Initial Comments:
Based on the findings of an onsite unannounced Recertification survey completed from June 29, 2021 through July 2, 2021, Lehigh Avenue 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 from June 29, 2021 through July 2, 2021, Lehigh Avenue Dialysis, was identified to have the following standard level deficiency that was 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 medical records (MR), facility policy and an interview with the facility's Administrator, the facility did not follow its policy regarding the reporting of abnormal Blood Pressures, (BP), to a Licensed Nurse for four (4) of 10 Incenter Hemodialysis MR's reviewed, (MR #6, 7, 8, and 9).
Findings include:
A review of a document titled, "In Center Hemodialysis Policies & Procedures Davit Inc.," under Subtitle, "Abnormal Findings," revealed that, Member of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time:
Pre-treatment:
. Systolic greater than 180 mm/Hg or less than 90 mm/Hg
. Diastolic greater than or equal to 100 mm/Hg
Blood Pressure Post Treatment:
. If the patient can stand:
Standing systolic BP greater than 140 mm/Hg or less than 90.
Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg.
. Sitting BP for Patient that can not 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.
1. On July 1, 2021, from approximately 2:00 to 2:30 p.m., a review of MR #6 revealed that MR #6 was born October 6, 1950; Admitted to service on August 1, 2020; Diagnosed with End Stage Renal Disease, Anemia, Hepatitis C, and Malnutrition. Review of a document titled, "IDT Patient POC Meeting Report" dated 02/02/2021, revealed that MR #6 was classified as, "Stable." The category subtitled Blood Pressure, (BP), and Fluid Management, identified a goal, "To meet or trend toward goal of Pre-dialysis Blood of less than, 140/90." It was documented as, "Not Met."
Documents titled, "Post Treatment," dated 06/05/2021 through 06/26/2021 revealed the following:
On 06/05/2021, 10:06 a.m, the Post Treatment Blood Pressure=185/97. There was no documented evidence that a Licensed Nurse was notified.
On 06/08/2021, MR #6's Post Treatment Sheets revealed a Pre-treatment Blood Pressure 6:16 a.m.=194/111-Sitting, and 209/109 Standing. 6:31 a.m.=229/124. There was no documented evidence that a Licensed Nurse was notified.
On 06/12/2021 before 6:25 a.m. Pre-treatment Blood Pressure =198/108-Sitting, and 199/107 Standing; 6:25 a.m.=183/106; 6:31, 195/98; 10:05=126/110. The Patient was documented as,"Stable," during dialysis. Post-Treatment,= 172/95. There was no documented evidence that a Licensed Nurse was notified.
On 06/24/2021, 6:06 a.m., during treatment read as follows: 6:06 a.m.=204/99; 6:30 a.m.=203/110; 07:00 a.m.=193/93; by 9:01 a.m.=209/100, 9:03=175/106; 9:30 a.m.=180/103; 10:00 a.m=186/100, 10:02 a.m.=192/106. No Post-treatment data. There was no documented evidence that a Licensed Nurse had been notified.
2. On July 2, 2021, from approximately 12:30 a.m. to 1:00 p.m., a review of MR #7 revealed that MR #7 was born 12/23/93; Admitted to service on August 1, 2020; Diagnosed with End Stage Renal Disease, Anemia, Hepatitis C, and Fluid overload.
Documents titled, "Post Treatment," dated 5/18/2021 through 5/29/2021 revealed the following:
On 5/18/2021 the Pre-Treatment Blood Pressure at 6:21 a.m.= 172/115; 6:33 a.m.= 178/117; 7:02 a.m.=189/118; 7:32 a.m.=190/101; 8:02 a.m.=167/100; 8:32 a.m.= 167/103; 9:02 a.m.=169/114; 9:32 a.m.=169/122; 9:33 a.m.=174/114; 9:38 a.m.=172/116. Documented as, "Routine Discharge." There was no documented evidence that a Licensed Nurse had been notified.
5/20/201 the Pre-Treatment Blood Pressure was 157/105; Blood Pressure at 9:04 a.m.= 174/117; at 9:39 a.m., the Post-treatment standing Blood Pressure was 182/108. There was no documented evidence that a Licensed Nurse had been notified.
3. On July 2, 2021, from approximately 1:00 p.m. to 1:30 p.m., a review of MR #8 revealed that MR #8 was born 02/18/1968; Admitted to service on 08/1/2020; Diagnosed with End Stage Renal Disease, Anemia, Type II Diabetes, and Fluid Imbalance. Review of a document titled, "IDT Patient POC Meeting Report" dated 02/12/2021, revealed that MR #8 was classified as, "Stable." Under Category: Blood Pressure, (BP), and Fluid Management, a goal was identified, "To meet or trend toward goal of Pre-dialysis Blood of less than, 140/90." It was documented as, "Not Met."
Documents titled, "Post Treatment," dated 5/20/2021 through 6/26/2021 revealed the following:
On 5/20/2021 10:44 a.m. Post treatment sitting Blood pressure=153/128, "Routine Discharge." There was no documented evidence that a Licensed Nurse had been notified.
4. On July 2, 2021, from approximately 1:30 p.m. to 2:00 p.m., a review of MR's revealed that MR #9 was born 02/02/1947; Admitted to service on 08/01/2020; Diagnosed with End Stage Renal Disease, Anemia, Type II Diabetes, and Hypercalcemia. Review of a document titled, "IDT Patient POC Meeting Report" dated 02/02/2021, revealed that MR #9 was classified as, "Stable." Under Category: Blood Pressure, (BP), and Fluid Management, a goal was identified, "To meet or trend toward goal of Pre-dialysis Blood of less than, 140/90." It was documented as, "Not Met."
A review of documents titled, "Post Treatment," dated 5/19/2021 through 06/04/2021 revealed the following:
On 5/21/2021 at 9:25 a.m., the Pre-treatment sitting, (wheelchair bound), Blood pressure=198/103. There was no documented evidence that a Licensed Nurse had been notified.
On 06/04/2021 at 10:01 a.m., the Pre-treatment sitting, (wheelchair bound), Blood pressure= 201/103. There was no documented evidence that a Licensed Nurse had been notified.
On July 2, 2021 at approximately 3:00 p.m., in an interview with the Administrator it was confirmed that the facility Policy regarding Blood Pressures was not being followed.
Plan of Correction:The Facility Administrator (FA) held mandatory in-service (s) for all clinical teammates starting on 7/15/2021. Education included but was not limited to a review of Policy 1-03-08 "Pre-Intra-Post Data Collection, Monitoring and Nursing Assessment under Subtitle "Abnormal Findings", member of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time". TMs must report and document any significant changes during treatment and post treatment, compare pre-dialysis findings to post for indicators that may preclude the discharge of the patient and report to licensed nurse. Licensed nurse must take appropriate action, contact physician if warranted, and follow physician orders including utilizing patient PRN orders. All findings, interventions and patient response will be documented in patient's medical record. Charge nurse is responsible for daily monitoring. Verification of attendance at In-service will be evidenced by teammates signature on In-service sheet. The FA or designee will conduct daily audits on 25% of patient treatment flowsheets for one (1) week, then weekly for four (4) weeks, and then monthly on 10% of treatment flowsheets to ensure compliance. Instances of non-compliance will be addressed immediately. FA will address specific trends and issues with specific teammates. The FA will review the results of the audits with teammates during homeroom meetings and with Medical Director during monthly Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. Continued frequency of audits determined by the team. The FA is responsible for compliance with this plan of correction.
Completion Date: 08/02/2021
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