QA Investigation Results

Pennsylvania Department of Health
ARA DIALYSIS UNIT AT OHIO VALLEY HOSPITAL LLC
Health Inspection Results
ARA DIALYSIS UNIT AT OHIO VALLEY HOSPITAL LLC
Health Inspection Results For:


There are  16 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 on September 28, 2018, ARA Dialysis unit at Ohio Valley Hospital 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 on September 28, 2018, ARA Dialysis unit at Ohio Valley Hospital 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:




494.80(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 review of facility policy, medical records (MR) and interview with facility staff, the facility failed to assess and manage patient's blood pressure and/or fluid management needs for one (1) of seven (7) in center hemodialysis medical records reviewed (MR#4).

Findings Included:

Review of facility policy on 9/28/18 at approximately 12:30 PM revealed "...PROCEDURE MANUAL...PRO-4-160...HYPERTENSION...Procedure...2. Assess current BP...5. Assess patient for any symptoms 6. If indicated per Standing Order...administer anti-hypertensive...8. Notify MD per unit policy, if no response to medication, or signs and symptoms worsen..."

MR4, admission date 7/12/18, reviewed eight treatment records (9/1/18 to 9/22/18) on 9/27/18 at approximately 1:35 PM, physician standing order "...Clonidine 0.1 mg PO for systolic >200 or diastolic >110 may repeat x1..."
The following treatment records revealed:
9/1/18, 30 minute checks, 11:00 am BP 202/109 "Resting", 11:30 am BP 215/114 "alert"...
9/11/18, Pre Treatment BP 200/111, Pre-Assessment findings ""Pt stated he did not take his BP meds today"...30 minute checks, 10:30 am BP 210/101 "tx initiated", 11:00 am BP 219/111 "pt alert", 11:30 am BP 211/114 ""stable", 12:00 pm BP 207/108 "stable", 12:30 pm BP 208/107 "stable", 1:00 pm BP 211/118 "pt alert", 1:30 pm BP 213/120 "stable", 2:00 pm BP 220/113 "stable", 2:30 pm BP 214/115 "stable", 3:00 pm BP 217/114 "tx term"...Post Treatment...Sitting BP 217/114...
9/15/18, 30 minute checks, 11:00 am BP 189/114 "pt alert", 11:30 am BP 189/110 "pt watching TV", 1:00 pm BP 184/110 ""resting"...Post Treatment...Sitting BP 195/111...
9/22/18, 30 minute checks, 11:00 am BP 212/116 "pt alert", 11:30 am BP 192

Plan of Correction:

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The governing body and management staff of this facility takes this deficiency statement very seriously and will ensure that these citations are corrected and that they remain in compliance. The governing body met on 10/4/18 to review and approve the plan of correction and the tools and updates that will keep approved plan in compliance. The in-services and tools are available for review in the facility.

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An in-service to all DPC staff and the Interdisciplinary Team (IDT) will be completed by 10/6/18 by the Clinic Manager regarding the importance assessing and managing patients with hypertension and on following physician's orders and the facility policy on charge nurse (CN) notification for hypertensive patients. Specific emphasis was placed on the revision to the standing order on 9/27/18 which states to give "Clonidine 0.1mg PO for systolic blood pressure (BP) that has been greater than 180 mmHg for two hours (may repeat x 1). During the in-service the recent revision to the standing orders and procedure for hypertension was reviewed. During the in-service it was stressed that the DPC staff must notify the charge nurse for assessment of any systolic BP over 160 mm/HG, as indicated in the procedure, unless different specific parameters for the patient was ordered by the physician and documented on the patient's medical record, or for any increase in systolic BP greater than 20 mm/HG from the previous reading. It was also stressed that systolic BP readings of > 180 mmHg must also be reported to the nurse in charge immediately. The nurse in charge will evaluate the patient and notify the patients physician if need be. Per the standing order, if the systolic BP is > 180 mmHg, the charge nurse will ensure that clonidine is given and will check to see if the systolic BP decreases to < 180 mmHg. If it remains higher than 180 mmHg systolic in one hour, a second dose of Clonidine is to be administered. The charge nurse is to follow up after the second administration of Clonidine to see if the systolic BP remains high. If the systolic BP remains > 180 mmHg, the charge nurse is to notify the patient's physician for further orders and this is to be documented on the patient's treatment sheet. It was also stressed that no patient is to be discharged from the facility with a systolic BP > 180 mmHg without notifying the charge nurse for evaluation and without notifying the patient's doctor. This information must be included in the patient's comprehensive assessment and plan of care. The Charge Nurse, after each shift of patients is on dialysis, is to round on each patient to make sure systolic BP readings > 180 mmHg are being reported by the DPC staff to the charge nurse and the physician notified if need be and that the standing orders for Clonidine are being followed as outlined above. A CN rounding tool has been developed to document findings. After each shift of patients has completed their treatments, the Charge Nurse is to review the treatment records and verify the BP's are being reported as outlined above. The clinic manager will spot check one day of treatment records once a week for the next 8 weeks to ensure systolic BP's are being reported and Clonidine is being administered as outlined above. A CM rounding tool has been developed to document findings. The clinic manager will ensure compliance by direct review of the treatment records and through review of the charge nurse rounding tool. The findings from the CM monitoring tool and CN rounding tool will be reviewed at the monthly TQM meeting where additional action will be taken by the committee such as continuing the weekly CM monitoring and/or disciplinary action.



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 medical records (MR) and interview with facility staff, the facility failed to provide the necessary care and services necessary to maintain the patient's volume status for two (2) of seven (7) in center hemodialysis medical records reviewed (MR1, MR3).

Findings Included:

MR1, admission date 7/12/13, reviewed nine treatment records (9/3/18 to 9/21/18) on 9/27/18 at approximately 11:00 AM, physician order for estimated dry weight (EDW) 99.5 kg...post wght w/in 1 kg +/- EDW.
The following treatment records revealed:
9/10/18 EDW post-treatment 100.7 kg (patient 1.2 kg over EDW post-treatment)
9/12/18 EDW post-treatment 101.3 kg (patient 1.8 kg over EDW post-treatment)
Surveyor was unable to discern that EDW was revised and plan of care for volume status was individualized for this patient.

MR3, admission date 1/2/18, reviewed nine treatment records (9/1/18 to 9/20/18) on 9/27/18 at approximately 1:05 PM, physician order for estimated dry weight (EDW) 42 kg...post wght w/in 1 kg +/- EDW.
The following treatment records revealed:
9/6/18 EDW post-treatment 44 kg (patient 2 kg over EDW post-treatment)
9/18/18 EDW post-treatment 45.5 kg (patient 3.5 kg over EDW post-treatment)
9/20/18 EDW post-treatment 45 kg (patient 3 kg over EDW post-treatment)
Surveyor was unable to discern that EDW was revised and plan of care for volume status was individualized for this patient.

During an exit interview on 9/28/18 at approximately 2:00 PM, the facility clinical manager (EMP1) and clinical manager (EMP2) confirmed the above findings.
















Plan of Correction:

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An in-service was initiated to all Direct Patient Care (DPC) staff and the Interdisciplinary Team (IDT) by 10/6/18 by the clinic manager stressing that every part of the patient's treatment must be supported by a physician order or justified as to why the order was not followed on the treatment sheet, including estimated dry weights (EDW). If the patient is not achieving their dry weight for 3 consecutive treatments, the physician is to be notified, the patient evaluated and a new individualized dry weight obtained. The plan of care must be updated with the new individualized dry weight. Additionally, the physician must be notified, prior to the patient's discharge, if a patient's post dialysis weight is above or below their dry weight of 1 Kg, as indicated in the physician order, or if the patient exhibits signs of fluid overload such as edema or abnormal lung sounds (such as rales) on discharge. All patients' records, including patient's # 1 and # 3, have been reviewed to make sure that all dry weights are accurate and the physician notified if inaccurate and new orders obtained if indicated. All corrections, if needed have been entered into the computer system so it is accurately reflected on the treatment sheet. A tracking tool has been developed to track patients not achieving their dry weights and after 3 treatments, doctor notified, and a new dry weight obtained. This is to be completed by the nurse in charge and reviewed with the Clinic Manager weekly. The Charge Nurse (CN) will also review each shift of patients' treatment records at the end of the day to ensure that the patient physician orders for EDW's is being followed and that the EDW's are being met. Findings from this review will be documented by the CN on the developed CN rounding tool. This will also be addressed on the patient's Plan of Care. If the patient continues to not meet his/her EDW a plan will be developed by the IDT, including the patient, to try and meet the goal of the prescribed EDW. The Clinic Manager will ensure compliance by reviewing the treatment records of one day of patients weekly for 8 weeks to ensure that the EDW's and physician orders are being followed and that each EDW is being met and that if trends are identified that the information is included in the Comprehensive Assessment and Plan of Care and plans formed when indicated. A CM rounding tool has been developed to document findings. The CN and CM tools will be brought to the monthly TQM meeting for review where additional action will be taken as deemed appropriate by the committee such as continued monitoring and/or disciplinary action.


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 review of facility policy, medical records (MR) and interview with facility staff, the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician two (2) of seven (7) in center hemodialysis medical records reviewed (MR1, MR3).

Findings included:

Review of facility policy on 9/28/18 at approximately 12:45 PM revealed "...PROCEDURE MANUAL...PRO-4-10...POOR ARTERIAL BLOOD FLOW...10. Notify Charge RN if unable to maintain blood flow and document the actual blood flow rate achieved..."

MR1, admission date 7/12/13, reviewed nine treatment records (9/3/18 to 9/21/18) on 9/27/18 at approximately 11:00 AM, physician order for BFR (blood flow rate) 450 ml/min (milliliters/minute).
The following treatment records revealed:
9/7/18, BFR at 400 ml/min from 12:00 pm to 1:00 pm.
9/10/18, BFR at 400 ml/min for the entire treatment time.
9/14/18, BFR at 400 ml/min from 1:00 pm to 2:30 pm.
9/17/18, BFR at 400 ml/min from 12:00 pm to 1:30 pm.
9/21/18, BFR at 400 ml/min from 1:30 pm to 2:30 pm.
There was no documented evidence in MR1 for aforementioned treatment dates of why BFR was not at rate as ordered or that the "Charge RN (registered nurse)" was notified per facility policy.

MR3, admission date 1/2/18, reviewed nine treatment records (9/1/18 to 9/20/18) on 9/27/18 at approximately 1:05 PM, physician order for BFR (blood flow rate) 350 ml/min (milliliters/minute).
The following treatment records revealed:
9/20/18, BFR at 400 ml/min for the entire treatment time.
There was no documented evidence in MR1 for aforementioned treatment dates \cf0

Plan of Correction:

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An in-service was initiated to all Direct Patient Care (DPC) staff and the Interdisciplinary Team (IDT) by 10/6/18 by the Clinic Manager (CM) reinforcing that every part of the dialysis prescription must be supported by a physician order or justified in writing on the treatment sheet as to why the order could not be achieved. This includes Blood Flow Rates (BFR). During the in-service Procedure 4-10 was reviewed which states "Notify Charge RN if unable to maintain ordered blood flow and document the actual blood flow rate achieved." The procedure PRO3-60 for safety checks, monitoring during treatment, was also reviewed during the in-service with emphasis on "Verify the prescribed blood flow is being attained, if not notify Charge RN to evaluate cause." It was also stressed during the in-service that if the BFR cannot be achieved as ordered, the DPC staff member must document on the treatment sheet the reason that the prescribed BFR could not be attained and the charge nurse notified. The charge nurse must perform and document an assessment of why the BFR cannot be achieved and the physician notified. If a patient continuously is unable to achieve an ordered BFR during treatment the IDT must document this on the Comprehensive Assessment and Plan of Care (CA/POC) and document action taken to achieve prescribed BFR with a goal and target dates indicated when goal will be achieved. The Charge Nurse (CN) will round on all patients shifts, at least twice per shift, to verify that treatment orders are followed per physician order, including BFR, and there is documentation on the treatment sheet as to why the BFR cannot be obtained. A CN rounding tool has been developed to document findings. The CM will review the findings of the CN rounding tool and will spot check the treatment sheets one day a week for the next 8 weeks to ensure all treatment orders are followed per physician order, including BFR, and there is documentation by the DPC staff on the treatment sheet that the CN was notified if unable to obtain BFR and why the BFR cannot be obtained. The CM will also ensure that if trends are identified that the information is included in the Comprehensive Assessment and Plan of Care and plans formed when indicated. A CM rounding tool has been developed to document the findings. The Clinic Manager will ensure compliance through direct observation and review of CN rounding tool and CM monitoring tool. All findings from these tools will be addressed at the monthly TQM meeting where additional action will be taken as deemed appropriate, such as additional training,continuing the weekly monitoring or if trends are identified, disciplinary action.