Initial Comments:
Based on the findings of an on-site, unannounced Medicare recertification survey conducted on May 17, 2021 through May 19, 2021, West Shore 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 on-site, unannounced Medicare recertification survey conducted on May 17, 2021 through May 19, 2021, West Shore Dialysis, was identified to have the following standard level deficiencies that were determined to be in compliance with the following requirements of 42 CFR, Subparts A, B, C, and D: Conditions for Coverage for End-Stage Renal Disease Facilities. As a result of this survey five (5) Standard level deficiencies were cited. No immediate jeopardy was identified.
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 policy, patient treatment area observations and interview with the facility Administrator (EMP# 1), it was determined the facility failed to ensure the staff followed infection control protocols, including but not limited to, ensuring staff performed hand hygiene/don clean gloves according to facility procedure, for two (2) of two (2) observations of 'Discontinuation of Dialysis with Central Venous Catheter' (Observations #1 and #2); for two (2) of two (2) observations of 'Cleaning and Disinfection of the Dialysis Station' (Observations #3 and #4); and for two (2) of one (2) observations of patient treatment area (Observations #5 and #6).
Findings include:
A review of facility policy, '1-05-01 Infection Control For Dialysis Facilities' section, 'Teammate Hygiene' on May 17, 2021 at approximately 1:00 p.m. reads, "Hand Hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, before touching clean areas such as supplies and on exiting the patient treatment area...Teammate/Patient Safety...11. Teammates will wear disposable gloves when caring for the patient or touching the patient's equipment a the dialysis station, and will remove gloves and wash hands or perform hand hygiene between each patient and/or station...13. Gloves should be changes when soiled with blood, dialysate or other body fluids, when going from a "dirty" area or task to a "clean" area or task, after touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient's dialysis delivery system..." (Facility policy is not in compliance with CDC standard infection control sequence procedure of cleaning and disinfection of the dialysis station .)
Observations conducted in the patient treatment area on May 17, 2021 between approximately 9:42 a.m. and 2:15 p.m. revealed the following:
Observation #1 'Discontinuation of Dialysis with Central Venous Catheter': On May 17, 2021 at approximately 1:20 p.m., patient #14 at station #4, Employee #1 failed to remove gloves/perform hand hygiene/don clean gloves after reinfusing the extracorporeal circuit.
Observation #2 'Discontinuation of Dialysis with Central Venous Catheter': On May 17, 2021 at approximately 2:05 p.m., patient 11 at station #12, Employee #2 failed to remove gloves/perform hand hygiene/don clean gloves after reinfusing the extracorporeal circuit.
Observation #3 'Cleaning and Disinfection of the Dialysis Station' : On May 17, 2021 at approximately 9:50 a.m., patient #17 at station #9, EF #2 failed to remove gloves/perform hand hygiene/don clean gloves after removing all bloodlines and disposable equipment and before beginning to disinfect the station.
Observation #4 'Cleaning and Disinfection of the Dialysis Station' : On May 17, 2021 at approximately 10:04 a.m., patient #18 at station #10, EF #1 failed to remove gloves/perform hand hygiene/don clean gloves after removing all bloodlines and disposable equipment and before beginning to disinfect the station.
Observation #5 Patient Treatment Area: On May 17, 2021 at approximately 10:15 a.m., EF #8 failed to don gloves prior to touching dialysis machine located in station #9. Surveyor asked Employee #8, "Should you be touching the machine with bare hands?" Employee #8 replied, "Probably not."
Observation #6 Patient Treatment Area: On May 17, 2021 at approximately 2:09 p.m., EF #8 was observed to be gloved and touching dialysis machine located in station #11. Then EF #8 walked from station #11 to station #12, touched dialysis machine located in station #12 and then returned to station #11 and touched dialysis machine located in station #11. EF #8 failed to remove gloves/perform hand hygiene/don clean gloves between stations #11 and #12.
An interview with the facility administrator on May 19, 2021 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:0113
The Facility Administrator (FA) and/or the Clinical Coordinator (CC) will hold an in-service for all clinical teammates (TMs) on 6/1/2021 and 6/2/2021 to review Policies: 1-05-01 Infection Control for Dialysis Facilities. Education will include, but not limited to: 1) removing gloves, performing hand hygiene and donning clean gloves after patient and dialysis delivery system contact, between patient contact, even if the contact is casual, between dirty and clean task such as reinfusing the extracorporeal circuit, after removing bloodlines and before beginning station disinfection. 2) TMs must wear disposable gloves when caring for the patient or touching the patient' equipment at the dialysis station. 3) Verification of attendance is evidenced by TM signature on sign-in sheet. The FA) or designee will perform infection control audits daily for two (2) weeks, then three (3) times a week for two (2) weeks, then monthly during internal infection control audits. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the TMs during Homeroom meetings and with the Medical Director during the monthly Facility Health Meeting (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion date: 6/18/2021
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 review of facility policy, patient treatment area observations and interview with the facility Administrator (EMP# 1), it was determined the facility failed to ensure staff followed standard infection control precautions by emptying the prime waste receptacle prior to disinfecting the dialysis station for two (2) of two (2) observations of 'Cleaning and Disinfection of the Dialysis Station' (Observation #1-2).
Findings include:
A review of facility policy, '1-05-01 Infection Control For Dialysis Facilities' section, 'Teammate Hygiene' on May 17, 2021 at approximately 1:00 p.m. reads, "Section Dialysis Station Management...67. Priming containers are to be emptied. The interior and exterior should be wiped down with 1:100 (one to one hundred) bleach solution before using on next patient treatment..." (Facility policy is not in compliance with CDC standard infection control sequence procedure of cleaning and disinfection of the dialysis station .)
Observations conducted in patient treatment area on May 17, 2021 between approximately 9:45 a.m. and 1:30 p.m. revealed the following:
Observation #1 'Cleaning and Disinfection of the Dialysis Station' On May 17, 2021 at approximately 9:50 a.m., station #9, Employee # 2, failed to empty prime waste receptacle after removing all bloodlines and disposable equipment and prior to disinfecting the dialysis station.
Observation #2 'Cleaning and Disinfection of the Dialysis Station' On May 17, 2021 at approximately 10:04 a.m., station #10, Employee # 1, failed to empty prime waste receptacle after removing all bloodlines and disposable equipment and prior to disinfecting the dialysis station.
An interview with the facility administrator on May 19, 2021 at approximately 1:00 p.m. confirmed the above findings.
Based on review of facility policy, patient treatment area observations and interview with the facility Administrator (EMP# 1), it was determined the facility failed to ensure expired items/supplies were discarded and replaced for one (1) of one (1) observations. (Observation #1).
Findings include:
A review of facility policy, '1-05-01 Infection Control For Dialysis Facilities' section, 'Teammate/Patient Safety' on May 17, 2021 at approximately 11:45 a.m. reads, "...20. The expiration date will be checked on all disposable supplies before the package is opened and the contents are used..."
Observations conducted in patient treatment area on May 17, 2021 between approximately 9:42 a.m. and 1:20 p.m. revealed the following:
Observation #1: The following expired items were observed in the crash cart located in the patient treatment area:
Two (2) Guardian Blood Leak Test Strips (25 count), expired 3/31/2021.
An interview with the facility administrator on May 19, 2021 at approximately 1:00 p.m. confirmed the above findings.
Based on review of facility policy, patient treatment area observations and interview with the facility Administrator (EMP# 1), it was determined the facility failed to ensure that correct cleaning and disinfection of environmental surfaces was performed for one (1) of two (2) observations of 'Cleaning and Disinfection of the Dialysis Station' (Observation #1).
Findings include:
A review of facility policy, '1-05-01 Infection Control For Dialysis Facilities' section, 'Facility Hygiene' on May 17, 2021 at approximately 11:45 a.m. reads, '...45. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials. Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for environmental surfaces. For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized. After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time..."
Observations conducted in patient treatment area on May 17, 2021 between approximately 9:42 a.m. and 1:20 p.m. revealed the following:
Observation # 1: On May 17, 2021 at approximately 10:35 a.m. surveyor observed EF #8, clean-up blood spill on the dialysis chair located at station #13. The area was not cleaned a second time with a new disposable towel.
An interview with the facility administrator on May 19, 2021 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:0122
The FA and/or CC will hold an in-service for all clinical TMs on 6/1/2021 and 6/2/2021. Education will include, but not limited to: 1) a review of Policy 1-05-01: Infection Control for Dialysis Facilities emphasizing that the priming containers are to be emptied. The interior and exterior should be wiped down with 1:100 (one to one hundred) bleach solution before using on next patient treatment. The CDC Dialysis Station Routine Disinfection form was also reviewed. 2) A review of Policy 1-02-08 Emergency Equipment Checks emphasizing the Emergency cart contents are checked weekly for expiration date. The expiration date will be checked on all disposable supplies before the package is opened and the contents are used. 3) A review of Policy 1-05-01 emphasizing that cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials. Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for environmental surfaces. For visible blood or gross spills, a 1:10 (one to ten) bleach solution must be utilized. After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, TMs are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean the area a second time. The FA or designee will perform infection control audits daily for two (2) weeks, then three (3) times a week for two (2) weeks, then monthly during internal infection control audits. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the TMs during Homeroom meetings and with the Medical Director during the monthly FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion Date: 6/18/2021
494.30(b)(2) STANDARD
IC-ASEPTIC TECHNIQUES FOR IV MEDS
Name - Component - 00
[The facility must-]
(2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and
Observations:
Based on review of facility policy, patient treatment area observations and interview with the facility Administrator (EMP# 1), it was determined the facility failed to ensure clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials for 1 (one) of one (1) observations conducted (Observation #1).
Findings include:
A review of facility policy, '1-06-01 Medication Policy' section, 'Policy' on May 17, 2021 at approximately 11:00 a.m. reads, "...29. Medications containing a preservative must be discarded 28 days after opening or accessed (e.g., needle punctured), unless the manufacturer specifies a different (shorter or longer date or as directed by the manufacturer as in the case of vaccines or state specific pharmacy regulations. Each vial is labeled with the initials of the person opening the vial and the expiration date..."
The CDC (Centers for Disease and Control) (https://www.cdc.gov/injection safety/providers/provider_faqs_multivials.html) website states the following: "The United States Pharmacopeia (USP) General Chapter 797 [16 ] recommends the following for multi-dose vials of sterile pharmaceuticals: "If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."
Observations conducted in patient treatment area on May 17, 2021 between approximately 9:42 a.m. and 1:20 p.m. revealed the following:
Observation #1: On May 17, 2021 at approximately 11:25 a.m. the following was observed: Three (3) opened multi-use medication vials (Epogen 20, 000 units/2 mL, Ondansetron 40 mg/20 mL and Hectorol 4 mcg/2 mL) in the medication storage drawer at the nursing station was not labeled with the initials of the person who opened the vials and the expiration date.
An interview with the facility administrator on May 19, 2021 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:0143
The FA and/or CC will hold an in-service for all clinical TMs on 6/1/2021 and 6/2/2021 to review Policy 1-06-01 Medication Policy emphasizing that medications containing a preservative must be discarded 28 days after opening or accessed (e.g., needle punctured), unless the manufacturer specifies a different (shorter or longer) date or as directed by the manufacturer as in the case of vaccines or state specific pharmacy regulations. Each vial is labeled with the initials of the person opening the vial and the FA or designee will perform an audit daily for two (2) weeks, then three (3) times a week for two (2) weeks, then monthly during internal audits. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the TMs during Homeroom meetings and with the Medical Director during the monthly FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion Date: 6/18/2021
494.60(b) STANDARD
PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU
Name - Component - 00
The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations.
Observations:
Based on a tour of the dialysis patient treatment area, policy review and interview with the facility Administrator (EMP# 1), it was determined facility failed to ensure that all equipment was maintained in accordance with the manufacturers's recommendations for four (4) of thirteen (13) stations. (Station #1, #3, #7 and #13)
Findings include:
A review of facility policy, '8-04-01 Physical Environment' section, 'Policy' on May 18, 2021 at approximately 11:45 a.m. reads, "1. The dialysis facility will be designated, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment... 5. The space for treating each patient will be sufficient to provide needed care and services, prevent cross contamination, and to accommodate medical emergency equipment and teammates... "
Observations conducted in patient treatment area on May 17, 2021 between approximately 9:42 a.m. and 1:20 p.m. revealed the following:
Station #1: On May 17, 2021 at approximately 10:56 a.m. during observation, it was observed that the treatment chair located at station #1 had a 0.5-inch tear on the left armrest.
Station #3: On May 17, 2021 at approximately 10:58 a.m. during observation, it was observed that the treatment chair located at station #3 had a 0.5-inch tear on the left armrest.
Station #7: On May 17, 2021 at approximately 11:00 a.m. during observation, it was observed that the treatment chair located at station #7 had a 1.5-inch tear on the cushion.
Station #13: On May 17, 2021 at approximately 11:05 a.m. during observation, it was observed that the treatment chair located at station #13 had a multiple punctures on both left and right armrests.
An interview with the facility administrator on May 19, 2021 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:0403
The FA and/or CC will hold an in-service for all clinical TMs on 6/1/2021 and 6/2/2021 to review Policy 8-04-01 Physical Environment emphasizing the dialysis facility will be designed, constructed, equipped and maintained to provide dialysis patients, TMs and the public a safe, functional and comfortable treatment environment. In addition, the space for treating each patient will be sufficient to provide needed care and services, prevent cross contamination and to accommodate medical emergency equipment and teammates. Verification of attendance will be evidenced by TM signature on in-service sheet. The FA to set up repair appointment with a chair repair vender for noted chairs by 6/4/2021. Once repairs are completed, chair inspections will be completed monthly during OSHA Safety audits to verify the integrity. Any noted issues will be addressed immediately and repairs/replacements scheduled as soon as possible. The results of the audits will be reviewed with the Medical Director during the monthly FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion Date: 6/18/2021
494.80(a)(2) STANDARD
PA-APPROPRIATENESS OF DIALYSIS RX
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
(2) Evaluation of the appropriateness of the dialysis prescription,
Observations:
Based on review medical records (MR), facility policies, and interview with the facility Administrator (EMP# 1), it was determined the facility failed to ensure that the patient prescription was being implemented as ordered by the physician for four (4) of seven (7) MRs reviewed. (MR# 1, #2, #3 and #5)
Findings include:
A review of facility policy, '1-03-06Q Machine Start Up and Priming a Non-ETO Sterilized Single Use Dialyzer Utilizing Fresenius 2008 Series Dialysis Delivery Systems and Streamline Blood Lines for First Shift of the Day' section, 'Policy' on May 19, 2021 at approximately 9:00 a.m. reads, " ...39. Verifies that dialysis delivery system is operating correctly and safely prior to initiation of each treatment ...
A review of facility policy, ' 1-04-05 Blood Flow Problems' section, 'Policy' on May 19, 2021 at approximately 9:15 a.m. reads, " 1. Blood flow problems may be identified by the following: Decreased ability to aspirate or maintain blood flow from CVC limb or successfully cannulated needle, changes in a patient ' s arterial or venous pressures at a given blood flow rate, needle gauge or Central Venous Catheter ...2. If blood flow problem remains unresolved, notify licensed nurse 3. The license nurse will assess the patient, their vascular access and extracorporeal circuit for the above and include the following: assess the effectiveness of above interventions, determine need to reduce blood flow and extend treatment time, notify nephrologist for further evaluation and/or interventions. 4. Document findings and interventions in patient ' s medical record. "
A review of facility policy, ' 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment ' section, 'Policy' on May 19, 2021 at approximately 9:30 a.m. reads, " ...3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment ...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed ...1. Abnormal 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 judgement based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notified the physician as needed of changed in patient status ... "
MR reviews were conducted on May 18, 2021 between 9:00 a.m. and 3:00 p.m. revealed the following:
MR #1: On May 18, 2021 at approximately 9:05 a.m. MR# 1 was verified for patient # 1.
Hemodialysis treatment prescription flowsheet dated May 3, 2021 showed BFR (blood flow rate) orders for "450". Flowsheet documentation indicated the dialysis machine BFR was set at " 400 " between 12:02 p.m. and 13:32 p.m. and " 305 " between 14:02 p.m. and 14:24 p.m.
Hemodialysis treatment prescription flowsheet dated May 14, 2021 showed BFR orders for "450". Flowsheet documentation indicated the dialysis machine BFR was set at " 400 " at 11:30 a.m., " 350 " between 12:02 p.m. and 12:32 p.m. and " 300 " between 13:02 p.m. and 14:29 p.m.
MR #2: On May 18, 2021 at approximately 9:25 a.m. MR# 2 was verified for patient # 2.
Hemodialysis treatment prescription flowsheet dated May 1, 2021 showed DFR (dialysate flow rate) orders for "800". Flowsheet documentation indicated the dialysis machine DFR was set at " 600 " for the entire duration of treatment.
Hemodialysis treatment prescription flowsheet dated May 15, 2021 showed DFR orders for "800". Flowsheet documentation indicated the dialysis machine DFR was set at " 600 " for the entire duration of treatment.
MR #3: On May 18, 2021 at approximately 9:55 a.m. MR# 3 was verified for patient # 3.
Hemodialysis treatment prescription flowsheet dated April 29, 2021 showed DFR orders for "700". Flowsheet documentation indicated the dialysis machine DFR was set at " 600 " for the entire duration of treatment.
Hemodialysis treatment prescription flowsheet dated May 1, 2021 showed BFR orders for " 450 " and DFR orders for "700". Flowsheet documentation indicated the dialysis machine BFR was set at " 400 " and DFR was set at " 800 " for the entire duration of treatment.
Hemodialysis treatment prescription flowsheet dated May 4, 2021 showed BFR orders for "450". Flowsheet documentation indicated the dialysis machine BFR was set at " 400 " for the entire duration of treatment.
Hemodialysis treatment prescription flowsheet dated May 6, 2021 showed BFR orders for " 450 " and DFR orders for "700". Flowsheet documentation indicated the dialysis machine BFR was set at " 400 " between 9:54 a.m. and 11:57 a.m. and at " 350 " between 12:20 p.m. and 13:27 p.m. DFR was set at " 800 " for the entire duration of treatment.
Hemodialysis treatment prescription flowsheet dated May 8, 2021 showed BFR orders for "450". Flowsheet documentation indicated the dialysis machine BFR was set at " 400 " for the entire duration of treatment.
Hemodialysis treatment prescription flowsheet dated May 11, 2021 showed BFR orders for " 450". Flowsheet documentation indicated the dialysis machine BFR was set at " 400 " between 9:54 a.m. and 12:26 p.m. and at " 350 " between 13:00 p.m. and 13:41 p.m.
Hemodialysis treatment prescription flowsheet dated May 13, 2021 showed BFR orders for " 450 " and DFR orders for "700". Flowsheet documentation indicated the dialysis machine BFR was set at " 400 " and DFR was set at " 600 " for the entire duration of treatment.
MR #5: On May 18, 2021 at approximately 10:35 a.m. MR# 5 was verified for patient # 5.
Hemodialysis treatment prescription flowsheet dated April 27, 2021 showed BFR orders for "500". Flowsheet documentation indicated the dialysis machine BFR was set at " 450 " between 10:01 a.m. and 10:45 a.m.
An interview with the facility administrator on May 19, 2021 at approximately 1:00 p.m. confirmed the above findings.
Plan of Correction:0503
The FA and/or CC will hold an in-service for all clinical TMs on 6/1/2021 and 6/2/2021 to review Policy 1-03-06Q Machine Start Up and Priming...Utilizing Fresenius 2008 Series..., Policy 1-04-05 Blood Flow Problems and Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nurse Assessment. In-service training will include, but not limited to: 1) TMs must verify that dialysis delivery system is operating correctly and safely prior to initiation for each treatment. 2) Blood flow problems may be identified by the following: decreased ability to aspirate or maintain blood flow from the CVC limb or successfully cannulated needle, changes in a patient's arterial or venous pressures at a given blood flow rate, needle gauge or Central Venous Catheter, TMP alarms, jumping blood lines, patient complains of "sucking" sensation in access, visible clotting of the dialyzer, drip chamber (s) or blood lines. If blood flow problems remain unresolved, notify licensed nurse. The licensed nurse will assess the patient, their vascular access and extracorporeal circuit for the above and include the following: assess the effectiveness of above interventions, determine need to reduce blood flow and extend treatment time, notify nephrologist for further evaluation and/or interventions and document findings and interventions in patient's medical record. 3) Patient identity, prescription and machine settings including dialysate flow rate, are verified by TM prior to initiation of treatment with the exception of blood flow rate, which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by State law. If the dialysis prescription is not being met, (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the license nurse informed. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status for further evaluation and/or interventions and document findings and interventions in patient's medical record. . Verification of attendance for the education will be evidenced by TM signature on sign-up sheet. The FA or designee will perform observational audits of machine settings daily for two (2) weeks, then 3 times a week for 2 weeks, then monthly on-going. In addition, the Clinical Coordinator or designee will audit 10% post-treatment flow sheet documentation daily for 2 weeks, then weekly for 2 weeks, then monthly. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the TMs during Homeroom meetings and with the Medical Director during the monthly FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion Date: 6/18/2021
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