QA Investigation Results

Pennsylvania Department of Health
ARA DIALYSIS UNIT AT OHIO VALLEY HOSPITAL LLC
Health Inspection Results
ARA DIALYSIS UNIT AT OHIO VALLEY HOSPITAL LLC
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite Medicare recertification survey completed on November 1, 2021, ARA Dialysis Unit at Ohio Valley Hospital 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 unannounced onsite Medicare recertification survey completed November 1, 2021, ARA Dialysis Unit at Ohio Valley Hospital LLC was identified to have the following standard level deficiency that was 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:




494.90(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/procedures, medical records (MR), dialysis treatment documentation and interview with the Clinical Manager (EMP) it was determined that the facility failed to follow it's policy for reporting and documentation of abnormal findings pre, post, and during dialysis and failed to provide the necessary care and services to manage the patient's volume status for one (1) of five (5) medical records reviewed (MR#2).

Findings include:

A review of policy titled "Hypertension" on 11/1/21 at approximately 10:30 a.m. Signs-systolic blood pressure >160, diastolic blood pressure >100, increase in systolic blood pressure >20 points from previous...Procedure ... 2. Assess current BP, 3. compare to previous reading or trends from last treatment, 4. Assess fluid status/edema, compare to EDW, 5. Assess patient for any symptoms, inquire about medications taken today, 6. If indicated per Standing Orders/Unit Policy, administer prn anti-hypertensive...

A review of policy titled "Obtaining Patient Weight" on 11/1/21 at approximatley 10:45 a.m.
Description: To determine patients weight pre-treatment and post-treatment. Accurate weight combined with a thorough assessment is the best indicator for the dialysis patient's fluid status. Procedure: ...3. Obtain weight from digital reading on scale and record immediately...6. Notify Charge RN if any abnormal findings. Post treatment: 7. Notify Charge RN if post weight is higher than pre-weight or if patient is >1 kg from EDW. 8. If post weight significantly varies from EDW verify net UF in machine and double check patient's post weight...9. Track patient's post weight trends per facility procedure. 10. Notify attending physician of any variances from estimated dry weight more than 2 kg, weekly or more often if indicated by nursing assessment.

A review of medical records was conducted on 10/29/21 between approximately 1:45 p.m. and 3:00 p.m.

A review of dialysis treatment records was conducted on 11/1/21 between 9:00 a.m. and 10:30 a.m..

MR #2, Admit date: 10/1/21, Dialysis treatment orders from 10/1/21: Hours: 3.5, Times/week: 3, Dialyzer: F 160, BFR- Blood Flow Rate: 400, DFR- Dialysate Flow Rate: 800, Dialysate: Na 140, K 2.0, Ca 2.5, Bicarb 40, Temperature 37. Clonidine 0. 1mg PO for systolic blood pressure >180 for two hours may repeat x 1 in one hour if BP remains elevated, notify MD.

Treatment record for 10/8/21: Time on: 08:15 a.m.: Pre treatment: No documented evidence of the EDW value. 12:05 p.m. Post treatment: Post weight w/in 1 kg +/- EDW?- no documented evidence of EDW addressed.

Treatment record for 10/11/21: Time on: 08:18 a.m.: Pre treatment: No documented evidence of the EDW value. 12:00 p.m. Post treatment: Post weight w/in 1 kg +/- EDW?- Y, N with an up arrow noted for the result.
08:15 a.m. Pre treatment blood pressure-194/113
08:18 a.m. B/P-219/129 Notes: "Tx started. B/P (arrow pointing up)"
09:00 a.m. B/P-119/113 Notes: "No complaints"
09:30 a.m. B/P-197/115
10:00 a.m. B/P-189/105 Notes: "Resting"
10:30 a.m. B/P-176/104 Notes: "Sleeping"
11:00 a.m. B/P-177/102 Notes: "Stable"
11:30 a.m. B/P-171/103 Notes: "Resting"
11:48 a.m. B/P-170/116 Notes: "Rinsed back"
Post treatment B/P-170/112
No documented evidence B/P addressed per policy.

Treatment record for 10/13/21: Time on: 09:22 a.m.: Pre treatment: No documented evidence of the EDW value. 12:05 p.m. Post treatment: Post weight w/in 1 kg +/- EDW?- no documented evidence of EDW addressed. Pre treatment findings indicated that patient took Midodrine pre treatment (used to treat low blood pressure). Blood pressures documentation as follows:
09:00 a.m. Pre treatment blood pressure-204/111.
09:22 a.m. B/P-203/115
09:30 a.m. B/P-211/110
10:00 a.m. B/P-206/113
10:30 a.m. B/P-202/115
11:00 a.m. B/P-201/106
11:30 a.m. B/P-193/110
No documented evidence that blood pressure was addressed during treatment, at treatment end or in post treatment assessment.

Treatment record for 10/15/21: Time on: 08:10 a.m.: Pre treatment: No documented evidence of the EDW value. 12:00 p.m. Post treatment: Post weight w/in 1 kg +/- EDW?-
no documented evidence of EDW addressed.
08:00 a.m. Pre treatment blood pressure-216/124
08:30 a.m. B/P-200/118 Notes: "Resting B/P high"
09:00 a.m. B/P-143/106 Notes: "Sleep"
09:30 a.m. B/P-193/106 Notes: "Sleep"
10:00 a.m. B/P-185/104 Notes: "Sleep"
10:30 a.m. B/P-176/105 Notes: "Sleep"
11:00 a.m. B/P- 167/97 Notes: "Complaints of being hot"
No documented evidence B/P addressed per policy.
No follow-up note addressing blood pressure from RN after PCT documentation or in RN discharge note.

Treatment record for 10/18/21:
07:00 a.m. Pre treatment blood pressure-218/102
07:30 a.m. B/P-218/101 Notes: "Sleeping"
08:00 a.m. B/P-218/108 Notes: "Sleep"
08:30 a.m. B/P-214/103 Notes: "Resting"
09:00 a.m. B/P-215/90 Notes: "Sleep"
09:30 a.m. B/P-213/107 Notes: "Sleep"
10:00 a.m. B/P-illegible Notes: illegible
10:30 a.m. B/P-223/107 Notes: "No complaints"
Post treatment B/P-205/100
No documented evidence B/P addressed per policy.
No follow-up note addressing blood pressure from RN after PCT documentation or in RN discharge note.

Treatment record for 10/20/21:
07:15 a.m. Pre treatment B/P-197/101
07:22 a.m. B/P-216/114 Notes: "Treatment started"
07:30 a.m. B/P-225/124
08:00 a.m. B/P- no blood pressure documented, no notes documented
08:30 a.m. B/P-219/119
09:00 a.m. B/P-217/122 Notes: "Stable"
09:30 a.m. B/P-204/115 Notes: "Stable"
10:00 a.m. B/P-179/109 Notes: "Watching TV"
10:30 a.m. B/P-159/99 Notes: "Resting"
11:00 a.m. B/P-152/106 Notes: "Treatment completed"
No documented evidence B/P addressed per policy. Missing B/P recording 08:00 a.m.

Treatment record for 10/22/21: 12:00 p.m. Post treatment: Post weight w/in 1 kg +/- EDW?- no documented evidence of EDW addressed.
Pre treatment B/P-219/114 no time documented
08:12 a.m. B/P-229/120 Notes: "Treatment started"
08:30 a.m. B/P-221/112 Notes: "Stable"
09:00 a.m. B/P-106/79 Notes: "Sleeping"
09:30 a.m. B/P-207/111 Notes: "Sleeping"
10:00 a.m. B/P-215/97 Notes: illegible
10:30 a.m. B/P-200/123 Notes: illegible
11:00 a.m. B/P-192/115 Notes: illegible
11:30 a.m. B/P-176/117 Notes: illegible
11:45 a.m. B/P-159/86 Notes: "Treatment ...illegible"
No documented evidence B/P addressed per policy.

An interview with the Clinical Manger on 11/1/21 at approximately 11:00 a.m. confirmed the above findings.

Repeat deficiency: 1/15/2020, 9/28/18, 10/30/17.













Plan of Correction:

V 543

An in-service was initiated to all DPC staff and the Interdisciplinary Team (IDT) on 12/1/21 by the Clinic Manager regarding the importance assessing and managing patients with hypertension and on following physician's orders and the facility policy on charge nurse (CN) notification for hypertensive patients. Specific emphasis was placed on the revision to the Hypertension procedure with removal of the parameter of reporting DBP>100mmHG, to ensure that it mirrors the reporting parameters as set in the facility standing order with signs of hypertension being set at "Systolic blood pressure (SBP) >180 mmHg." Following the facility standing order was also reinforced during the in-service and states to give "Clonidine 0.1mg PO for systolic blood pressure (BP) that has been greater than 180 mmHg for two hours (may repeat x 1)." The following was also discussed during the in-service:
Hypertension:
- All DPC staff must report patients with an SBP >180 mmHg to the nurse in charge.
- The nurse in charge must complete an assessment of the patient and follow the facility standing order for administering Clonidine (unless different specific parameters for the patient was ordered by the physician and documented on the patient's medical record).
- The nurse in charge is to follow up with the patient, in a timely manner, to ensure that clonidine administered was effective. If patient's SBP remains elevated the physician is notified for further orders, if indicated.
- No patient is to be discharged from the facility with an SBP >180 mmHg without notifying the nurse in charge, who will notify the patients physician for further orders, if indicated.
- The facility quality indicator for SBP is for all patients to have a post dialysis sitting SBP of <160mmHG. The patients post sitting SBP must be entered into the clinic portal (the facilities computerized tracking system) to monitor and report those patients not meeting goal, to the patient's physician.
- The nurse in charge must ensure that all assessment, intervention, and follow up assessment findings is documented on the patient treatment record. As well as, any notifications to, or orders received by the patient's physician.
Estimated Dry Weight (EDW):
- Each patient must have evidence of a physician order for the EDW on their medical record and this must be documented on the daily treatment sheet.
- A post treatment assessment of the patients EDW must be conducted to ensure the patient's post weight is within 1 kg +/- their EDW and that there is no evidence of fluid overload, such as edema or abnormal lung sounds.
- If the patient's post treatment EDW is > 1kg +/-, the nurse in charge must be notified, and the nurse in charge must notify the patient's physician for further orders if indicated.
- Each patients pre and post weight will be entered onto the Fluid Management Report in the clinic portal at the end of each treatment day. The CN will review this report and if the patient is not achieving their EDW for 3 consecutive treatments, the physician must be notified, the patient evaluated, and a new EDW obtained, if indicated.
Treatment safety checks:
- Per policy, safety checks must be conducted every 30 minutes during the treatment to ensure the patient vital signs, including blood pressure, is stable and this must be documented on the patient treatment record. It is unacceptable to miss these 30-minute checks.
- Also, per policy, all entries must be legible.
- Documentation of the 30-minute safety checks and all documentation on the treatment record must be legible in order for staff to safely determine the patient's condition and progression throughout the dialysis treatment.
The IDT team will meet with patient #2 by 11/29/21 to address incidents of hypertension and barriers to meeting their blood pressure goals. The IDT will establish goals and reasonable timelines in order for patient to achieve their individualized blood pressure goals (including evaluating the patient current EDW). This information will be documented in the patient Comprehensive Assessment and Plan of Care (CA/POC). All active patient records have been reviewed and any patient not meeting their individualized blood pressure goals will have a CA/POC implemented by the IDT to establish goals and reasonable timelines in order for the patient to achieve their individualized blood pressure goals.
The nurse in charge will round on all patients, at least twice per shift, to ensure (A CN rounding tool was developed to monitor this action:
- DPC staff are reporting incidents of patient with SBP >180 mmHG, and that there is documentation on the medical record that the charge nurse was notified and the patient's physician was notified, if need be, and that the standing orders and facility procedure are followed as outlined above.
- After each shift of patients has completed treatments, the CN is to review the treatment records and verify the BP's are being reported as outlined above.
- Additionally, the CN will enter the patient's post sitting SBP on the SBP tracking report into the clinic portal. Any patient not meeting a post sitting SBP <160mmHG will be reported to the patient's physician, at the end of the week, for further review and orders if indicated. Those patient's continually not meeting the goal will be referred to the IDT and a CA/POC will be implemented by the IDT to establish goals and reasonable timelines in order for the patient to achieve their individualized blood pressure goals.
- Additionally, the CN is to review the post treatment records to ensure the patient's pre and post EDW was assessed and patient is not discharged with a post treatment weight > 1kg +/- their EDW, without notifying the CN. Any patient not meeting their EDW for 3 consecutive treatments will be reported to the patient's physician for further orders, if indicated. Those patient's continually not meeting the goal will be referred to the IDT and a CA/POC will be implemented by the IDT to establish goals and reasonable timelines in order for the patient to achieve their individualized blood pressure goals.
- Additionally, all records will be reviewed by the CN to ensure there are no missed 30-minute safety checks and that all treatment documentation is legible. Any discrepancies will be reported to the CM immediately.
The clinic manager will spot check one day of treatment records once a week for the next 12 weeks to ensure (A CM monitoring tool has been developed to document these findings):
- SBP's are being reported to the nurse in charge and Clonidine is being administered as outlined above.
- The CN is conducting a reassessment of the patient to ensure the patient's SBP has improved and if not, the physician is notified and this is documented on the patient's treatment record.
- All pre and post assessments of the patient EDW is documented on the treatment sheet and that no patient is discharged with a post treatment weight > 1kg +/- their EDW, without notifying the CN.
- All DPC staff are recording each 30-minute safety check and that all entries onto the treatment record are legible.

The clinic manager will ensure compliance by direct review of the treatment records and through review of the charge nurse rounding tool. Additionally, as a member of the IDT and Total Quality Management (TQM) team, the CM will ensure compliance through review of the SBP tracking report and the Fluid Management Summary Report monthly prior to the TQM meeting where all outliers will be discussed and appropriate interventions taken to achieve goal, such as initiation of an individualized CA/POC by the IDT to establish goals and reasonable timelines in order for the patient to achieve their fluid management goals. The findings from the CM monitoring tool and CN rounding tool will also be reviewed at the monthly TQM meeting where additional action will be taken by the committee such as continuing the weekly CM monitoring and/or disciplinary action.