QA Investigation Results

Pennsylvania Department of Health
FRESENIUS MEDICAL CARE SHALER
Health Inspection Results
FRESENIUS MEDICAL CARE SHALER
Health Inspection Results For:


There are  8 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 June 27, 2018, Fresenius Medical Care Shaler 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 an onsite unannounced Medicare recertification survey completed on June 27, 2018, Fresenius Medical Care Shaler was identified to have the following standard level deficiencies. The clinic was determined to be in substantial compliance with the requirements 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) STANDARD
IC-WEAR GLOVES/HAND HYGIENE

Name - Component - 00
Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.




Observations:


Based on review of facility policies, direct observations, a review of the manufacturer's directions for use, and interview with staff (EMP), it was determined that the facility failed to ensure staff donned gloves prior to touching dialysis machines and washed hands and changed gloves during patient care for one (1) of four (4) staff observed (EMP7). Additionally, the facility failed to ensure that agency staff were using an acceptable product as per agency policy and procedure for one (1) of four (4) staff observed utilizing waterless antiseptic hand rub on the treatment floor for hand hygiene (EMP4).

Findings Included:

A review of facility policy and procedure, conducted on 6/26/18 at approximately 2:00 p.m. revealed"

"... Personal Protective Equipment ... Gloves ... Disposable gloves must be used: ... When touching any part of the dialysis machine or equipment at the dialysis station. Gloves must be worn appropriately. ... ."

"... Hand Hygiene ... Policy: Hand Hygiene ...Hands will be decontaminated using alcohol based hand rub or by washing hands...immediately after removing gloves...Hand Hygiene included either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content ... "

Observation on 6/25/18 at approximately 10:32 a.m., 12:29 p.m. and 12:40 p.m. at stations 2, 4, and 5, EMP 7 was observed using a glove (not donned) to cover the index finger of the left hand and touching the machine at the station. Additionally, EMP7 did not sanitize hands prior to these observations.

Observation on 6/25/18 at approximately 3:25 p.m., 4:03 p.m. 4:08 p.m. and 5:15 p.m. at stations 2, 3 and 4, EMP 7 was observed using a glove (not donned) to cover the index finger of the right hand and touching the machine at the station. Additionally, EMP8 did not sanitize hands prior to or after these observations.

An interview with the agency administrator (EMP1) on 6/26/18 at approximately 1:30 p.m. confirmed that the above observation did not meet agency expectations and stated "I will address this with [EMP7] immediately".

An observation on 6/25/18 at approximately 3:30 p.m. at station 2, EMP7 was observed discontinuing a patient with an arteriovenous fistula. EMP7 failed to remove gloves, perform hand hygiene, and don clean gloves after re-infusion of the blood and prior to removal of the needles from the patient.

An observation on 6/25/18 at approximately 5:05 p.m. at station 3, EMP7 was observed discontinuing a patient with a central venous catheter. EMP7 failed to remove gloves, perform hand hygiene and don clean gloves after re-infusion of the blood and prior to disconnection of the bloodlines from the patient.

During observation of the access of an AV Fistula or Graft on 6/25/18 at approximately 10:10 a.m., EMP4 was observed using a product called "Clean Well Natural Foaming Hand Sanitizer ALCOHOL FREE" several times during the procedure. When EMP4 was asked, he/she replied "I have an allergy to the other hand sanitizers so I use this instead". After further inspection, there was approximately six (6) additional bottles of "Clean Well Natural Foaming Hand Sanitizer ALCOHOL FREE" throughout the treatment floor.

A review on 6/26/18 at approximately 1:45 p.m. of the manufacturer's recommendations for use for the product "Clean Well Natural Foaming Hand Sanitizer" revealed the active ingredient in the product was "Thymus Vulgaris Oil (Thymol 0.05%)" A further review of the product ingredients failed to list alcohol as an ingredient as per aforementioned policy.

An interview on 6/26/18 at approximately 1:30 p.m. with the administrator (EMP1) confirmed that the hand sanitizer used by EMP4 did not meet agency policy and procedure stating "I will remove them [non approved hand sanitizer] for the treatment floor".



Plan of Correction:

For immediate compliance, on 7/11/18, all bottles of Clean well Natural Foaming Hand sanitizer were removed from the facility by the Clinic Manager (CM).
The Education Coordinator (EC) will educate all the direct patient care (DPC) staff on:
- FMS-CS-IC-11-155-090A Hand Hygiene Policy
- FMS-CS-IC-II-155-080A Personal Protective Equipment Policy

Emphasis will be placed on ensuring that gloves are donned when touching the machines and hands are sanitized before donning the gloves. The meeting reinforced that a glove may not be used to simply cover a finger while touching a machine. Also addressed at the meeting was the importance of ensuring that gloves are removed, hand hygiene performed, and new gloves donned after re-infusion of the blood and before the needles are removed of the catheter disconnected.
In-servicing is scheduled to be completed by 7/20/18.
Documentation of the training will be on file at the facility.
The CM or designee will perform daily audits for 2 weeks on the DPC for proper hand washing and glove use. At that time, if improved compliance is observed the audits will then be completed 2 times/week for 2 weeks. If compliance is maintained after the 2 weeks, the audits will be completed monthly following the Quality Assessment Improvement (QAI) program. A Plan of Correction (POC) specific auditing tool will be used for the audits.
Staff found to be non-compliant will be re-educated and counseled.
The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting for ongoing guidance and sustained compliance.



494.30(a)(4)(ii) STANDARD
IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL

Name - Component - 00
[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.



Observations:


Based on a review of facility policy and procedure, direct observation (OBS), and staff (EMP) interview, the facility failed to ensure staff (EMP7) cleaned/disinfected contaminated surfaces/equipment for one (1) of two (2) observations of cleaning/disinfection of the dialysis station between patient treatments.

Findings Included:

A review of agency policy completed on 6/26/18 at approximately 3:00 p.m. revealed "Cleaning and Disinfection of the Dialysis Station...externally disinfect the dialysis machine...after each dialysis treatment. Give special attention to cleaning control panels on the dialysis machines and other surfaces that are frequently touched and potentially contaminated...non-disposable items such as blood pressure cuffs, IV poles, TVs, TV remotes...etc...used or unused should be disinfected with 1:100 bleach solution after each treatment..."

An observation completed on 6/25/18 at approximately 3:50 p.m. at station 1. EMP7 was observed cleaning and disinfecting the dialysis station after use. EMP7 failed to clean and disinfect the right side and back of the dialysis machine, to lower the tables attached to the dialysis chair to clean and disinfect the edge of the table nearest the chair, to clean and disinfect the TV arm and the shelf directly behind the dialysis station.

An interview with the agency administrator (EMP1) on 6/26/18 at approximately 1:30 p.m. confirmed that the above observation did not meet agency expectations and stated "I will address this with [EMP7] immediately".



Plan of Correction:

The EC or designee will re-educate all the DPC staff on:
- FMS-CS-IC-II-155-110A Cleaning and Disinfection of the Dialysis Station
The emphasis of the meeting will be on ensuring that all surfaces of the dialysis machines, including the sides and backs, are cleaned and disinfected after each treatment. Also reviewed at the meeting will be review the cleaning and disinfection of the dialysis stations being sure to clean and disinfect the shelf behind the dialysis stations, the TV arm and to clean the chairside table on the edges and also to lower the tables to clean all sides.
In-servicing is scheduled to be completed by 7/20/18.
All training documentation will be on file at the facility.
The CM or designee will perform daily audits for 2 weeks on the DPC staff until evidence of improved compliance is observed. If compliance is observed the audits will then be completed 2 times/week for 2 weeks. At that time if compliance is sustained, the audits will then be completed monthly following the QAI program. A POC specific auditing tool will be used for the audits.
Staff found to be non-compliant will be re-educated and counseled.
The CM will review the audits and report the findings monthly at the QAI Committee meeting for ongoing guidance and sustained compliance.



494.80(a)(2) STANDARD
PA-ASSESS B/P, FLUID MANAGEMENT NEEDS

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

Blood pressure, and fluid management needs.




Observations:


Based on a review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure staff assessed the patient's intradialytic blood pressures every 30 minutes and monitored for adverse effects of dialysis treatment for four (4) of four (4) MR reviewed (MR1-MR4).

Findings Included:

Review of agency policy completed on 6/26/2018 at approximately 2:30 p.m. revealed: "Patient Monitoring During Patient Treatment...vital signs will be monitored at the initiations of dialysis and every 30 minutes, or more frequently, as needed..."

Review of MR1 on 6/25/2018 at approximately 12:15 p.m. revealed date of admission 4/27/2018. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
On 6/20/2018 patient BP was 112/62 at 11:31 a.m. patient BP was not assessed again until 12:31 p.m. patient BP was 128/61. [60 minutes between assessments]

Review of MR2 on 6/25/2018 at approximately 12:55 p.m. revealed date of admission 5/28/2018. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
On 6/8/2018 patient BP was 118/67 at 1:08 p.m. patient BP was not assessed again until 2:08 p.m. 118/65 [60 minutes between assessments]
On 6/15/2018 patient BP was 112/63 at 11:32 a.m. patient BP was not assessed again until 12:32 p.m. patient BP was 145/76 [60 minutes between assessments]

Review of MR3 on 6/26/2018 at approximately 9:30 a.m. revealed date of admission 6/1/2004. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
On 6/15/2018 patient BP was 159/74 at 5:58 a.m. patient BP was not assessed again until 6:39 a.m. patient BP was 120/74 [41 minutes between assessment]
On 6/22/2018 patient BP was 117/95 at 7:30 a.m. patient BP was not assessed again until 8:34 a.m. patient BP was 100/90 [64 minutes between assessments]

Review of MR4 on 6/26/2018 at approximately 10:45 a.m. revealed date of admission 6/20/2014. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
On 6/8/2018 patient BP was 106/66 at 1:01 p.m. patient BP was not assessed again until 2:07 p.m. patient BP was 139/79 [66 minutes between assessments]

An interview completed on 6/27/2018 at approximately 2:00 p.m. with EMP1 and EMP10 confirmed the findings. EMP1 stated, "I am so disappointed, we try so hard to not miss blood pressures." EMP10 stated "they are down 1 person [staff member] as a tech has transferred to Texas."



Plan of Correction:

The EC will re-educate all the DPC staff on the following policy:
- FMS-CS-IC-I-110-133A Monitoring During Patient Treatment Policy
The focus of the education will be on ensuring that the patients vital signs, including blood pressures (BP), will be monitored and documented every 30 minutes during their treatment.
In-servicing is scheduled to be completed by 7/20/2018.
All training documentation will be on file at the facility.
The CM or designee will perform daily audits of 20% of the treatment flowsheets for 2 weeks. If 100% compliance is observed, then the audits will be completed 2 times/week for 2 weeks. If compliance is maintained at that time, the audits will be completed monthly following the QAI schedule. A PO) specific audit tool will be used to complete the audits
Staff found to be non-compliant will be referred for reeducation and counseling.
Results of the audit will be summarized by the CM who will report the audit results at the monthly QAI meetings for ongoing guidance and sustained compliance.



494.90(a)(1) STANDARD
POC-ACHIEVE ADEQUATE CLEARANCE

Name - Component - 00
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.


Observations:


Based on a review of facility policy, medical records (MR) and staff (EMP) interviews, it was determined that the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for two (2) of four (4) MR reviewed (MR3, MR4).

Findings Included:

Review of agency policy completed on June 27, 2018 at approximately 10:30 a.m. revealed: "Early Termination or Arriving Late for Treatment...If a patient insists on terminating treatment early and this has not been previously approved by the patient's physician the patient must take full responsibility for consequences of the missed or shortened treatment. If a patient requests to leave treatment early: Patients requesting to terminate treatment early will be referred to the supervising registered nurse. The registered nurse (RN) will evaluated the pateints and discuss with the patient their reasons for requesting to terminate their treatment earlier than prescribed...The RN who evaluates the patient must document the rationale for early termination and reinforce the consequences of not receiving the entire prescribed treatment. The RN is responsible to notify the physician, and document on the "AMA" or Against Medical Advice form...AMA forms are signed by the patient and witnessed by the supervising nurse upon completion...signed with each early termination event and filed in the patients medical record..."

Review of MR3 on 6/26/2018 at approximately 9:30 a.m. revealed date of admission 6/1/2004. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
Physician ordered treatment time 3 hours and 30 minutes.
6/13/2018 treatment time 3 hours and 20 minutes, record did not contain evidence physician was notified of patient request to terminate treatment early, why patient requested early termination or AMA form.

Review of MR4 on 6/26/2018 at approximately 10:45 a.m. revealed date of admission 6/20/2014. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
Physician ordered treatment time 2 hours and 45 minutes
6/8/2018 treatment time 2 hours 32 minutes
6/11/2018 treatment time 2 hours 34 minutes
6/18/2018 treatment time 2 hours 35 minutes
6/22/2018 treatment time 2 hours 30 minutes
Record did not contain evidence physician was notified of patient request to terminate treatment early, why patient requested early termination or AMA form.

An interview completed on 6/27/2018 at approximately 2:00 p.m. with EMP1 and EMP10 confirmed the findings. EMP1 stated, "this patient [indicating MR4] should have AMA forms in her file, however, she rarely completes a treatment. She is very noncompliant."



Plan of Correction:

The EC will re-educate all the DPC staff on the following policy and form:

- FMS-CS-IC-I-110-144A Early Termination or Arriving Late for Treatment Policy
- FMS-CS-IC-I-110-144D1 Early Termination of Treatment Against Medical Advice Form

Emphasis will be placed on the importance of following the physician's orders, including the treatment time. The meeting will reinforce that the charge nurse (CN) must be informed when the patient is requesting to sign off treatment early with documentation of CN notification and why the patient is signing off early. The CN will advise the physician of the early termination and document the physician notification and also ensure that an Against Medical Advice (AMA) form has been completed.

In-servicing is scheduled to be completed by 7/20/2018.
All training documentation will be on file at the facility.
To establish and maintain compliance the CM or designee will monitor daily 20% of flow sheets for evidence of compliance. If compliance is observed the auditing will then be completed twice a week for 2 weeks. At that time if compliance is sustained monitoring will be completed monthly following the QAI auditing schedule.

Staff found to be non-compliant will be re-educated and referred for counseling.

Results of the audit will be summarized by the CM during monthly QAI meetings for ongoing guidance and sustained compliance.



494.90(a)(5) STANDARD
POC-VA MONITOR/PREVENT FAILURE/STENOSIS

Name - Component - 00
The patient's vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis.




Observations:


Based on a review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure staff monitored the patient's vascular access every 30 minutes to prevent access failure for four (4) of four (4) MR reviewed (MR1-MR4).

Findings Included:

Review of agency policy completed on 6/26/2018 at approximately 2:30 p.m. revealed: "Patient Monitoring During Patient Treatment...Observe and document at the initiation of dialysis and at every safety check that all connections are secure and visible...no bleeding or infiltration is noted..."

Review of MR1 on 6/25/2018 at approximately 12:15 p.m. revealed date of admission 4/27/2018. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
On 6/20/2018 patient access was assessed at 11:31 a.m. patient access was not assessed again until 12:31 p.m. [60 minutes between assessments]

Review of MR2 on 6/25/2018 at approximately 12:55 p.m. revealed date of admission 5/28/2018. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
On 6/8/2018 patient access was assessed at 1:08 p.m. patient access was not assessed again until 2:08 p.m. [60 minutes between assessments]
On 6/15/2018 patient access was assessed at 11:32 a.m. patient access was not assessed again until 12:32 p.m. [60 minutes between assessments]

Review of MR3 on 6/26/2018 at approximately 9:30 a.m. revealed date of admission 6/1/2004. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
On 6/15/2018 patient access was assessed at 5:58 a.m. patient access was not assessed again until 6:39 a.m. [41 minutes between assessment]
On 6/22/2018 patient access was assessed at 7:30 a.m. patient access was not assessed again until 8:34 a.m. [64 minutes between assessments]

Review of MR4 on 6/26/2018 at approximately 10:45 a.m. revealed date of admission 6/20/2014. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
On 6/8/2018 patient access was assessed at 1:01 p.m. patient access was not assessed again until 2:07 p.m. [66 minutes between assessments]

An interview completed on 6/27/2018 at approximately 2:00 p.m. with EMP1 and EMP10 confirmed the findings. EMP1 stated, "I am so disappointed, we try so hard to not miss assessments." EMP10 stated "they are down 1 person [staff member] as a tech has transferred to Texas."



Plan of Correction:

The EC will reeducate the DPC staff on:
- FMS-CS-IC-I-110-133A Monitoring During Patient Treatment Policy
The reeducation will focus on ensuring that the patient's access is monitored every 30 minutes during the treatment. The meeting will reinforce the need to document that the patient lines are secure and visible and that no bleeding or infiltration has occurred.

The in-service will be completed by 7/20/2018

All training documentation is on file at the facility.

The CM or designee will perform daily audits of 20% of the treatment flowsheets for 2 weeks. If 100% compliance is observed, then the audits will be completed 2 times/week for 2 weeks. If compliance is maintained at that time, the audits will be completed monthly following the QAI schedule. A PO) specific audit tool will be used to complete the audits

Staff found to be non-compliant will be referred for reeducation and counseling.

The CM will review the audits and report the findings to the QAI Committee at the monthly meeting for further guidance and ongoing oversight.




494.110(b) STANDARD
QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE

Name - Component - 00
The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time.


Observations:


Based on review of agency policy and procedure, Quality Assurance and Performance Improvement (QAPI) program, patient lab results, and staff (EMP) interview, the facility failed to develop an improvement plan for areas identified as needing improvement. Specifically the agency failed to develop an improvement plan for low patient albumin [measurement of the amount of protein in the bloodstream] levels in 2017 and 2018.

Findings Included:

A review of agency policy and procedure, conducted on 6/26/18 at approximately 1:30 p.m. revealed "... Quality Assessment and Performance Improvement Program (QAPI) ... QAI Meeting Requirements QAI Program activities for each facility or program include: ... Review of aggregate patient data by modality to identify opportunities for improvement for clinical outcomes, and track progress by: ... 2. Identify commonalities among patients who do not reach the minimum expected patient targets 3. Develop a plan to address those causes 4. Implement the plan 5. Monitor the effectiveness of the plan 6. Adjust portions of the plan that are not successful ... ."

An interview with the agency dietician (EMP5) was conducted on 6/26/18 at approximately 10:45 a.m. When asked, as part of the QAPI program what areas the facility was working on to improve, EMP5 stated "Albumin".

An interview with the agency social worker (EMP6) was conducted on 6/26/18 at approximately 11:00 a.m. When asked, as part of the QAPI program, what areas the facility was working on to improve, EMP6 stated "Albumin levels".

A review of the agency "Lab Results/Medication Administration Summary" from 4/02/18 to 6/18/18, ten (10) of thirty four (34) patients had Albumin levels equal to or less than 3.5g/dL (grams per deciliter, preferred level is 4.0 g/dL or higher) and twenty two (22) out of thirty four (34) patients had Albumin levels equal or less than 3.9 g/dL.

A review of the facility QAPI program on 6/26/18 at approximately 12:30 p.m. revealed that the facility had two active "Action Plans". One action plan related to transplant education and another action plan related to physical environment issues [old cracked countertops].

An interview with the agency administrator (EMP1) at 6/26/18 at approximately 1:45 p.m. confirmed that they currently do not have an action plan relating to albumin levels explaining that the agency had an action plan for albumin, but closed it out in early 2017 because they (facility) were not able to get albumin levels to increase despite working through the plan. EMP1 went on to explain that the facility has had problems with albumin levels for "a long time". EMP1 also revealed that since the facility had a long time action plan and numbers were not improving, they were advised (by facility corporate personnel) to close it (action plan for albumin) out and work on improving the numbers without an actual action plan in place.



Plan of Correction:

For immediate compliance, on 7/13/18, the Dietitian will create an Action Plan for Albumin which will be reviewed at the 7/25/18 QAI meeting for review by the QAI team.

The Regional Quality Manager (RQM)/designee will re-educate the QAI Committee on the following policy:

- FMS-CS-IC-1-101-001A Quality Assessment and Performance Improvement (QAPI) Policy

Emphasis will be placed on the importance of recognizing a focus area, such as albumin levels, completing a root cause analysis (RCA), development of an action plans, including monitoring the lab results of the albumins and oversight of the implementation and follow up with action plan for the albumin. The education will also include monitoring and sustaining improvements, as well as what actions the committee will take if improvements with the action plans are not observed within an acceptable timeframe.
In-servicing will be completed by 7/20/2018

The training documentation will be on file at the facility.

The Director of Operations (DO) will monitor the QAI program for the next 4 months to ensure tracking, trending, RCA and development, implementation and oversight of action plans with development of a new plan if progress is not noted.

The DO will report the findings of the review to the QAI Committee at the monthly meeting for further guidance and ongoing oversight.






494.170 STANDARD
MR-COMPLETE, ACCURATE, ACCESSIBLE

Name - Component - 00
The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.


Observations:


Based on a review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure staff maintained complete and accurate medical records for the care provided and medications administered for one (1) of four (4) MR reviewed (MR3).

Findings Included:

Review of facility policy completed on June 27, 2018 at approximately 10:45 a.m. revealed: "Heparinzation...The physician must order the heparin dose and method of administration..."

"Use of the Heparin Pump...Follow the procedure below to deliver infusion of heparin using the heparin pump...

"Medication Preparation and Administration...Document drug name, dose given, route, date and time administered...Record your signature and title on treatment sheet..."

Review of MR3 on 6/26/2018 at approximately 9:30 a.m. revealed date of admission 6/1/2004. Review included 9 treatment records dated between 6/4/2018 and 6/22/2018.
Physician orders included Heparin 7,000 unit bolus and Heparin 2,000 units per hour during treatment. Treatment time 3 hours and 30 minutes.

Treatment records dated 6/4/2018, 6/6/2018, 6/8/2018, 6/11/2018, 6/13/2018, 6/15/2018, 6/18/2018, 6/20/2018, and 6/22/2018 were all documented at the end of treatment under "admin presc" [administration prescribed] "NO" indicated that patient did not receive Heparin infusion of 2,000 units per hour during treatment.

Interview completed on 6/26/2018 at approximately 3:00 p.m. with EMP1 confirmed the findings. EMP1 stated, "the patient is receiving the Heparin infusion. I see the set up every day. They are not documenting it correctly. I will be reeducating the staff first thing."



Plan of Correction:

The EC will in-service all DPC staff on:
- FMS-CS-IC-II-155-040A Medication Preparation and Administration Policy
Emphasis will be placed on proper delivery and documentation of the heparin administration.

The inservicing was completed on 7/20/2018

Documentation of the training will be on file at the facility.

The CM or designee will perform daily audits for 2 weeks. At that time if compliance is observed the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is observed. At that time the audits will then follow the monthly QAI schedule. A POC specific auditing tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling
The CM will review the audits and report the findings to the QAI Committee at the monthly meeting for ongoing guidance and sustained compliance.