QA Investigation Results

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


There are  8 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey completed October 31, 2017, Corry Dialysis was found not to be in compliance with the following requirement(s) of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.


Plan of Correction:




494.30(a)(1)(i) STANDARD
IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT

Name - Component - 00
Routine Testing for Hepatitis B

The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit.

Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results.


Observations:

Based on review of facility policy and medical records (MR) and staff (EMP) interview, the facility failed to discern Hepatitis B serological status of a patient prior to admission for one (1) of three (3) MR reviewed who were admitted in 2017 (MR5).

Findings included:

Review of MR5 on 10/31/17 at approximately 9:10 a.m. revealed "New Patient Pre-Treatment Initial Nurse Assessment...to be completed prior to start of first dialysis by RN" dated 6/30/17, "...Hepatitis B Status: Date: 2/23/16 Result: Neg [negative]..." Unclear which test was assessed as negative (i.e. antigen, antibody). No laboratory tests for Hepatitis B status noted in the MR completed on this date (2/23/16). Results from 2/23/16 not appropriate for discerning Hepatitis B serological status of the new patient as they preceded admission to agency by greater than a year (admitted on 6/30/17).
Laboratory tests for "HEP B SURFCE Ag [surface antigen]" drawn 5/11/17 with negative results noted in MR; however, the test was completed over 30 days prior to admission on 6/30/17.
No evidence in the MR that the medical director was consulted and determined immediate admission of a suspect patient for Hepatitis B was needed with results to be known within seven (7) days. Moreover, facility does not admit suspect patients for Hepatitis B as it has no isolation room/station to treat them.
There was no evidence in the MR to show the facility discerned Hepatitis B serological status of the patient prior to admission.

Review of facility policy on 10/31/17 at 1 p.m. revealed:
"...Policy: 3-01-03...ACCEPTING END STAGE RENAL DISEASE PATIENTS FOR TREATMENT...Listed below are the following documents that are required for in-center dialysis patients and home dialysis patients prior to first treatment at a DaVita Dialysis facility...Hepatitis...Resting Results: For Hepatitis...testing requirements, refer to policies: Hepatitis Surveillance, Vaccination and Infection Control measures..."
"...Policy: 1-05-02...HEPATITIS SURVEILLANCE, VACCINATION AND INFECTION CONTROL MEASURES...In order to prevent the transmission of Hepatitis B among patients, all new patients should be tested and their HBV serologic status (i.e., Hepatitis B Surface antigen [HBsAg], Total Hepatitis B core Antibody [total anti-Hbc or HBcAb], and Hepatitis B Surface Antibody [anti-HBs or HBsAb]) results should be known prior to first treatment...If the results of this testing are not known and the Medical Director determines that the patient needs to be admitted for treatment before prior testing can be completed, then the patient should be tested immediately upon intake and results known within seven (7) days of admission...Hepatitis B surface antigen results drawn within 30 days prior to first treatment date OR positive hepatitis B surface antibody results drawn within one (1) year of first treatment date will be accepted...If the hepatitis B surface antigen (HBsAg) status is unknown, the facility Medical Director will be notified and the patient treated as a suspect patient for hepatitis B infection...Documentation of hepatitis B surface antibodies (HBsAb or anti-HBs) and the hepatitis B total core antibody (total anti-HBc or HBcAb) will remain in the patient's current active medical record..."

Staff interview with EMP7 on 10/31/17 at approximately 2:30 p.m. confirmed findings.



Plan of Correction:

V124
The Facility Administrator (FA) will in-service all licensed nurses on Policy 1-05-02 "Hepatitis Surveillance, Vaccination and Infection Control Measures" and Policy 3-01-03 "Accepting End Stage Renal Disease Patients for Treatment" by 11/17/17. Verification of attendance at in- service is evidenced by a signature sheet. Teammates will be instructed using surveyor observations as examples with emphasis on, but not limited to the following: 1) Listed below are the following documents that are required for in-center dialysis patients and home dialysis patients prior to first treatment at a DaVita Dialysis facility... Hepatitis...Testing Results: For Hepatitis... testing requirements, refer to policies: "Hepatitis Surveillance, Vaccination and Infection Control Measures"..., 2) In order to prevent the transmission of Hepatitis B among patients, all new patients should be tested and their HBV serologic status (i.e., Hepatitis B Surface Antigen (HBsAg), Total Hepatitis B core Antibody (total anti-Hbc or HBcAb) results should be known prior to first treatment... If the results of this testing are not known and the Medical Director determines that the patient needs to be admitted for treatment before prior testing can be completed, then the patient should be tested immediately upon intake and results known within seven (7) days of admission..., 3) Hepatitis B surface antigen results drawn within 30 days prior to first treatment date OR positive hepatitis B surface antibody results drawn with one (1) year of first treatment date will be accepted..., 4) If the hepatitis B surface antigen (HBsAg) status is unknown, the facility Medical Director will be notified and the patient treated as a suspect patient for hepatitis B infection..., and 5) Documentation of hepatitis B surface antibodies (HBsAb or anti-HBs) and the hepatitis B total core antibody (total anti-HBc or HBcAb) will remain in the patient's current active medical record... The FA or designee will audit 100% of new patients' medical records monthly x 3 to verify that the facility follows the policy related to verifying the patient's HBV serologic status per policy. Ongoing compliance will be monitored by 10% of medical records audited per the medical record audit. The FA will report findings to the Medical Director in the monthly QAPI meeting, known as the Facility Health Meeting (FHM). The FA is responsible for ongoing compliance with this Plan of Correction (POC).

Completion date: 11/30/17



494.60(d) STANDARD
PE-EMERGENCY PREPAREDNESS-PROCEDURES

Name - Component - 00
The dialysis facility must implement processes and procedures to manage medical and non medical emergencies that are likely to threaten the health or safety of the patients, the staff, or the public. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.



Observations:

Based on review of facility policy, medical records (MR), and manufacturer directions for use and staff (EMP) interview, the facilty failed to develop and implement a process/procedure for hypoglycemic medical emergencies for one (1) of one (1) MR reviewed who experienced a hypoglycemic episode (MR1).

Findings included:

Review of MR1 on 10/30/17 at approximately 12:35 a.m. and 10/3/17 at approximately 10:45 a.m. revealed diabetes management protocol ordered by physician. The protocol did not include interventions for responding to a hypoglycemic episode (low blood sugar). Dialysis treatment 10/6/17, patient experienced hypoglycemic episode, EMP1 (RN) noted the following: Blood sugar 22 at 1:19 p.m., "BG [blood glucose] LOW WILL GIVE INSTAGLUCOSE PT [patient] ALERT AT THIS TIME." Blood sugar 37 at 1:25, "WILL GIVE ANOTHER INSTAGLUCOSE AND NOVASOURCE." Blood sugar 49 at 1:40 p.m., "BG IMPROVING." Blood sugar 65 at 1:44 p.m., "PT ALERT AND ORIENTED X3 [person, place, time], GOING HOME TO EAT NOW." Progress note by EMP1 at 2:45 p.m. "...At end of treatment patient's BG went down to 22 patient had 2 doses of Insta-glucose and also had novasource. Patient's BG came up to 65 and when leaving patient was alert and oriented x3. Patient stated he was eating lunch when as soon as he got home..." No reassessment of blood sugar prior to patient departure despite reading still low at 65. No evidence to show physician informed of hypoglycemic episode.

Review of manufacturer directions for use of Insta-Glucose on 10/31/17 at approximately 11:15 a.m. revealed "...Instructions...Twist off cap and discard...Bring tube to mouth and squeeze slowly and evenly, swallowing entire contents...If no response after 10 minutes, repeat with another tube. If condition persists or recurs, contact a doctor..." (Retrieved from https://instaglucose.com) Use of product for MR1 on 10/6/17 not per manufacturer's instructions.

Surveyor asked EMP7 for facility policies pertaining to management of hypoglycemic episodes on 10/3/17 at approximately 11:30 a.m.

EMP7 provided the below policies on 10/31/17 at approximately 1:10 p.m. which revealed:
"...Policy: 1-08-06...BLOOD GLUCOSE TESTING..." addressed storage of device and quality control testing. No stepwise process/procedure to direct staff in response to hypoglycemic medical emergency.
"...Policy: 1-10-01...MEDICAL EMERGENCY..." No stepwise process/procedure to direct staff in response to hypoglycemic medical emergency.

Aforementioned MR findings confirmed with EMP7 on 10/3/17 at approximately 1:15 p.m.

Staff interview on 10/31/17 at approximately 1:50 p.m. confirmed facility does not have a process/protocol for hypoglycemic medical emergencies.



Plan of Correction:

V408
The FA will in-service all clinical teammates on Policy 1-10-01 "Medical Emergency" by 11/17/17. Verification of attendance will be evidenced by a signature sheet. Teammates will be instructed using surveyor observations as examples with emphasis on, but not limited to the following: 1) In the event of a medical emergency, the charge nurse will: Initiate emergency treatment according to signs and symptoms shown by the patient, 2) Monitor the patient, 3) Contact the patient's nephrologist. If unable to reach patient's nephrologist, contact the Medical Director, and 4) If the situation warrants, contact emergency medical system (EMS 911) or Hospital Code Team, as applicable. A process for managing hypoglycemic medical emergencies will be developed and approved by Governing Body. All licensed teammates will be in-serviced on the process and the manufacturer's instructions for the use of Insta-glucose by 11/17/17 as evidenced by attendance sheet. The FA is responsible for ongoing compliance with this POC.

Completion date: 11/30/17



494.70(a)(15) STANDARD
PR-INFORMED OF EXTERNAL GRIEVANCE PROCESSES

Name - Component - 00
The patient has the right to-

(15) Be informed of external grievance mechanisms and processes, including how to contact the ESRD Network and the State survey agency;



Observations:

Per Department letter dated 8/20/12 disseminated to all agency/facility administrators: "...Effective September 3, 2012, the Division of Home Health will be consolidating our toll-free complaint Hotline within the Department of Health to receive complaints/concerns relative to the care provided by multiple agencies and facilities...The NEW centralized toll-free number is 1-800-254-5164 Please ensure that this number is communicated to all consumers/clients/patients and incorporated in all applicable postings and written notices..."

Based on review of medical records (MR), observation, and staff (EMP) interview, the facility failed to ensure grievance acknowledgement form signed by patients upon admission listed the correct hotline telephone number for the state survey agency for six (6) of six (6) MR reviewed (MR1 - MR6).

Findings included:

MR1 reviewed on 10/30/17 at approximately 12:35 a.m. and 10/3/17 at approximately 10:45 a.m. revealed "PATIENT GRIEVANCE PROCEDURE" form signed 7/13/15.

MR2 reviewed on 10/30/17 at approximately 2:20 p.m and 10/31/17 at approximately 11:20 a.m. revealed "PATIENT GRIEVANCE PROCEDURE" form signed 5/8/17.

MR3 reviewed on 10/30/17 at approximately 1:45 p.m. and 10/31/17 at approximately 11:45 a.m. revealed "PATIENT GRIEVANCE PROCEDURE" form signed 7/31/17.

MR4 reviewed on 10/30/17 at approximately 10:15 a.m. and 10/31/17 at approximately 12:30 p.m. revealed "PATIENT GRIEVANCE PROCEDURE" form signed 7/25/16.

Aforementioned forms listed "...External Grievance Process: Patients may seek external help to resolve grievances that cannot be resolved internally or if patients are not comfortable using the internal process..." and the incorrect (old) hotline telephone number for the Division of Home Health.

Staff interview with EMP7 on 10/31/17 at approximately 2:25 p.m. confirmed findings. EMP7 and surveyor then walked into patient waiting area/lobby and compared hotline telephone number for the Division of Home Health listed on the grievance form to the one posted in the waiting area/lobby. Surveyor observed correct Department hotline telephone number posted in the waiting area/lobby. EMP7 confirmed the telephone number posted did not match the one listed on the grievance form.



Plan of Correction:

V466
The FA will in-service all clinical teammates on Policy 3-01-06B "Patient Grievance Procedure" by 11/17/17. Verification of attendance will be evidenced by a signature sheet. Teammates will be instructed using surveyor observations as examples with emphasis on, but not limited to the following: 1) Patients may seek external help to resolve grievances that cannot be resolved internally or if patients are not comfortable using the internal process, and 2) Contact the State Department of Health and Human Services at: (must include address and phone number). Patient Grievance Form in Reggie was updated on 11/3/17 with the correct toll-free complaint Hotline for the Division of Home Health. All current patients will be given the correct phone number as evidenced by placing a signed copy of the grievance form with the updated phone number in their medical record by 11/29/17. 100% of medical records will be audited for correct information on the "Patient Grievance Procedure Form" in each patient medical record. Ongoing compliance will be monitored by 10% of medical records audited per the medical record audit. The FA will report findings to the Medical Director in the monthly FHM. The FA is responsible for ongoing compliance with this POC.
Completion date: 11/30/17



494.80(a)(3) STANDARD
PA-IMMUNIZATION/MEDICATION HISTORY

Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:

Immunization history, and medication history.




Observations:

Based on review of medical records (MR), facility forms, and staff (EMP) interview, the facility failed assess patient medication history, including allergies, for one (1) of six (6) MR reviewed (MR2).

Findings included:

Review of MR2 on 10/30/17 at approximately 2:20 p.m and 10/31/17 at approximately 11:20 a.m. revealed health and physical (H&P) completed 9/12/17 by hospital "...present to the ER today with dialysis catheter that was pulled out..." Allergies and reactions listed on the H&P as follows: "Tylenol [fluid retention]; Bextra [Swelling, NOS, fluid retention]; Ceftin [unknown]." These allergies were not noted on the allergy sticker on the front of the hardcopy MR or in the electronic MR. There was no evidence facility staff reviewed the H&P to clarify/reconcile allergies.

Staff interview with EMP7 on 10/31/17 at 2:06 p.m. confirmed findings. Surveyor asked EMP7 for facility policy pertaining to medication allergies. EMP7 directed surveyor to three (3) facility forms entitled "New Admission Allergy Verification," "Patient Acknowledgement of Allergy Review," and "Verification of Allergy Correct in [electronic MR]." EMP7 reported there was no facility policy pertaining to medication allergies and stated "just the forms."

Immediate review of the aforementioned forms revealed "H&P reviewed" listed on the "New Admission Allergy Verification" form as an item to check when verifying allergies of the newly admitted patient. H&P not listed on the other forms which functioned as forms for the patient to verify and acknowledge allergies with facility staff who then ensured the patient-reported allergies were entered in the electronic MR and noted on the allergy sticker on the hardcopy MR. There was no evidence on the form to suggest that staff involved the physician or other health care providers in verification of allergies.



Plan of Correction:

V506

Facility Administrator (FA) will in-service teammates (TMs) and the Administrative Assistant (AA) on the use of Forms: Post-Hospitalization/H&P Allergy Review, Patient Acknowledgement of Allergy Review, Verification of Allergy Correct in Snappy and the Hospitalization Log Checklist by 11/17/17 as evidenced by TM signature on attendance sheet. 100% of all MR will be audited for correct allergy information and all patients will review their allergies we have on file for accuracy by 11/29/17 using the Patient Acknowledgement of Allergy Review form and Verification of Allergy Correct in Snappy form. 100% of all new admissions and post hospitalization medical records will be audited upon admission/return to the facility, monthly using the Post Hospitalization/H&P Allergy Review which includes the Patient Name/ID, Date, Time, and acknowledgment that the H&P was reviewed. Patient verified allergies and type of reaction will be entered into SNAPPY (electronic health record), verified on allergy label on outside of hard chart, RN note in medical record regarding allergy verification, and RN signature. The Hospitalization Log was also developed and instituted which includes the Patient Name/ID, Date, H&P received post hospitalization, Dialysis Treatment Records, Additional Labs/Tests received, and the Audit Signature. The FA will audit and sign off these logs monthly and they will be kept in an Allergy Review Log Book. In addition, FA or designee will audit 10% of medical records per the medical record audit. The FA will report findings to the Medical Director in the monthly FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for ongoing compliance with this POC.


Completion date: 11/30/17



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 medical records (MR) and staff (EMP) interview, the facility failed to provide the necessary care and services to manage patient volume status for two (2) of six (6) MR reviewed (MR2, MR3).

Findings included:

Review of MR2 on 10/30/17 at approximately 2:20 p.m. and 10/31/17 at approximately 11:20 a.m. revealed dialysis treatment 10/20/17. Blood pressure at start of treatment 10:49 a.m. 143/44, at 11:01 a.m. 119/64, at 11:17 a.m. 74/35 "PT [patient] ALERT," at 11:32 a.m. 95/56 "PATIENT WATCHING TELEVISION," at 12:01 p.m. 104/48 "PATIENT WATCHING TELEVISION," at 12:32 p.m. 112/78 "PT ALERT. VITALS STABLE," at 1:01 p.m. 114/47 "PATIENT WATCHING TELEVISION," at 1:31 p.m. 148/71 "PATIENT WATCHING TELEVISION," at 2:06 p.m. 139/105 "PT ALERT. VITALS STABLE." No intervention or evidence to show nurse informed/aware of elevated reading. BP reassessed at 2:31 p.m. 139/72 "PATIENT WATCHING TELEVISION." Treatment ended at 3:02 p.m. with BP of 116/37. No intervention or evidence to show nurse informed/aware of low diastolic reading.
Dialysis treatment 10/25/17. Blood pressure at start of treatment 141/95, at 11:03 a.m. 119/61, at 11:31 a.m. 138/83, at 12:01 p.m. 144/80, at 12:32 p.m. 84/49 "PT ALERT. BP LOW/ADJ [adjusted] CUFF AND RETAKING," at 12:43 p.m. 42/24 "BP STATES IT IS LOW WILL READJUST AND TAKE AGAIN" noted by EMP1 (RN), at 12:45 p.m. 115/53 "BP INCREASED, SHUT UF OFF PT STATES SHE IS FEELING A LITTLE WARM" noted by EMP1. All subsequent BP readings documented by patient care technicians (EMP3 and EMP4) with no evidence to show nurse informed/aware of low readings at the time of obtained. At 1:02 p.m. 61/45 "ADJUSTED THE CUFF RETAKE," at 1:06 p.m. 72/28 "100 ML NS GIVEN FOR BP PT NOT FEELING WELL," at 1:14 p.m. 79/27 "PT BP LOW. ADJ CUFF RETAKING," at 1:15 p.m. 90/45 "PT ALERT. BP BETTER 100 SALINE GIVEN. WILL WATCH," at 1:31 p.m. 76/50 "CHECKING," at 1:34 p.m. 87/37 "NO COMPLAINTS," at 1:53 p.m. 90/37 "PATIENT WATCHING TELEVISION," at 2:01 p.m. 102/51 "PATIENT WATCHING TELEVISION," at 2:31 p.m. 103/60 "PATIENT WATCHING TELEVISION," at 2:59 p.m. 93/46 "PATIENT WATCHING TELEVISION." Treatment ended at 3:01 p.m. with BP of 120/58. EMP1 documented progress note 10/25/17 at 4:14 p.m. (over an hour after patient's treatment ended) "Pt gains around 1-2kg between tx's. Pt does get symptomatic hypotension when removing larger amounts of fluids, will shut uf goal off and give NSS."
Physician ordered increase in target from 136.5 to 138.5. Dialysis treatment 10/27/17 tolerated by patient. Subsequent dialysis treatment 10/30/17. Arrived at 141.3 kg. Blood pressure at start of treatment 155/91, at 11:33 a.m. 134/78, at 12:03 p.m. 155/74, at 12:33 p.m. 124/78, at 1:03 p.m. 128/75, at 1:33 p.m. 98/58 "PT WATCHING TV. SET BP TO 15 MIN INTERVALS TO MONITOR. FEELS FINE" noted by EMP7 (RN). EMP7 continued to monitor patient as follows:
1:49 p.m. 117/33 "PT DENIES C/O [complaints] AT THIS TIME"
1:52 p.m. 109/93 "DOES NOT SEEM LIKE ACCURATE READING. RECHECKING BP"
1:57 p.m. 139/123 "STILL UNABLE TO OBTAIN ACCURATE BP. CUFF ADJUSTED."
2:02 p.m. 158/109 "PT FEELS HOT/COLD. 200 CC NSS GIVEN. UFR OFF."
2:10 p.m. 163/148 "BP CUFF REPLACED. NSS GIVEN. ATTEMPTING ANOTHER BP"
2:25 p.m. 74/52 "UFR REMAINS OFF. ADDITIONAL NSS GIVEN. RECHECKING BP"
2:27 p.m. 99/47 "PT SLIGHTLY BETTER AFTER 400CC NSS. UFR REMAINS OFF. WILL CONTINUE TO MONITOR...PT INITIALLY C/O FEELING HOT/COLD. TEMP 96 DEGREE F. DIFICULTY [sic] OBTAINING BP SO BP CUFF READJUSTED PT CONTINUING TO IMPROVE"
2:33 p.m. 90/49 "BP IMPROVED. WILL CONTINUE TO MONITOR. PT FEELING SLIGHTLY BETER [sic]"
2:36 p.m. 84/36 "UFR REMAINS OFF. WILL CONTINUE TO MONITOR. STAYING WITH PT"
2:37 p.m. 79/37 "BP DROPPING AGAIN. ADDITIONAL 100CC NSS GIVEN. UFR REMAINS OFF"
2:46 p.m. 67/48 "BP DROPPED AGAIN. NSS 200CC GIVEN. RECHECKING BP"
2:48 p.m. 91/41 "UFR REMAINS OFF. BP IMPROVED AFTER NSS. PT REQUESTING TO END TX [treatment]"
2:57 p.m. 90/41 "PT WANTS OFF...Treatment Terminated" Last BP (also timed at 2:57 p.m.) 105/60.
No documentation in the MR to show physician informed patient required 700 ml of normal saline solution for hypotensive episode lasting over an hour and that the patient was unable to tolerate fluid removal to achieve new target weight ordered.

Review of MR3 on 10/30/17 at approximately 1:45 p.m. and 10/31/17 at approximately 11:45 a.m. revealed dialysis treatment 10/18/17. Blood pressure at start of treatment 98/47. Dropped to 74/43 at 1:58 p.m. "RECHECKING BP," at 2 p.m. 79/41 "TURNED OFF UF. PT BP LOW TOLD RN" noted by EMP 3 (patient care technician), at 2:28 p.m. 90/48, at 2:58 p.m. 88/46, at 3:05 p.m. 85/49 "READJUSTED CUFF. STILL BP LOW TOLD RN." BP increased to 95/55 when "Treatment Terminated." No intervention/assessment by nurse.
Dialysis treatment 10/27/17. Blood pressure at 1:02 p.m. 131/60, dropped to 94/52 at 3:02 p.m., 81/31 at 4:03 p.m. "RECHECKING BP," then 70/47 at 4:08 p.m. "TURNED OFF UF, TOLD RN, GAVE 200ML NS" noted by EMP3. BP increased to 97/52 when "Treatment Terminated." No intervention/assessment by nurse.

Review of facility policy on 10/31/17 at approximately 1:30 p.m. revealed "...Procedure: 1-09-01...HYPOTENSION...Procedure...1. Take vital signs. Place patient in a flat supine position...2. Decrease ultrafiltration rate (UFR) on turn off UFR depending on patient's condition...3. Administer normal saline bolus of 100 - 200 mL for severe hypotensive symptoms. Patient care technicians may give up to 200 mL and will inform licensed nurse of intervention...For less severe signs of hypotension give oral fluids (i.e., water)...5. continue monitoring blood pressure. If blood pressure stabilizes, evaluate Target Weight and adjust UF as determined by patient's condition...6. If patient continues to show signs and symptoms of hypotension, notify physician and follow physician's orders...7. Document event, orders, treatment and patient response in the patient's medical record..."

Staff interview with EMP7 on 10/31/17 at approximately 2:25 p.m. confirmed findings. In regards to MR2, EMP7 stated the patient "was stable when she left." When asked if the physician was informed of need for 700 ml of normal saline solution to stabilize the patient's BP, EMP7 stated "No."

Repeat deficiency 11/3/14, 9/10/14



Plan of Correction:

V543
The FA will in-service all direct patient care teammates on Policy 1-09-01 " Hypotension" and Policy 1-03-08 "Pre-Intra-Post Data Collection, Monitoring and Nursing Assessment" by 11/17/17. Verification of attendance will be evidenced by a signature sheet. Teammates will be instructed using surveyor observations as examples with emphasis on, but not limited to the following: 1) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary, 2) The licensed nurse notifies the physician (or AHP if applicable) as needed of changes in patient status, 3) All findings and interventions and patient response will be documented in the patient's medical record, 4) Take vital signs. Place patient in a flat supine position..., 5) Decrease ultrafiltration rate (UFR) or turn off UFR depending on patient's condition..., 6) Administer normal saline bolus of 100-200 mL for severe hypotensive symptoms. Patient care technicians may give up to 200 mL and will inform licensed nurse of intervention.... For less severe signs of hypotension give oral fluids (i.e., water)..., 7) continue monitoring blood pressure. If blood pressure stabilizes, evaluate Target Weight and adjust UF as determined by patient's condition..., 8) If patient continues to show signs and symptoms of hypotension, notify physician and follow physician's orders..., and 9) Document event, orders, treatment and patient response in the patient's medical record... The FA or designee will audit 10% of post treatment flow sheets each shift daily x 2 weeks and then 10% of post treatment flow sheets weekly x 2 to verify that hypotension is addressed per policy. Ongoing compliance will be monitored by 10% of flow sheets monthly per the medical record audit. Results of audits will be reviewed with Medical Director during monthly FHM. The FA is responsible for ongoing compliance with this POC.

Completion date: 11/17/17