...Decrease ultrafiltration rate (UFR) or turn off UFR depending on patient's condition...Administer normal saline bolus of 100 - 200 mL for severe hypotensive symptoms...For less severe signs of hypotension given oral fluids (i.e., water)...Administer oxygen per physician's order...Continue monitoring...Document events, orders, treatment and patient response in the patient's medical record. ... ."

"...Normal Saline Solution...100 ML IVP [intravenous piggyback] PRN FOR HYPOTENSION. may repeat x 3...200 ml IV prn for hypotension. may repeat x 2. Notify MD if systolic remains <70." Surveyor unable to determine indications for use for each intervention. No mention of placing patient flat, decreasing ultrafiltration rate, or giving oral fluids (identified in aforementioned "HYPOTENSION" policy). Surveyor unable to determine facility-adopted procedure or protocol for hypotension.

"...NOTIFY RN WHEN....will need a RN note or pre/post assessment...SBP [systolic blood pressure] >200 or <90...DBP [diastolic blood pressure] >120 [pretreatment]...20 mmHg difference from last reading...S&S [signs and symptoms] of low BP; drop in BP [during treatment]...SBP >180 or <90...DBP >100 <50 [post treatment]..."

Review of MR1 on 7/9/18 at approximately 12:40 pm revealed dialysis treatment 2/8/18. Blood pressure assessed during treatment at 1 pm as 150/77, dropped to 75/59 at 1:30 pm with "RE TAKE" documented. No intervention for low blood pressure noted. No evidence blood pressure reassessed until 2:01 pm with result of 132/72. Further review of MR#1 revealed dialysis treatment 2/24/18 with blood pressure of 175/136 when "Treatment Terminated." No reassessment of blood pressure. No intervention for high blood pressure noted. No notification to physician.

A review of MR3 (admit date 8/24/10) on 7/9/18 at approximately 11:30 a.m. revealed dialysis treatment sheets with a documented end of treatment blood pressure of 190/79 on 6/29/18 and 191/75 on 7/2/18. There was no documentation that any follow up blood pressures were taken prior to discharge and/or that the nurse or physician was notified of the elevated blood pressures for further evaluation and/or intervention.

A review of MR4 (admit date 2/16/11) on 7/9/18 at approximately 12:00 p.m. revealed a physician's order that stated "0.1mg [milligram] clonidine to be given any time during tx [treatment] when bp [blood pressure] is greater than 160/100. A futher review of MR#4 revealed dialysis treatment sheets with a documented blood pressure greater than 160/100 on 6/11/18 at 11:46 a.m., 6/14/18 at 7:19 a.m. and 7:27 a.m., 6/16/18 at 7:24 a.m., 7:28 a.m., 7:58 a.m. and 9:57 a.m., 6/19/18 at 11:53 a.m., 11:57 a.m., and 12:27 p.m. There was no documentation to show that 0.1mg clonidine was given with any of the documented blood pressures above 160/100 as per physician order.

Review of MR6 on 7/9/18 at approximately 2:25 pm revealed dialysis treatment 6/28/18. Blood pressure at 6:27 am of 81/48 "PT [patient] BP LOW RECHECKED BP." At 6:28 am, blood pressure 86/50 "PT BP STILL LOW PT STATED FELT WOZZY [sic] UF [ultrafiltration - fluid removal from the blood] OFF 100ML SALINE GIVEN." Blood pressure at 6:30 am 95/50 "RECHCEKED [sic] BP UF REMAINS OFF PT STATED FELT LITTLE BETTER." Blood pressure at 6:57 am 126/61 "PT RESTING EYES CLOSED UF DECREASED 1.8." No evidence patient placed in flat supine position. Surveyor unable to determine if staff response reflected adherence to facility policies/procedures given aforementioned inconsistencies.

An interview with EMP25 and EMP26 on 7/10/18 at approximately 2:00 p.m. confirmed all of the above findings.





Plan of Correction:

The surveyor observations were shared with the clinical TMs immediately after the survey completed 7/11/18. The Facility Administrator (FA) will hold a formal in-service for direct patient care teammates (TMs) to review policy 1-03-08 Pre-Intra-Post treatment Data Collection, Monitoring and Nursing Assessment and 1-09-01 Hypotension by 7/21/18 Education will include but not be limited to: 1) intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes vital signs and treatment monitoring at least every thirty (30) minutes; 2) abnormal findings such as hypertension and hypotension will be reported to the licensed nurse immediately; 3) the licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary; 4) the licensed nurse notifies the physician as needed of changes in patient status and all findings, interventions and patient response will be documented in the patient's medical record; 5) TM will place patient in a flat supine position, decrease ultrafiltration rate (UFR) or turn off UFR depending on patient's condition and administer normal saline bolus of 100 - 200 mL for severe hypotensive symptoms. For less severe signs of hypotension give oral fluids. Administer oxygen per physician's order and continue monitoring blood pressure. If patient continues to show signs and symptoms of hypotension, notify physician and follow physician's orders. Document event, orders, treatment and patient response in the patient's medical record; 6) parameters for blood pressure: Pre dialysis: systolic greater than 180 mm/Hg or less than 90 mm/Hg; diastolic greater than or equal to 100 mm/Hg. Intradialytic: a difference of 20 mm/Hg increase or decrease from patient's last intradialytic treatment BP reading. Post Treatment: if the patient can stand: standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. If patient is not able to stand: sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. Any TM not present will be in-serviced on their next scheduled work day. Attendance will be evidenced by TM signature on in-service sheet. The FA or designee will then audit ten percent (10%) of the flowsheets daily for five (5) days, weekly for four (4) weeks and then monthly for two (2) months to verify compliance. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the TMs during home room meetings and with the Medical Director during monthly Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.




494.90(a)(5) STANDARD
POC-VASCULAR ACCESS-MONITOR/REFERRALS

Name - Component - 00
The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.


Observations:


Based on review of facility policy and procedure, direct observation (OBS), and staff (EMP) interview, the facilty failed to monitor vascular access for cessation of bleeding and replace soiled bandages on needle sites with clean dressings prior to discharge for two (2) of three (3) discontinuations of dialysis and post dialysis access care for arteriovenous fistula or graft (OBS1, OBS3).

Findings Included:

Review of facility policy and procedure on 7/10/18 at approximately 2:25 pm revealed "...Procedure: 1-04-01B...TITLE: POST DIALYSIS VASCULAR ACCESS CARE: FISTULA/GRAFT USING SAFETY FISTULA NEEDLES...Remove needle...dispose...patient will be encouraged to hold their own sites...Hold site for at least 5-10 minutes...Once bleeding has stopped, discard gauze or band-aid used to hold site. Inspect site for any trauma and for hemostasis...Apply band-aid type or sterile dressing over cannulation site..."

OBS1 on 7/9/18 at approximately 9:52 am of EMP18 discontinuing dialysis and providing post dialysis access care for a patient with an arteriovenous fistula or graft at station 17. EMP18 removed needles, applied gauze and tape to each site, and then the patient held pressure to the sites with a gloved hand. At approximately 10:05 am, EMP18 stated to the patient "Want more tape? Are you done?" EMP18 then applied more tape to the sites and the patient left the treatment area. Staff failed to remove soiled exit site dressings to observe to cessation of bleeding and apply clean dressings prior to discharge.

OBS3 on 7/9/18 at approximately 10:30 am of EMP10 discontinuing dialysis and providing post dialysis access care for a patient with an arteriovenous fistula or graft at station 20. EMP10 removed needles, applied gauze and tape to each site, and then held pressure to the sites with a gloved hand. After approximately 5 minutes, EMP10 applied more tape to the sites and the patient left the treatment area. Staff interview with EMP10 on 7/9/18 at approximately 10:40 am confirmed findings. EMP10 stated "give her a few minutes...put on extra tape."

Staff interview with EMP25 and EMP26 on 7/10/18 at approximately 2:00 p.m. confirmed exit sites should be visualized by staff to ensure bleeding has stopped and clean dressings applied prior to discharge.




Plan of Correction:

The surveyor observations were shared with the clinical TMs immediately after the survey completed 7/11/18. The Facility Administrator (FA) will hold a formal in-service for direct patient care TMs to review policy 1-04-01B Post Dialysis Vascular Access Care: Fistula/ Graft using Safety Fistula Needles by 7/21/18. Education will include but not be limited to: 1)TMs will remove needle and sites will be held for at least 5-10 mins; 2) once bleeding has stopped, discard gauze or band aide used to hold sites, inspect site for hemostasis, then apply new band aide type or sterile dressing over cannulation site. Any TM not present will be in-serviced on their next scheduled work day. Attendance will be evidenced by TM signature on in-service sheet. The FA or designee will perform observational audits daily for 5 (five) days on random shifts, then weekly for 4 (four) weeks on random shifts, and then monthly for two (2) months on random shifts to verify compliance. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the TMs during home room meetings and with the Medical Director during monthly Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.