QA Investigation Results

Pennsylvania Department of Health
FRESENIUS MEDICAL CARE OF MURRYSVILLE
Health Inspection Results
FRESENIUS MEDICAL CARE OF MURRYSVILLE
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 conducted December 26, 2018 through December 28, 2018, Fresenius Medical Care of Murrysville 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 conducted December 26, 2018 through December 28, 2018, Fresenius Medical Care of Murrysville was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following 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(b)(1) STANDARD
IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P

Name - Component - 00
The facility must-
(1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit;



Observations:


Based on direct observation and interview with staff (EMP), the facility failed to ensure expired supplies were not available for use during incenter hemodialysis treatments.

Findings included:

During observations on 12/26/18 at approximately 10:48 a.m., of the facility supply area, expired items found on shelving units for stock supplies included Conductivity Standard Solution Lot #ML-C14-1359 expired 2018-06-06 (one bottle); MyronL-TD/Conductivity Standard Solution Batch #110272CA expired 03 Nov 18 (one bottle) and Batch 121175CA expired 12 Dec 18 (two bottles); Glucometer Enhance PRO - glucose control solution (one bottle) expired 2018-10-24 Lot # C17D24U1/2; and expired (12/22/18) electrode pads for AED (Automated external defibrillator) was found in emergency cart.

During interview on 12/26/18 at approximately 12:30 p.m., EMP 3 (RN) and EMP 6 (Technician) confirmed findings. EMP 3, removed pads "...just expired...will have replaced today..."





Plan of Correction:

V 0142 IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P
For immediate compliance on 12/26/2018, the expired supplies identified during the survey were disposed of and replaced with new supplies.
On 1/7/2019, the direct patient care (DPC) staff and the Biomedical Technician (BMT) were educated by the Clinical Manager (CM) or Education Coordinator (EC) on:
- FMS-CS-IC-II-120-005A Storage of Supplies Policy
- FMS-CS-IC-II-120-008A Expiration Dates of Sterile Supplies Policy

Emphasis of the meeting will be on ensuring:
- Supplies including the storage area and emergency cart are audited monthly for expiration dates.
- Stock supplies including Conductivity Standard Solution, Myron L-TD/Conductivity Standard Solution, Glucometer Enhance PRO - glucose control solution on shelving unit will be rotated according to expiration dates.
- Any solutions or sterile items including Automated external defibrillator (AED) pads will be checked before use to ensure that they have not expired.
- Staff are appropriately disposing of items that have reached the expiration date.

The In-servicing will be completed by 1/7/2019 with documentation of the training on file at the facility.

For ongoing compliance, the CM or designee will complete weekly audits for two (2) months. If one hundred percent (100%) compliance is observed the audits will then be completed monthly following the Quality Assessment Improvement (QAI) auditing schedule. 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.
Results of the audit will be summarized by the CM who will report the findings at the monthly QAI meetings for ongoing oversight.

Date of completion: February 12, 2019



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 policies and procedures, medical records (MR), and interviews with staff (EMP), the facility failed to monitor patient vital signs, access sites and/or machine safety checks every thirty minutes during incenter hemodialysis treatments to ensure plan of care for volume status was implemented for three (3) of three (3) patient clinical records reviewed (MR 1, MR 2, MR 3).

Findings included:
Review on 12/28/18 at approximately 3:30 p.m., of facility policy and procedure for Patient Assessment and Monitoring (FMS-CS-IC-I-110-131C) revealed, "...Monitoring During Treatment...Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes...Document machine parameters and safety checks every 30 or more often as needed to not exceed 45 minutes...Mental status...confirm alertness...Access...Observe connections are secure and visible...Document findings and interventions in the medical record..."


MR1, reviewed on 12/27/18 at approximately 9:37 a.m., revealed 8 of 9 treatment sheets reviewed indicated a concern.
12/05/2018: BP dropped to 77/38 at 2:07 p.m., from 114/60 at 1:02 p.m.. Intervention of 500 cc NSS total given from 2:08 p.m. to 2:55 p.m., without BP retaken till 3:02 p.m., with reading of 124/68. Pretreatment BP was 146/90 at 11:03 a.m. In addition no vital signs (vs) or machine safety checks or vascular access checks were recorded between 1:02 p.m.(114/60) and 2:07 p.m. (77/38) and then 3:02 p.m. (124/68). Clinical note by RN (registered nurse) read at 2:55 p.m., "BP dropped, pt unresponsive; adm 300 cc of saline; pt stable and alert";
12/07/2018: no recorded vital signs (Blood pressure, pulse or mental status) or machine safety checks or vascular access checks between 11:07 to 12:05 p.m.;
12/10/2018: no recorded VS or access/safety checks between 11:36 a.m. and 12:34 p.m.;
12/12/2018: BP dropped to 89/53 at 2:37 p.m., with 200 cc NSS given; no c/o (complaints) elicited by PCT (patient care technician) with RN notified. BP not rechecked till 30 minutes later at 3:05 p.m., with 105/54. Pretreatment BP was 155/84 at 11:04 a.m.;

12/14/2018: no recorded VS or safety/access checks between 2:34 p.m. and 3:36 p.m.;
12/17/2018: no recorded VS or safety/access checks between 11:36 a.m. to 12:34 p.m.;
12/21/2018: no recorded VS or safety/access checks between 11:08 a.m. and 12:03 p.m., and 2:38 p.m. and 3:44 p.m.;
12/24/2018: BP 73/31 with 200 CC NSS given at 10:36 a.m., by PCT with RN notified; BP not recorded as rechecked till 30 minutes later at 11:07 a.m., with reading of 90/52. Pretreatment blood pressure was recorded as 162/84 at 9:00 a.m.

During interview on 12/27/18 at approximately 11:40 a.m., EMP 3 (RN) confirmed findings, stated regarding 12/5/18 treatment "vitals were done...not pulled over..." by the interface for the electronic record. EMP 3 acknowledged blood pressure/pulse rates were not performed more frequently when hypotensive episodes occurred and required interventions during hemodialysis treatments.

MR2, reviewed on 12/27/18 at approximately 11:45 a.m., revealed 5 of 9 treatment sheets reviewed indicated a concern.
12/03/2018: no vs or safety/access checks performed between 2:05 p.m. and 3:10 p.m.;
12/10/2018: no vs/access or safety checks between 11:44 a.m. and 12:35 p.m.;
12/14/2018: no vs or safety/access check between 12:04 p.m. and 1:45 p.m.;
12/17/2018: no vs/safety/access check between 3:04 p.m. and 3:53 p.m. 250 cc NSS was given at 3:54 p.m. and at 4:08 p.m., 200 cc NSS was given for "low BP" with resulting BP reading of 124/45 at 4:08 p.m. Interim reading for "low blood pressure" was not found.
12/21/2018: no vs or access/safety checks between 2:33 p.m. and 4:06 p.m.

MR3 reviewed on 12/27/18 at approximately 1:27 p.m., revealed 6 of 9 reviewed indicated a concern.
12/05/2018: no VS or safety checks between 3:04 p.m. and 4:02 p.m.;
12/07/2018: no BP/P between 1:06 p.m. and 2:04 p.m.;
12/12/2018: no VS between or access/safety checks between 2:04 p.m. and 3:04 p.m. and 4:16 p.m.;
12/14/2018: no vs or access checks documented between 2:35 p.m. and 4:28 p.m.;
12/19/2018: no VS or access/safety checks documented between 3:04 p.m. and 4:03 p.m.;
12/21/2018: no VS or access/safety between 12:34 p.m. and 4:19 p.m.

During interview on 12/28/18 at approximately 3:30 p.m., EMP 2 (interim clinic manager) confirmed staff are expected to monitor vital signs more frequently during interventions with hypotensive episodes and routinely monitor access sites, machine parameters and patient's mental status with vital signs at least every 30 minutes during in-center hemodialysis treatments and stated "...we identified this as a problem during audits and began a corrective action intervention in November..."








Plan of Correction:

V 0543 POC-MANAGE VOLUME STATUS
On 1/7/2019, the DPC Staff were educated by the CM or EC on:
- FMS-CS-IC-I-110-131C Patient Assessment & Monitoring Procedure
- FMS-CS-IC-II-125-006A Complications of Hemodialysis - Management and Prevention of Hypotension Policy

Emphasis of the meeting will be on:
- Ensuring DPC staff are obtaining vital signs (VS) every 30 minutes or more as needed.
- Staff documenting machine parameters and safety checks every 30 or more often as needed.
- Staff ensuring VS are checked more frequently during episodes of hypotension and RN provides and documents the appropriate interventions.
- Staff ensuring re-checking of patient's VS post interventions provided by RN during episodes of hypotension.
- Ensuring DPC staff are observing the patient's overall condition during treatment, and reporting any changes in patient's overall condition or any changes in mental status to the RN.

The In-servicing will be completed by 1/7/2019 with documentation of the training on file at the facility.

For ongoing compliance, the CM or designee will complete daily audits for 2 weeks. If 100% compliance is observed the audits will then be completed three times a week for 4 weeks. At that time if 100% compliance is sustained the audits will be completed monthly following the QAI auditing schedule. A POC specific auditing tool will be used for the audits.

Staff found to be non-compliant will be re-educated and counseled.
Results of the audit will be summarized by the CM who will report the findings at the monthly QAI meetings for ongoing guidance.

Date of completion: February 12, 2019