QA Investigation Results

Pennsylvania Department of Health
BMA OF CAMBRIA
Health Inspection Results
BMA OF CAMBRIA
Health Inspection Results For:


There are  14 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 conducted November 6, 2023 through November 9, 2023, BMA of Cambria 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 November 6, 2023 through November 9, 2023, BMA Cambria 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:




494.60 STANDARD
PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT

Name - Component - 00
The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment.


Observations:

Based on a review of facility policy, observations (OBS) of the hemodialysis treatment and supply areas, and an interview with the facility administrator, the facility failed to remove expired supplies from the treatment and storage areas.

Findings include:

Review of facility policy, "Storage of Supplies" conducted on November 8, 2023 at approximately 1:30 PM reads in part, "Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated or damaged;" and "Supplies must be rotated First in-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date."

Observation of the hemodialysis treatment area was conducted on November 6, 2023 from 11:00 AM to 1:00 PM.

Observation #1: The emergency cart contained one (1) bottle of Aniosgel Hand Sanitizing Gel which expired on 10/2023, lot number C32807S.

Observation #2: A cabinet labeled "Labs" found the following expired items: Eighty-six (86) no additive Z blood Tubes, lot number 2080632, expired 09/30/2023, and ninety-six (96) Buffered Na (Sodium) Citrate Blue Top Tubes lot number 2347019, expired 09/30/2023.

Observation #3: A drawer in the Medication Room labeled "Foot Check" found the following expired items: Jamar Disposable Monofilaments (used for foot checks): lot number R0610XT, quantity of 8, expired 06/10/2019, and lot number N0620GS, quantity of nineteen (19), expired 06/20/2023.

Observation #4: The nurses' station contained one (1) bottle of Aniosgel Hand Sanitizing Gel, lot number C10704S, expired 03/2023.

The above items were removed and given to the administrator.

Observation of the storage supply area was conducted on November 7, 2023 from 9:00 to 10:00 AM.

Observation #5: The bottom shelf of a storage rack located in the far corner of the storage supply room found the following expired items: one (1) box containing nine (9) bottles of Aniosgel Hand Sanitizing Gel, lot number C326068, expired 10/2023; a second full, unopened box (12 bottles) of Aniosgel Hand Sanitizing Gel was found at the back of the shelf, lot number C1121S, expired 03/2023.

The above items were removed and given to the biomedical technician who was in the storage area at the time.

An interview conducted with the administrator on November 9, 2023 starting at 11:30 AM confirmed the above findings.





Plan of Correction:

V 401

For immediate compliance all expired items, including the hand sanitizer, lab tubes, and monofilaments found at the time of the survey were removed. The items were discarded on November 6, 2023, by the facility Administrator (FA) and the biomedical technician (BMT).
For ongoing compliance, the FA or designee will in-service all direct patient care (DPC) staff on the following policy:
- Storage of Supplies
Emphasis will be placed on ensuring that all medications and supplies are all within the current date for use. The meeting reviewed that medications and supplies must follow the manufacture's direction for use (MDU) and that stock must be rotated First In First Out when restocking. The meeting will reinforce that staff must check the expiration date of medications and supplies before using them.
The inservice will be completed by December 1, 2023, and the education records will be on file in the facility.
The FA or designee will perform daily audits for two (2) weeks. At that time if compliance is noted, the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, if one hundred percent (100%) compliance is sustained, the audits will then follow the monthly Quality Improvement and Performance Improvement (QAPI) schedule. A plan of correction (POC) audit tool will be used for the audits.

Staff found to be non-compliant will be re-educated and referred for counseling.

The FA will review the audit results and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.

Completion date: December 29, 2023



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 facility policies/procedure, medical records (MR), direct observations, and an interview with the facility administrator, the facility failed to ensure that blood flow rates (BFR) and/or the dialysate flow rates (DFR) were administered per physician orders for nine (9) of nine (9) MR's reviewed: MR #1, MR#2, MR#3, MR#4, MR#5, MR#6, MR#7, MR#8 and MR#9; the facility failed to follow its policy for monitoring vital signs and machine safety checks for four (4) of nine (9) MR's reviewed: MR#1, MR#4, MR#5, and MR#9; and the facility failed to report and/or document abnormal findings pre, during and/or post hemodialysis (HD) for six (6) of nine (9) records reviewed: MR#2, MR#4, MR#5, MR#6, MR#7, and MR#9.

Findings include:

A review of facility policy titled "Physician Order Documentation on November 9, 2023 at approximately 9:00 AM reads in part, "Nurse practice acts require nurses to carry out treatment care, medication administration, lab tests, procedures, and other treatments, based on physician orders."

A review of facility policy titled "Patient Assessment and Monitoring" on November 7, 2023 at approximately 9:30 AM reads in part,

"Pre-Treatment: Direct patient care staff may collection pre-treatment weight, BP (blood pressure), pulse respirations, temperature, general observations, access and complaints reported by the patient. If the PCT/LPN (Patient Care Technician/Licensed Practical Nurse) notes any changes or abnormal findings in the patient's condition or vascular access are observed or reported by the patient...the patient care technician must report the changes in the patient condition to a registered nurse who will further assess the patient prior to initiation of treatment. An abnormal finding confirmed by the registered nurse (RN) will be reported to the attending physician for assessment and intervention if necessary as determined by the clinical judgement of the registered nurse;"

"During Treatment: The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed;"

"Post Treatment: Non-licensed staff may collect post treatment weight, BP, pulse, respirations, temperature, general observations, access.... The staff member who collected the information and evaluates the patient post-treatment will document their findings on the hemodialysis treatment record. If any changes or abnormal findings in the patient's condition, vital signs, or vascular access are observed or reported by the patient, the PCT/LPN must report the changes in the patient condition to a registered nurse whowill further assess the patient prior to discharge after the treatment. An abnormal finding confirmed by the RN will be reported to the attending physician is necessary as determined by the clinical judgement of the registered nurse for assessment and intervention. The Registered Nurse will assess/re-assess any findings address pre-treatment prior to discharge."

"Monitoring During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulation. Document machine parameters and safety checks every 30 (minutes) or more often as needed but not to exceed 45 minutes or per state regulations."

"Follow the steps below for monitoring patient and machine parameters during treatment: Blood Pressure - Record blood pressure. Recheck blood pressure after a drop that requires interventions such as administering normal saline. Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to the nurse: Systolic blood pressures greater than 180 mmHg, Diastolic blood pressure greater than 100 mmHg, Blood Pressure less than or equal to 100 mmHg systolic."

"Machine Parameters and Extracorporeal Circuit: Check machine setting and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct and the prescribed flow is being delivered. Document any findings and interventions in the medical record."

"Post Treatment: Weight - ensure the post weight is consistent with the goal set of the machine. Blood Pressure - ensure vital signs and overall condition are stable for discharge."

A review of facility policy titled "Initiation of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer" and "initiation of Treatment Using an Arteriovenous Graft or Fistula and Optiflux Single Use Ebeam Dialyzer" on November 7, 2023 at approximately 9:45 AM reads in part, "Initiation of Treatment: Starting Hemodialysis - ....Start the blood pump and turn slowly to 100-150 mL/min (milliliters per minutes) and assess the following - extracorporeal circuit is correctly and securely connected, no pain or extravasation (leakage) at the catheter site, no flow problems or inappropriate pressure readings noted. If no problems are noted, turn up the blood flow rate to the rate prescribed by the physician to achieve optimal clearances;....if prescribed by the physician, activate other prescribed treatment parameters...document ...all required patient and machine data in the patient's hemodialysis treatment sheet or electronic medical record."

A review of patient medical records (MR) was conducted on November 7, 2023 from approximately 12:25 PM to 3:30 PM, November 8, 2023 from approximately 8:15 AM to 3:30 PM, and November 9, 2023 from approximately 8:10 AM to 9:30 AM.

MR #1 Admission Date: 09/01/2023. Dialysis Treatment Records reviewed between 10/25/2023 and 11/06/2023 found the following:

10/25/2023: Hemodialysis (HD) Treatment was initiated at 11:05 AM. Vital sign and machine check occurred at 1:05 PM by the PCT but did not occur again until 2:01 PM (56 minutes after the last check). The next vital sign and machine check were not performed until 3:02 PM, 61 minutes after the last check. There was no documentation as to the reason why vital sign and machine checks were not obtained every 30 to 45 minutes per facility policy.

11/01/2023: HD orders included a BFR 350 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 11:05 PM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 11:13 AM: BFR 200 ml/min and DFR 500 ml/min; 11:37 AM: BFR 300 ml/min; DFR was increased to the prescribed rate of 800 ml/min. 12:02 PM: BFR 300 ml/min; At 12:31, the BFR was increased to the prescribed rate of 350 ml/min. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

11/03/2023: HD orders included a BFR 350 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 11:47 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 1:35 PM, the DFR was decreased to 500 ml/min and remained at that rate until treatment ended at 3:15 PM. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

11/06/2023: HD orders included a BFR 350 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 11:41 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 12:04 PM: BFR 450 ml/min and remained at that rate for the entire treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR and/or DFR to be administered at a rate different from the prescribed HD physician order rate, nor was there documentation as to why the BFR and/or DFR were not administered at the rate prescribed by the physician for any of the above dates.

MR#2 Admission Date: 05/01/2023. Dialysis Treatment Records reviewed between 10/25/2023 and 11/06/2023 found the following:

10/30/2023: 1:04 PM: Blood pressure was 80/63. There was no documentation from the PCT indicating that the RN was informed of a systolic blood pressure (SBP) below 100 mmHg per facility policy. 1:34 PM: BP 78/51. PCT documentation states BP low, UF (ultrafiltration) off, and RN aware. There was no documentation from the RN at the time of the occurrence or via the post HD assessment that addressed the low SBP. The post assessment documentation by the RN noted no unusual findings.

10/30/2023: HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 11:15 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 11:15 AM - DFR rate was 800 ml/min; 12:00 PM DFR was decreased to 500 ml/min and remained at the rate for the entire treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders. Estimated dry weight (EDW): 57.5 kg. Pre HD treatment weight: 59.0 kg. Post HD treatment weight: 58.9. There was no documentation or interventions on the treatment record addressing goal weight (EDW) not being met.

11/03/2023: HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 11:10 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: BFR was 300 ml/min at the start of treatment and remained at that rate for the entire treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders. Estimated dry weight (EDW): 57.5 kg. Pre HD treatment weight: 63.3 kg. Post HD treatment weight: 61.25 kg. RN documentation noted that patient was 3.7 kg above dry weight, but no further interventions were addressed.

There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR and/or DFR to be administered at a rate different from the prescribed HD physician order rate, nor was there documentation as to why the BFR and/or DFR were not administered at the rate prescribed by the physician for any of the above dates.

MR#3 Admission Date: 07/24/2023. Dialysis Treatment Records reviewed between 10/25/2023 and 11/06/2023 found the following:

10/30/2023: HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 11:11 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 11:32 AM DFR 500 ml/min; 12:00 PM DFR increased to prescribed rate of 800 ml/min; 12:32 PM DFR decreased to 500 ml/min and remained at that rate for the entire treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

11/01/2023: HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 11:00 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 11:02 AM DFR was running at the prescribed rate of 800 ml/min; 12:02 PM DFR was decreased to 500 ml/min and remained at that rate for the entire treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR and/or DFR to be administered at a rate different from the prescribed HD physician order rate, nor was there documentation as to why the BFR and/or DFR were not administered at the rate prescribed by the physician for any of the above dates.

MR#4 Admission Date 02/15/2023. Dialysis Treatment Records reviewed between 10/25/2023 and 11/06/2023 found the following:

10/25/2023: EDW 136.0 kg. Pre HD treatment weight: 146.8 kg. Post HD treatment weight: 144.4 kg. There was no documentation or interventions on the treatment record addressing goal weight (EDW) not being met.

10/27/2023: Hemodialysis (HD) Treatment was initiated at 6:50 AM. Vital sign and machine check occurred at 7:02 AM but did not occur again until 8:04 AM (62 minutes after the last check). The next vital sign and machine check was performed at 9:04 AM, 60 minutes after the last check. There was no documentation as to the reason why vital sign and machine checks were not obtained every 30 to 45 minutes per facility policy. EDW: 140.0 kg; Pre HD treatment weight: 145.8 kg. Post HD treatment weight: 141.8. There was no documentation or interventions on the treatment record addressing goal weight (EDW) not being met nor was there an RN assessment/evaluation post HD treatment.

10/30/2023: Blood pressure (BP) recordings by the PCT were as follows: 6:50 AM 198/80; 7:03 AM 195/91; 7:30 AM 194/80. There was no documentation from the PCT indicating that the RN was informed of a SBP greater than 180 per facility policy. The HD post assessment documentation by the RN stated no unusual findings.

11/01/2023: HD orders included a BFR 425 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 6:46 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 7:01 AM BFR 300 ml/min; the BFR was increased to the prescribed rate of 425 ml/min at 7:35 AM. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders. EDW: 140.0 kg. Pre HD treatment weight: 147.1 kg. Post HD treatment weight: 143.1. There was no documentation or interventions on the treatment record addressing goal weight (EDW) not being met nor was there an RN assessment/evaluation post HD treatment.

11/03/2023: HD orders included a BFR 425 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 6:39 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 7:01 AM BFR 450 ml/min where it remained until 10:06 AM at which time the BFR was decreased to the prescribed rate of 425 ml/min for the remainder of the treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders. EDW: 140.0 kg. Pre HD treatment weight: 146.4 kg. Post HD treatment weight: 143.7. RN post assessment documentation notes that patient is 3.7 kg above goal weight, but no further interventions were documented.

11/06/2023: HD orders included a BFR 425 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 6:52 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 7:38 AM BFR 400 ml/min; 8:04 AM BFR increased to 450 ml/min for the remainder of the treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR and/or DFR to be administered at a rate different from the prescribed HD physician order rate, nor was there documentation as to why the BFR and/or DFR were not administered at the rate prescribed by the physician for any of the above dates.

MR#5 Admission Date 04/28/2023. Dialysis Treatment Records reviewed between 10/25/2023 and 11/06/2023 found the following:

10/25/2023: 11:45 AM Pre-Dialysis Assessment by PCT: BP 180/115 sitting and 177/116 standing. There was no documentation that the RN was notified of the elevated diastolic BP (DBP) prior to the start of treatment. 11:45 AM Treatment initiated. 11:53 AM BP 171/114. PCT documentation states that the RN was notified of the elevated DBP per facility policy. 12:31 AM BP 170/114 per PCT note. RN not notified of elevated DBP; 1:05 PM BP 171/114 RN notified of elevated DBP; 2:33 PM BP 204/123 RN notified of BP by PCT; 3:08 PM BP 178/110. Treatment ended. Post-Dialysis Assessment by the PCT at 3:08 PM: BP 197/110 sitting and 194/112 standing. There is no documentation that the RN was notified of the post assessment BP by the PCT. The RN pre-assessment and post-assessment note does not include any documentation addressing the elevated diastolic blood pressure during the HD treatment nor was there evidence that the physician was notified or any interventions implemented. HD orders included a BFR 400 ml/min and a DFR 600 ml/min. HD Treatment was initiated at 11:45 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 11:53 AM BFR 250 ml/min; DFR 500 ml/min; 12:31 PM BFR increased to 450 ml/min and DFR increased to 800 ml/min for the remainder of the treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders. EDW: 68 kg. Pre HD treatment weight: 79.5 kg. Post HD treatment weight: 76.8. There was no documentation or interventions on the treatment record addressing goal weight (EDW) not being met.

10/27/2023: 11:19 AM Pre-Dialysis Assessment by the PCT: BP 176/108 sitting and 178/115 standing. There was no documentation that the RN was notified of the elevated DBP prior to the start of treatment. HD Treatment was initiated at 11:28 AM. PCT documentation included the following: 11:29 AM BP 170/110; 12:02 PM BP 173/116; 12:32 PM BP 175/114; BP was not checked again for another 63 minutes at which time BP was 184/125; 2:07 PM: BP 179/109; 2:32 PM BP 165/111; 2:54 PM BP 178/112. Treatment ended. Post Dialysis Assessment by the PCT: BP 173/108 sitting and 164/99 standing. There was no documentation that the PCT notified the RN of the DBP readings above 100 mm Hg per facility policy before, during or after the HD treatment. HD orders included a BFR 400 ml/min and a DFR 600 ml/min. HD Treatment was initiated at 11:28 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 11:29 AM DFR 800 ml/min which continued for the duration of the HD treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

10/30/2023: 11:34 AM Pre-Dialysis Assessment by the PCT: BP 180/131 sitting and 175/115 standing. There was no documentation that the RN was notified of the elevated DBP prior to the start of treatment. HD Treatment was initiated at 11:50 AM by the PCT at which time BP 170/113. PCT documentation included the following: 12:32 PM BP 185/118; 1:02 PM BP 168/114; 1:34 PM BP 179/118; 2:03 PM BP 180/120. 2:25 PM - Clonidine (medication to lower BP) 0.1 mg was administered by the RN. 2:32 PM BP 185/120; 3:15 PM BP 176/124 and treatment ended. Post-Dialysis Assessment by the PCT: BP 165/100 sitting and 160/104 standing. There was no documentation that the PCT notified the RN of the DBP readings above 100 mm Hg per facility policy before, during or after the HD treatment. Other than the administration of the Clonidine, there is no documentation by the RN addressing the elevated DBP before, during or after treatment. The RN pre and post assessment note states no unusual findings. There was also no documentation addressing the effectiveness of the antihypertensive medication. HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 11:50 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: from the start of treatment at 11:50 AM to the end of treatment at 3:15 PM, the BFR was 300 ml/min, and the DFR was 500 ml/min. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR and/or DFR to be administered at a rate different from the prescribed HD physician order rate, nor was there documentation as to why the BFR and/or DFR were not administered at the rate prescribed by the physician for any of the above dates.

MR#6 Admission Date: 08/01/2023. Dialysis Treatment Records reviewed between 10/24/2023 and 11/04/2023 found the following:

10/26/2023: HD orders included a BFR 400 ml/min and a DFR 600 ml/min. HD Treatment was initiated at 10:45 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: from the start of the HD treatment until the end of treatment, the BFR was 250 ml/min and the DFR was 500 ml/min with the exception of 12:32 PM whereby the DFR was recorded as 0. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

10/31/2023: 11:26 AM Pre-Dialysis Assessment by the PCT: BP 208/121 sitting and 207/113 standing. There was no documentation that the RN was notified of the elevated SBP and DBP prior to the start of treatment. HD Treatment was initiated at 11:26 AM. PCT documentation included the following: 11:35 AM BP 215/117. RN notified; 12:08 PM BP 218/119. Patient did not take blood pressure medication before treatment. RN notified; 12:33 PM: BP 214/110. RN notified; 1:05 PM: BP 208/123. No documentation of notification to RN. 1:22 PM: BP 223/118. No documentation of notification to the RN; 2:00 PM BP 211/124. RN notified. 2:25 PM: BP 188/103. RN notified. 3:26 PM Treatment ended. Post-Dialysis Assessment by the PCT: BP 165/100 sitting and 160/104 standing. There was no documentation addressing the elevated blood pressure readings by the RN before, during or after treatment. HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 11:26 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 11:35 AM: BFR 200 ml/min and DFR 400 ml/min; 12:08 PM: BFR 200 ml/min (DFR was increased to the prescribed rate of 800 ml/min); 12:33 PM: BFR was increased to the prescribed rate of 400 ml/min. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR and/or DFR to be administered at a rate different from the prescribed HD physician order rate, nor was there documentation as to why the BFR and/or DFR were not administered at the rate prescribed by the physician for any of the above dates.

MR#7 Admission Date: 08/18/2023. Dialysis Treatment Records reviewed between 10/25/2023 and 11/06/2023 found the following:

11/01/2023: 7:20 AM Pre-Dialysis Assessment by the PCT: BP 193/96 sitting and 194/103 standing. There was no documentation that the RN was notified of the elevated SBP and DBP prior to the start of treatment. HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 7:20 AM. PCT documentation included the following: 7:27 AM: BFR 200 ml/min and DFR 400 ml/min. BP 196/106. RN notified. Patient fluid overloaded. RN increased time and goal; From 8:00 AM to the end of HD treatment at 12:16 PM, the BFR rate was 300 ml/min and the DFR rate was 500 ml/min. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders. EDW: 57.5 kg. Pre-HD treatment weight: 75.0 Post HD treatment weight: 70.2. There was no documentation or interventions on the treatment record addressing goal weight (EDW) not being met. There was no documentation of an RN assessment/evaluation post treatment.

11/03/2023: 6:52 AM AM Pre-Dialysis Assessment by the PCT: BP 236/126 sitting and 178/163 standing. There was no documentation that the RN was notified of the elevated SBP and DBP prior to the start of treatment. Treatment started at 7:02 AM. Further PCT documentation included the following: 7:31 AM: BP 218/110; 10:31 AM: BP 186/111 at which time treatment ended. There was no documentation that the RN was notified of the elevated blood pressure readings post treatment. EDW 57.5. Pre-HD treatment weight: 75.0. Post HD treatment weight: 71.6. RN documentation notes that patient is 14.1 kg above EDW, but no further inventions are noted.

11/06/2023: 6:54 AM Pre-Dialysis Assessment by the PCT: BP 198/109 sitting and 178/163 (this is not a typo) standing. There was no documentation that the RN was notified of the elevated SBP and DBP prior to the start of treatment. Treatment started at 6:54 AM. Further PCT documentation included the following: 7:39 AM: BP 205/109. RN notified; 8:32 AM BP 193/110; 9:05 AM: BP 195/109; 9:33 AM: BP 193/113. There was no notification to the RN of the elevated BP at 8:32 AM, 9:05 AM or 9:33 AM. HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 7:20 AM. The PCT documented the following BFR/DFR readings: 7:39 AM: BFR 450 ml/min and DFR 500 ml/min; 8:01 AM: BFR 400 ml/min and DFR 500 ml/min; 9:33 AM: BFR 400 ml/min and DFR 500 ml/min. There was no further documentation of BFR or DFR up until the end of treatment at 10:57 AM. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR and/or DFR to be administered at a rate different from the prescribed HD physician order rate, was there documentation as to why the BFR and/or DFR were not administered at the rate prescribed by the physician for any of the above dates.

MR#8 Date of Admission: 02/02/2017. Dialysis Treatment Records reviewed between 10/26/2023 and 11/07/2023 found the following:

11/07/2023: HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was initiated at 5?53 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 6:30 AM: BFR 400 ml/min and DFR 500 ml/min; 7:04 AM: BFR 400 ml/min; DFR 500 ml/min; 7:31 AM: BFR decreased to 350 ml/min and DFR 500 ml/min; 8:02 AM: BFR 350 ml/min and DFR 500 ml/min; 8:31 AM: BFR decreased to 325 ml/min and DFR 500 ml/min; 9:04 AM: BFR increased to 400 ml/min and DFR 500 ml/min. At approximately 9:15 AM, the surveyor directly observed the HD machine and noted that the BFR was 400 ml/min and the DFR was 500 ml/min. PCT #4 was asked by the surveyor about the discrepancy between the HD orders and the HD machine readings. The PCT #4 stated that s/he was not sure 'why the machine was doing that." PCT#4 changed the DFR to 800 ml/min and stated that s/he planned to "take the machine out of service after the end of treatment." At 9:34 AM, the BFR/DFR was recorded on the treatment record as 400 ml/min and 800 ml/min respectively, at which time treatment was ended. PCT#4 took the machine out of service at the end of the treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR and/or DFR to be administered at a rate different from the prescribed HD physician order rate, nor was there documentation as to why the BFR and/or DFR were not administered at the rate prescribed by the physician. EDW 53.5 kg. Pre Treatment Weight: 56.0 kg. Post-Treatment Weight: 54.6 kg. There was no documentation addressing goal weight not being met.

MR#9 Date of Admission: 05/09/2023. Dialysis Treatment Records reviewed between 10/26/2023 and 11/07/2023 found the following:

1026/2023: There was no RN HD post assessment/evaluation.

10/28/2023: HD Treatment was initiated at 6:18 AM. PCT documentation included the following: 6:19 AM BP 221/91; 7:06 AM: BP 200/85. There was no documentation indicating that the RN was notified of the high SBP readings per facility policy.

10/31/2023: HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was started at 5:40 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 6:31 AM: BFR 350 ml/min. The BFR remained at 350 ml/min until the end of treatment. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

11/02/2023: HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was started at 5:35 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 5:45 AM: BFR 300 ml/min and DFR 500 ml/min; 6:01 AM BFR 300 (DFR was increased to the prescribed rate of 800 ml/min). BFR remained at 300 ml/min until 8:30 AM. BFR 320 ml/min and PCT note stated, "UF off. Patient felt sick. 200 ml saline given. RN notified." 9:00 AM BFR 300 ml/min until end of treatment at 9;20 AM. The PCT post assessment note included an answer of "no" addressing the question "did pre-dialysis complaints improve by the end of dialysis treatment." There was no further documentation explaining the comment/complaints nor was there an RN note during or after completion of the HD treatment regarding assessment/evaluation of the patient. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

11/04/2023: HD treatment was initiated at 5:30 AM at which time vital signs and a machine safety check were completed. The next vital sign and machine check were not performed until 6:38 AM, 68 minutes after the last check. There was no documentation as to the reason why vital sign and machine checks were not obtained every 30 to 45 minutes per facility policy.

11/07/2023: HD orders included a BFR 400 ml/min and a DFR 800 ml/min. HD Treatment was started at 5:30 AM. The following flow rate discrepancies (when compared to the HD physician prescribed treatment) were noted: 7:34 AM: BFR 450 ml/min; 8:04: BFR 450 ml/min. At approximately 8:35 AM, the surveyor directly observed the HD machine and noted that the BFR was 450 ml/min. PCT #4 was asked by the surveyor about the discrepancy between the HD orders and the HD machine readings. PCT #4 stated that MR#9 was not his/her patient and did not know why the BFR was 450 ml/min. PCT #4 changed the BFR to 400 ml/min. The BFR recordings on the HD treatment record at 8:38 AM and 9:07 AM reflected the change to 400 ml/min. The prescribed HD treatment orders for BFR and/or DFR were not followed per physician orders.

There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR and/or DFR to be administered at a rate different from the prescribed HD physician order rate, nor was there documentation as to why the BFR and/or DFR were not administered at the rate prescribed by the physician for any of the above dates.

An interview conducted with the administrator on November 9, 2023 starting at 11:30 AM confirmed the above findings.






Plan of Correction:

V 543

For ongoing compliance, the Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on policy:

- Patient Assessment and Monitoring
- Physician Order Documentation
- Initiation of treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer
- Initiation of treatment Using an Arteriovenous Graft or Fistula and Optiflux Single Use Ebeam Dialyzer


The in-service will focus on ensuring that the physician's treatment orders are carried out as prescribed. This includes the patient care technicians (PCT) reporting any out of range finding to the registered nurse (RN). These include machine parameters such as: dialysate flow rate (DFR) and blood flow rate (BFR). The meeting will also review that monitoring and safety checks must be completed every 30-45 minutes with documentation. The reason the DFR/BFR are not being met must be documented as well as any interventions taken to remedy the issue. The in-service will also review the importance of the DPC staff reporting any abnormal vital signs (VS), including blood pressures (BP), to the RN with documentation of the notification. The RN must complete an assessment, intervene as needed and notify the physician if indicated. Staff will be informed that patients not reaching their estimated dry weight (EDW) post treatment must be reported to the RN. The RN will assess the patient prior to discharge. The nurse will document any interventions taken and physician notification if indicated.

In-servicing will be completed by December 1, 2023, and the training documentation will be on file at the facility.

The Charge Nurse (CN) or designee will perform daily audits on twenty-five percent (25%) of patients per shift for two (2) weeks. At that time if ninety-five (95) % compliance is observed the audits will then be completed 2 times/week for 2 weeks. At that time, if compliance is maintained, the audits will then follow the monthly QAPI schedule. A POC specific auditing tool will be used for the audits.

Issues of non-compliance will be addressed by the FA with re-education and counseling.

The FA will review the audit results and report the findings at the monthly QAPI meetings for ongoing oversight and compliance.

Completion Date: December 29, 2023