Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on January 28, 2021, Liberty Dialysis - Washington Llc 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 January 28, 2021, Liberty Dialysis - Washington Llc 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:
494.80(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 a review of facility policy, medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure staff assessed the patient's Intradialytic blood pressures every 30 minutes and monitored the patients for adverse effects of dialysis treatment for five (5) of seven (7) MR reviewed. (MR1, MR3, MR4, MR5, MR7)
Findings Included:
Facility policies were reviewed on 1/28/2021 at approximately 11:30 a.m. Patient Assessment and Monitoring policy read "During treatment the registered Nurse will assess/reassess any findings addressed pre or during treatment as needed. Post treatment ... If any changes or abnormal findings in the patient ' s condition, vital signs, or vascular access are observed, the PCT/LPN MUST report the changes in the patient condition to a registered nurse who will further assess the patient prior to discharge after the treatment. 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 regulations, Document machine parameters and safety checks every 30 minutes or more 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 ... Report to the nurse Systolic blood pressures greater than 180 mm/Hg, ... Blood pressure less than or equal to 100 mm/Hg systolic ..." The Nursing Supervision and Delegation policy read "Daily Treatment Record Review: Prior to discharge, The RN must review the treatment record to: Confirm patient is stable for discharge, ...The record must be reviewed for: ... Low or high blood pressures ... The following criteria can be used as a guideline to identify when a PCT/LPN shall refer a patient to the Team Lead/Charge nurse for further assessment Pre, during or post treatment. The Team Lead/Charge nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. ... A drop in systolic BP of 20 mm/HG between sitting and standing. ..."
Review of MR1 on 1/26/21 at approximately 12:15 p.m. revealed: admission date of 11/5/2020, 9 treatment sheets reviewed dated between 1/5/2021 and 1/23/2021.
1/7/2021 patient was assessed at 11:06 a.m. patient was not assessed again until 12:06 p.m. [60 minutes between assessments]
1/14/2021 patient was assessed at 1:12 p.m. patient was not assessed again until 2:13 p.m. [61 minutes between assessments]
1/16/2021 at 2:43 p.m. patients blood pressure [BP] was 157/70 sitting and 120/64 standing at the end of treatment [a drop in systolic BP of 20 mm/Hg], comment at 3:02 p.m. read "patient stable post treatment" by EMP3/Patient Care Technician (PCT). MR does not contain evidence BP was rechecked, RN was notified, or RN assessed prior to discharge.
1/23/2021 patient was assessed at 11:27 a.m. patient was not assessed again until 12:28 p.m. [61 minutes between assessments]
Review of MR3 on 1/26/21 at approximately 1:50 p.m. revealed: admission date of 11/20/2020, 8 treatment sheets reviewed dated between 1/4/2021 and 1/22/2021.
1/4/2021 at 6:57 a.m. patients BP was 181/93, comments read "denies complaints, access visible" by EMP3/PCT.
BP was 185/91 at 8:30 a.m., comment read "denies complaints, access visible" by EMP4/Certified Clinical Hemodialysis Technician (CCHT).
BP was 180/90 at 8:58 a.m., comment read "denies complaints, access visible" by EMP4/CCHT.
BP was 195/89 at 9:28 a.m., comment read "patient alert, access visible" by EMP5/LPN.
BP was 209/86 at 9:50 a.m. comment read "denies complaints, access visible" by EMP4/CCHT.
BP sitting was 190/97, standing 145/95 at 10:33 a.m. by EMP3/PCT.
Comment at 12:33 p.m. "pt stable post tx" by EMP3/PCT.
MR does not contain evidence BP was rechecked, RN was notified, or RN assessed prior to discharge.
Review of MR4 on 1/27/21 at approximately 2 p.m. revealed: admission date of 5/30/2011, 8 treatment sheets reviewed dated between 1/4/2021 and 1/22/2021.
1/8/2021 at 11:18 a.m. patients BP was 93/66 sitting and 90/60 standing at the end of treatment, discharged to home at 12:18 p.m. by EMP3/PCT at 3:02 p.m. MR does not contain evidence BP was rechecked, RN was notified, or RN assessed prior to discharge.
Review of MR5 on 1/28/21 at approximately 9:15 a.m. revealed: admission date of 7/20/2020, 8 treatment sheets reviewed dated between 1/4/2021 and 1/22/2021.
1/6/2021 patient was assessed at 5:59 a.m. patient was not assessed again until 7:03 a.m. [64 minutes between assessments]. At 8:52 a.m. patients BP was 77/51, comment read "denies complaints" by EMP7/CCHT. MR does not contain evidence BP was rechecked, RN was notified.
1/8/2021 at 8:27 a.m. patients BP was 84/57 by EMP6/CCHT.
BP was 87/56 at 8:49 a.m. by EMP6/CCHT.
BP was 91/46 at 9:14 a.m. by EMP6/CCHT.
BP was 72/46 at 10:04 a.m. by EMP6/CCHT.
BP sitting was 94/56, standing 98/58 at 10:13 a.m. by EMP6/CCHT.
Comment at 10:31 a.m. "pt stable when d/c" by EMP6/CCHT.
MR does not contain evidence BP was rechecked, RN was notified, or RN assessed prior to discharge.
1/13 at 8:15 a.m. BP was 92/64 comments read "denies complaints" by EMP7/CCHT.
BP was 96/58 at 8:46 a.m. by EMP7/CCHT.
BP was 84/54 at 9:09 a.m. comments read "denies complaints" by EMP4/CCHT.
BP was 84/59 at 9:31 a.m. comments read "sleeping" by EMP7/CCHT.
BP was 63/47 at 9:36 a.m. comments read "200 nss [normal saline solution] given, chair back, recheck denies complaints" by EMP4/CCHT. BP was 102/69 at 9:56 a.m.
MR does not contain evidence BP was rechecked, RN was notified, or RN assessed prior to discharge.
Review of MR7 on 1/28/21 at approximately 10:45 a.m. revealed: admission date of 12/19/2019, 2 treatment sheets reviewed dated between 1/3/2021 and 1/23/2021.
1/14/2021 patient was assessed at 11:47 a.m. patient was not assessed again until 12:45 p.m. [58 minutes between assessments]
Interview on 1/28/2021 from approximately 11:45 a.m. to 1 p.m. with EMP1 and EMP2 confirmed the findings.
Plan of Correction:V 504
To ensure compliance the Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on policy:
- Patient Assessment and Monitoring
Emphasis will be placed on ensuring that vital signs (VS) including blood pressures (BP) are monitored every 30 minutes, with documentation of the VS within thirty (30) to forty-five (45) minutes. The in-service will also review that staff must notify the registered nurse (RN) of any VS that are outside of the policy parameters and document the notification. The RN must assess the patient for the abnormal findings. The RN staff were informed that any changes in VS during treatment will be re-assessed prior to discharge with documentation of assessment, interventions and notification of physician if necessary.
The inservicing will be completed by 2/11/2021 with documentation of the training on file at the facility.
The CM or designee will perform random daily audits on twenty percent (20%) of flowsheets on each shift, for two (2) weeks. At that time if one-hundred (100)% compliance is observed the audits will then be completed 2x/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly Quality Assessment Improvement (QAI) schedule. A Plan of Correction (POC) specific audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee.
Completion Date: 3/12/2021
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