Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on January 6, 2021, Jefferson 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 and certification of facility additional peritoneal dialysis training room completed on January 6, 2021, Jefferson Dialysis was found 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, heart rate, and/or fluid management needs for two (2) of five (5) in center hemodialysis patient medical records reviewed (MR1, MR5).
Findings Included:
Review of facility policy on 1/6/2021 at approximately 3:30 PM revealed: "Policy: 1-03-08 ...1. Patient data will be obtained and documented by the patient care technician (PCT or a licensed nurse...a...ii...blood pressure (BP) 1. sitting and standing BP...required pre and post treatment...iii. pulse rate...INTRADIALYTIC DATA COLLECTION/ASSESSMENT...9...a...i..at least every thirty (30) minutes...b. At a minimum...i. BP...ii..pulse...11 Abnormal findings...will be reported to the licensed nurse immediately...The licensed nurse will use...clinical judgement...to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician...as needed of changes in patient status...ABNORMAL FINDINGS...Blood Pressure: Pre Dialysis...Systolic greater than 180 mm/Hg or less than 90 mm/Hg Diastolic greater than or equal to 100 mm/Hg...Blood pressure Intradialytic...Difference of 20 mm/Hg increase or decrease from patient's last Intradialytic treatment BP reading...Blood pressure post treatment...sitting...systolic greater than 140 mm/Hg or less than 90 mm/Hg,..diastolic greater than 90 mm/Hg or less than 50 mm/Hg...Heart or Pulse Rate Pre/Intra/Post...Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat..."
Review of MR1 on 1/4/2021 at approximately 11:05 AM: Admission 6/28/2016. Physician PRN (as needed) order, start date 1/2/2018: "...Intradialytic Hypotension...Normal Saline Solution 0.9%...100 ml (milliliter) Intravenous IV prn (as needed)...NOTIFY MD IF 1000 CC (cubic centimeters) NSS (normal saline solution) GIVEN DURING TREATMENT..." Review of hemodialysis treatment flow sheets from 12/11/2020 to 12/23/2020 revealed:
12/14/2021, Intradialytics: 2:31 PM Pulse 108, 2:53 PM Pulse 113.
12/16/2021, Intradialytics: 12:34 PM Pulse 108, 1:02 PM Pulse 113, 1:32 PM Pulse 112, 2:02 PM BP (blood pressure) 68/52, 2:05 PM, 2:17 PM BP 78/57...Pulse 108, 2:32 PM BP...Pulse 105.
12/18/2021, Pre-Treatment Pulse: 126, Intradialytics: 11:31 AM Pulse 125, 12:03 PM Pulse 120, 12:35 PM BP 87/42...Pulse 119, 1:01 PM Pulse 118, 1:39 PM Pulse 120, 2:32 PM Pulse 117, Post-Treatment Pulse: 114.
12/20/2020, Pre-Treatment: Pulse 122.
12/23/2020, Pre-Treatment: Pulse 111.
There was no documented evidence of intervention/re-assessment provided for patient blood pressures below parameters and pulse greater than 100 beats per minute per physician orders and/or facility policy noted in MR1 hemodialysis treatment records for aforementioned treatment dates.
Review of MR5 on 1/6/2021 at approximately 12:15 PM: Admission 4/1/2015. Physician PRN (as needed) order, start date 1/2/2018: "...Intradialytic Hypotension...Normal Saline Solution 0.9%...100 ml (milliliter) Intravenous IV prn (as needed)...NOTIFY MD IF 1000 CC (cubic centimeters) NSS (normal saline solution) GIVEN DURING TREATMENT..." Review of hemodialysis treatment flow sheets from 12/12/2020 to 12/27/2020 revealed:
12/14/2020, Intradialytics: 10:32 AM BP 104/45, 11:04 AM BP 85/43, 11:35 AM BP 75/32, 12:02 PM BP 71/30, 12:32 PM BP 84/39, 1:04 PM BP 69/39, 1:29 PM BP 85/47, Post-Treatment Blood Pressure Sit: 85/49.
12/18/2020, 11:02 AM BP 94/44, 11:32 AM BP 96/55.
There was no documented evidence of intervention/re-assessment provided for patient blood pressures below parameters per physician orders and/or facility policy noted in MR5 hemodialysis treatment records for aforementioned treatment dates.
An exit conference was conducted on 1/6/2021 at approximately 1:30 PM with the facility Administrator and Manager of Clinical Services. Above findings were reviewed.
Plan of Correction:All patient care teammates were in-serviced by the Facility Administrator (FA) during team meetings on 1/12/2021 & 1/14/2021 on Policy 1-03-08 "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" and Procedure 1-09-01 "Hypotension". All patient care teammates signed an in-service sheet as evidence of participation and training. Patient care teammates were instructed in but not limited to: 1). Intradialytic treatment monitoring and data collection will be obtained a minimum of every thirty (30) minutes. 2). All findings, interventions and patient responses will be documented in the patient's medical record. 3). Abnormal finding(s) including blood pressure and heart rate noted to be outside 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 intervention is necessary. 4) Special consideration should be taken to prevent hypotensive events from occurring. Per physician order as appropriate, special consideration may include but are not limited to accurate pre and post weight documentation, frequent evaluation of Target Weight (TW), evaluation of hypertensive medications, ultrafiltration (UF) profiling, decrease in dialysate temperature, encouraging adherence to fluid and sodium restrictions. 5). As approved by the 10/5/2020 Governing Body Meeting, the Clinical Coordinator (CC) or RN designee will address at least monthly with the physician or Nurse Practitioner, any patient that may need an order for a specific blood pressure or heartrate parameter. This is to address patients whose baseline may normally be outside the DaVita abnormal findings parameters outlined in Policy 1-03-08. FA or designee will perform audits beginning on 1/15/2021 on twenty-five percent (25%) of post treatment sheets for compliance with process and documentation daily for two (2) weeks, then weekly for two (2) weeks. If improved, audits will be twice monthly for two (2) months on a random day. Instances of non-compliance will be addressed immediately. Results will reviewed with the patient care teammates during homeroom meetings and with the Medical Director at Monthly Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
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