There are  13 surveys for this facility. Please select a date to view the survey results.

1. All clinical staff will be retrained by the Nurse Manager or Designee by 8/30/2024 on the facility's "Weight" policy. Training on these policies will be conducted with emphasis on (1) careful monitoring of patient when weighing patients before and after initiation of treatment, (2) notifying an RN (registered nurse) if a patient's weight is (1) one kg (kilogram) above or below the EDW (estimated dry weight) post treatment, (3) evaluating patient's post weight to EDW before patient is discharged from the clinic, (4) appropriately documenting on the patient's flowsheet that the RN is notified when the patient's weight is outside the 1 (one) kg parameter of the EDW, and (5) appropriately documenting on the nursing assessment addressing the post weight when outside of the 1 (one) kg parameter of the EDW.

2. Nurse Manager or Designee will ensure that all clinical staff review and sign acknowledgement of understanding of policy. Acknowledgement will be placed in facility's education manual and/or employee's personnel file.

3. Initially, Nurse Manager and/or Designee will audit 50% of the treatment flow sheets daily for one (1) week to ensure that staff is following the policy with emphasis on proper evaluation and documentation of post weight and EDW. If standards are met, 50% of the treatment flow sheets will be audited weekly for four (4) weeks. If standards are met, 50% of the treatment flow sheets will be audited monthly for three (3) months. If standards are met, 50% of the treatment flow sheets will be audited semi-annually. The audit results will be reviewed at monthly QAPI meetings.

1. The facility policy titled "Central Venous Catheter (CVC) Removal Protocol, will be eliminated and the following will be added to the "Vascular Access" portion of the Hemodialysis Standing Orders: For new Fistulas (1) Week One – If patient has a catheter: use one 17 gauge needle for the arterial line and on limb of catheter for venous line at BFR < 300 ml/min. (2) Week One – If patient does not have a catheter: use two 17 gauge needles at BFR < 300 ml/min. (3) Week Two – Use two 17 gauge needles at a blood flow rate < 300 ml/min. If cannulation attempts are unsuccessful on two occasions, refer for access intervention. (4) Week Three – Use two 16 gauge needles at a blood flow rate < 350 ml/min. If catheter present: After six successful cannulations, arrange to have catheter removed. (5) Week Four – Use two 16 gauge needles at a blood flow rate < 350 ml/min. (6) Week Five – Use two 15 gauge needles at a blood flow rate < 500 ml/min. (7) Complications: If any vascular access event occurs, such as an infiltration or any other "unsuccessful" cannulation, let AVF "rest" for one week, and then start new protocol on following treatment. If fistula infiltrates a second time, refer for access intervention.

2. All clinical staff will be retrained by the Nurse Manager or Designee by 8/30/2024 on the facility's revised "Hemodialysis Standing Orders" with emphasis on the "Vascular Access" portion of the Hemodialysis Standing Orders.

3. The Nurse Manager or Designee will ensure that all clinical staff review and sign acknowledgement of understanding of the revised "Hemodialysis Standing Orders" – Vascular Access. Acknowledgement will be placed in facility's education manual and/or employee's personnel file.

4. Nurse Manager and/or Designee will perform a record review on all newly admitted patients monthly for (6) months to ensure that the Vascular Access protocol of the Hemodialysis Standing Orders is being followed appropriately. If standards are met, the record review will be performed semi-annually. The audit results will be reviewed at monthly QAPI meetings.