QA Investigation Results

Pennsylvania Department of Health
COMMONWEALTH DIALYSIS
Health Inspection Results
COMMONWEALTH DIALYSIS
Health Inspection Results For:


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Initial Comments:

Based on the findings of an unannounced, onsite Medicare complaint investigation survey conducted on November 22, 2021, with the off-site portion of the complaint investigation survey being conducted November 24, November 29, December 6 and December 8, 2021, Commonwealth Dialysis was determined to be in substantial compliance with the requirements of 42 CFR, Part 494, Subparts A, B, C, and D: Conditions for Coverage for End-Stage Renal Disease Facilities.





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 agency policies/procedures, documentation and medical records and based on interview with the medical director, the administrator, the regional operations director and the manager of clinical services, the facility failed to ensure in-center hemodialysis (ICHD) staff assessed a post-treatment standing blood pressure for two (2) of three (3) hemodialysis patients who were documented as being ambulatory prior to and after completion of the hemodialysis (HD) treatment. (Patients #1 and #3)

Findings include:

On November 22, 2021 at approximately 1:08 PM, review of facility policy 1-03-08, titled "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" revealed the following:
Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient's dialysis treatment, monitoring during the treatment and for reviewing the patient's response to the treatment and status prior to discharge...
Policy: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse.
a.Data collection includes but is not necessarily limited to...
ii. Measurement of Blood Pressure (BP)
1.Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)...

On December 6, 2021 at approximately 2:35 PM, review of the facility dimensions included on administrator's email and the "Emergency Evacuation Plan" revealed the following:
-The waiting room length is 26 feet.
-The length of the hallway to access the HD treatment room is 36 feet.
-The length of the HD treatment room is 58 feet.
-The ICHD treatment room entry door is located on the left-hand side of the facility.
-HD station #5 is next to last HD station located adjacent to the wall located on the left-hand side of the ICHD treatment room.
-HD stations #7 and #9 are located adjacent to far wall of the ICHD treatment room.
-HD station #12 is located adjacent to the wall located on the right-hand side of the ICHD treatment room.

On December 6, 2021 at approximately 1:03 PM, review of the administrative email revealed the transportation methods for the below identified ICHD patients were/are as follows:
-Patient #1 drove to/from the HD treatment.
-Patients #3 utilized a county van for transport to and from the HD treatment.

Patient #1: Review of the medical record on November 22, 2021 at approximately 10:55 AM, November 24, 2021 at approximately 1:32 PM, November 29, 2021 between the approximate times of 10:30 AM and 2:42 PM and December 8, 2021 at approximately 8:50 AM revealed chronic ICHD treatments were initiated on August 3, 2021 and that the patient was 68 years old as documented on the CMS-2728-U3 form titled "End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration".
Review of hemodialysis treatment orders dated 09/09/2021 revealed the ICHD treatment time was four (4) hours and that the ICHD treatment frequency was three (3) times a week.
Review of the interdisciplinary (IDT) plan of care (POC) documented on the "IDT Patient POC Meeting Report" revealed patient goals included "To meet or trend toward goal of pre-dialysis blood pressure of less than 140/90" but there were no post HD treatment BP goals included on the POC report dated 06/10/2021.
Review of the "IDT Patient POC Meeting Report" dated 09/24/2021 revealed the following entry was included adjacent to the pre-dialysis blood pressure goal: BP trends down on treatment per the MD (Medical Doctor/physician).
Review of the ICHD "Post Treatment" sheet dated 09/28/2021 revealed the following:
-Machine Setup:
The patient was assigned to ICHD station #5.
-Pretreatment Data Collection and Assessment:
6:49 AM: Patient ambulated with a walker and the patient offered no complaints as documented by the registered nurse (RN-employee #1).
-Vitals:
Pre-HD treatment sitting BP reading was 166/83.
-Intradialytics (during treatment) Patient Statistics:
6:28 AM: HD treatment initiated and blood pressure reading was 166/83 as documented by the PCT (employee #5).
8:31 AM: Patient moaning, states "feels fine", UF (ultrafiltration-fluid removal) off, 100 cc (cubic centimeters) of normal saline solution (NSS) administered and BP reading was 128/83 as documented by the registered nurse (RN-employee #1).
8:33 AM: BP retaken, blood sugar 175, UF off, pulse oximetry (blood oxygen reading) 99, registered nurse (RN) aware and BP reading 124/81 as documented by the certified clinical hemodialysis technician (CCHT-employee #2)
10:03 AM: Alert, UF off, patient has no signs/symptoms of low BP and BP reading was 121/77 as documented by the CCHT (employee #2).
10:33 AM: Patient feels fine, offers no complaints and BP reading was 133/80 as documented by the RN (employee #1).
10:35 AM: Treatment terminated and BP reading was 139/79 as documented by the PCT (employee #5).
-Post Treatment Data Collection and Assessment:
10:35 AM (Assessment): Patient was alert/oriented, ambulated with walker, tolerated treatment well but suffered fall after treatment and was transported to the hospital as documented by RN (employee #1).
10:48 AM (Data Collection): Patient alert, ambulated with walker and the patient offered no complaints as documented by the PCT (employee #5).
-Vitals:
Post-HD treatment sitting BP reading was 139/79.
There was no documentation in the medical record which provided evidence that the patient refused a standing blood pressure after completion of the HD treatment on 09/28/2021 and there was no documentation in the medical record which provided evidence that a post-HD treatment standing BP was assessed by the RN (employee #1), nor the PCT (employee #5), on 09/28/2021 when the patient was documented as having been ambulatory after completion of the ICHD treatment.

Patient #3: Review of the medical record on November 22, 2021 at approximately 2:00 PM, December 6, 2021 at approximately 3:42 PM and December 8, 2021 at approximately 8:57 AM revealed the admission date was 09/10/2021 and that the patient is 84 years old.
Review of hemodialysis treatment orders dated 09/24/2021 revealed the ICHD treatment time is 3.5 hours and that the ICHD treatment frequency is three (3) times a week.
Review of the "IDT Patient POC Meeting Report" revealed there were no post HD treatment BP goals included on the POC report dated 10/04/2021.
Review of ICHD "Post Treatment" sheet documentation revealed the following:
11/08/2021:
-Machine Setup:
The patient was assigned to ICHD station #7.
-Pretreatment Data Collection and Assessment:
10:05 AM (Assessment): The patient was alert/oriented, ambulated with a walker and offered no complaints as documented by the RN (employee #1).
-Post Treatment Data Collection and Assessment:
1:42 PM (Collection): The patient was alert and ambulated-no assistance needed and the patient offered no complaints as documented by the CCHT (employee #6).
-Vitals:
Pre-HD treatment sitting BP reading was 149/70.
Pre-HD treatment standing BP reading was 103/69.
Post-HD treatment sitting was BP 123/104.
11/15/2021:
-Machine Setup:
The patient was assigned to ICHD station #9.
-Pretreatment Data Collection and Assessment:
10:08 AM (Assessment): The patient was alert/oriented and the patient ambulated with a walker as documented by the RN (employee #7).
-Post Treatment Data Collection and Assessment:
1:32 PM (Assessment): Patient was alert/oriented and ambulated-no assistance needed and that the patient offered no complaints as documented by the RN (employee #8).
-Vitals:
Pre-HD treatment sitting BP reading was 149/70.
Pre-HD treatment standing BP reading was 129/60.
Post-HD Treatment sitting BP reading was 122/67.
11/17/2021:
-Machine Setup:
The patient was assigned to ICHD station #12.
-Pretreatment Data Collection and Assessment:
10:19 AM (Assessment): Patient was alert/oriented and ambulated without assistance and the patient offered no complaints as documented by the RN (employee #8)
-Intradialytics Patient Statistics:
10:23 AM: ICHD treatment initiated and blood pressure was 123/52 as documented by the RN (employee #8).
11:02 AM: "BP is low" and that the BP reading was 89/41 as documented by the RN (employee #7).
11:04 AM: Patient had taken blood pressure medication and that the BP reading was 86/40 as documented by the RN (employee #7).
11:32 AM: BP reading was 102/48 as documented by the RN (employee #7).
12:36 PM: BP reading was 65/48, 100 cc normal saline administered, UF off as documented by the CCHT (employee #2).
12:38 PM: BP reading was 107/77 and UF turned on as documented by the CCHT (employee #2).
1:02 PM: BP reading was 93/48 as documented by the RN (employee #9).
1:32 PM: BP reading was 89/46 as documented by the RN (employee #9).
1:34 PM: Bp reading was 98/43 as documented by the RN (employee #9).
1:55 PM: BP reading was 103/48.
-Post Treatment Data Collection and Assessment:
1:53 PM (Collection): The patient alert and ambulatory and the patient offered no complaints as documented by the CCHT (employee #2).
-Vitals:
Pre-HD treatment sitting BP reading was 128/78.
Pre-HD treatment standing BP reading was 133/67.
Post-HD treatment sitting BP reading was 103/58.
There was no documentation in the medical record which provided evidence that the patient refused a standing blood pressure after completion of the HD treatment on 11/08/2021, 11/15/2021 and 11/17/2021 and there was no documentation in the medical record which provided evidence that a post-HD treatment standing BP was assessed on 11/08/2021, 11/15/2021 and 11/17/2021 when the patient was documented as having been ambulatory after completion of the ICHD treatment.

During telephone interview conducted on December 6, 2021 at approximately 3:09 PM, the medical director reported that a standing BP should be assessed for patients who are capable of standing.

During telephone interview conducted on December 8, 2021 at approximately 2:01 PM, the facility administrator, regional operations director and manager of clinical services confirmed a standing BP was not assessed after completion of the ICHD for the above identified ambulatory patients on the above referenced dates.
























Plan of Correction:

The Facility Administrator or designee will hold mandatory in-services for all clinical teammates starting 12/31/2021. Surveyor observations will be reviewed. Education will include a review of Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment emphasizing that patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes but is not necessarily limited to:
1) Measurement of Blood Pressure (BP): a) sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet).
2) Abnormal finding including:
Pre dialysis:
Systolic greater than 180 mm/Hg or less than 90 mm/Hg
Diastolic greater than or equal to 100 mm/Hg
Intradialytic:
Difference of 20 mm/Hg increase or decrease from patient's last intradialytic treatment BP reading
Post Treatment:
If the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg
Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg.
3) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance is evidenced by teammate signature on in-service sheet.
The care plan for patient #3 will be reviewed and updated to include goals for both pre and post blood pressure.
The Facility Administrator or designee will perform audits on twenty five percent (25%) of the flow sheets daily for two (2) weeks, then once weekly for 2 weeks then on ten percent (10%) during monthly medical records audits to verify blood pressures are being done per policy and there is follow up for abnormal finding. In addition, all care plans completed each month will be audited to verify pre and post blood pressure goals are address when indicated. Instances of non-compliance will be addressed immediately. The results of the audits to be reviewed with teammates during homeroom meetings and with the Medical Director during Quality Assurance and Performance Improvement meetings known as Facility Health meetings with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.




494.170 STANDARD
MR-COMPLETE, ACCURATE, ACCESSIBLE

Name - Component - 00
The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.


Observations:

Based on review of agency policies/procedures, documentation and medical records and based on interview with the administrator, regional operations director and manager of clinical services, the facility failed to ensure accurate documentation was maintained in the medical record regarding the reason a post-hemodialysis (HD) treatment standing blood pressure was not assessed for two (2) of two (2) hemodialysis patients who were documented as being ambulatory after completion of the HD treatment. (Patients #1 and #3)

Findings include:

On November 22, 2021 at approximately 1:08 PM, review of facility policy 1-03-08, titled "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" revealed the following:
Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient's dialysis treatment, monitoring during the treatment and for reviewing the patient's response to the treatment and status prior to discharge...
Policy: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse.
a.Data collection includes but is not necessarily limited to...
ii. Measurement of Blood Pressure (BP)
1.Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)...


Patient #1: Review of the medical record on November 22, 2021 at approximately 10:55 AM, November 24, 2021 at approximately 1:32 PM, November 29, 2021 between the approximate times of 10:30 AM and 2:42 PM and December 8, 2021 at approximately 8:50 AM revealed chronic ICHD treatments were initiated on August 3, 2021 and that the patient was 69 years old as documented on the CMS-2728-U3 form titled "End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration".
Review of electronic data-entry screenshot (capture) documentation revealed the certified clinical hemodialysis technician (CCHT-employee #2) documented that post-HD treatment vital signs were not assessed on 09/28/2021 because the patient was unable to stand.
Review of the ICHD "Post Treatment" sheet dated 09/28/2021 revealed the following:
-Post Treatment Data Collection and Assessment:
10:35 AM (Assessment): Patient was alert/oriented, ambulated with walker, tolerated treatment well but suffered fall after treatment and was transported to the hospital as documented by RN (employee #1).
10:48 AM (Data Collection): Patient alert, ambulated with walker and the patient offered no complaints as documented by the PCT (employee #5).
-Vitals:
Post-HD treatment sitting BP reading was 139/79.
There was no documentation in the medical record which provided evidence that a post-HD treatment standing BP was assessed by the RN (employee #1), nor the PCT (employee #5), on 09/28/2021 when the patient was documented as having been ambulatory after completion of the ICHD treatment.
Patient assessment findings documented under the electronic data-entry screenshot differed from the "Post Treatment Data Collection and Assessment" findings included on the "Post Treatment" sheet dated 09/28/2021.

Patient #3: Review of the medical record on November 22, 2021 at approximately 2:00 PM, December 6, 2021 at approximately 3:42 PM and December 8, 2021 at approximately 8:57 AM revealed the admission date was 09/10/2021 and that the patient is 84 years old.
Review of electronic data-entry screenshot (capture) documentation revealed the following:
-11/08/2021: the CCHT (employee #6) documented that there was "no standing post" (BP) and under the post-vitals line, the RN documented that the patient was transported by wheelchair.
-11/15/2021: The RN (employee #8) documented that there was "no standing post" (BP) and under the post-vitals line, the RN documented that the patient was transported by wheelchair.
-11/17/2021: The RN (employee #7) documented that there was "no standing post" (BP) and under the post-vitals line, the RN documented that the patient was transported by wheelchair.
Review of the ICHD "Post Treatment" documentation revealed the following:
11/08/2021:
-Post Treatment Data Collection and Assessment--1:42 PM (Collection): The patient was alert and ambulated-no assistance needed and the patient offered no complaints as documented by the CCHT (employee #6). Vitals: Post-HD treatment sitting was BP 123/104.
11/15/2021:
-Post Treatment Data Collection and Assessment--1:32 PM (Assessment): Patient was alert/oriented and ambulated-no assistance needed and that the patient offered no complaints as documented by the RN (employee #8). Vitals: Post-HD Treatment sitting BP reading was 122/67.
11/17/2021:
-Post Treatment Data Collection and Assessment:
1:53 PM (Collection): The patient was alert and ambulatory and the patient offered no complaints as documented by the CCHT (employee #2). Vitals: Post-HD treatment sitting BP reading was 103/58.
There was no documentation in the medical record which provided evidence that a post-HD treatment standing BP was assessed on 11/08/2021, 11/15/2021 and 11/17/2021 when the patient was documented as having been ambulatory after completion of the ICHD treatment.
Patient assessment findings documented under the electronic data-entry screenshot differed from the "Post Treatment Data Collection and Assessment" findings included on the "Post Treatment" sheets dated 11/08/2021, 11/15/2021 and 11/17/2021.

During telephone interview conducted on December 8, 2021 at approximately 2:01 PM, the facility administrator, regional operations director and manager of clinical services confirmed patient assessment findings documented under the electronic data-entry screenshot differed from the "Post Treatment Data Collection and Assessment" findings included on the "Post Treatment" sheets for the above identified patients on the aforementioned dates.












Plan of Correction:

The Facility Administrator or designee will hold mandatory in-service(s) for all clinical teammates starting 12/13/21. Surveyor observations will be reviewed. Education will include a review of Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment emphasizing accurate documentation of all assessment and that patient pretreatment data will be obtained and documented by the PCT or a licensed nurse. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. All findings and interventions will be documented accurately in the patient medical record. In addition, the licensed nurses responsible for daily reconciliation of the treatments will be re-educated on Policy 3-02-15 Hemodialysis Daily/Monthly Reconciliation, Audit and Close Process emphasizing their responsibility to review Daily Audit Report for accuracy of treatments, events, and medical justification. If manual flowsheets were used, then compare the Flowsheet and Daily Audit Report for 100% accuracy, legibility and completeness and review the Flowsheet and Daily Audit Report against one another for consistency. Verification of attendance will be evidenced by teammate signature on in-service sheet.
The Facility Administrator or designee will perform audits on twenty five percent (25%) of the flow sheets daily for two (2) weeks, then once weekly for 2 weeks then on ten percent (10%) during monthly medical records audits to verify accuracy with documentation. In addition, daily reconciliation will be reviewed weekly for four (4) weeks then monthly for two (2) months to verify compliance. Instances of non-compliance will be addressed immediately. The results of the audits to be reviewed with teammates during homeroom meetings and with the Medical Director during Quality Assurance and Performance Improvement meetings known as Facility Health meetings with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.




494.170(b)(1) STANDARD
MR-COMPLETE RECORDS PROMPTLY

Name - Component - 00
(1) Current medical records and those of discharged patients must be completed promptly.


Observations:

Based on review of agency policies/procedures, documentation and medical records and based on interview with the certified clinical hemodialysis technician (CCHT-employee #2), the registered nurse (RN-employee #1), the medical director, the administrator, the regional operations director and the manager of clinical services, the facility failed to ensure the documenting clinician completed medical record corrections on the day a documentation error was identified for one (1) of two (2) patients who experienced an adverse event after completion of the in-center hemodialysis (ICHD) treatment. (Patient #1)

Findings include:

On December 6, 2021 at approximately 2:23 PM, review of facility policy 3-02-27, titled "Medical Record Corrections" revealed the following:
Purpose: The purpose of this policy is to provide guidance on the instances in which a late entry, erroneous entry, or amendment is necessary to support the integrity of the medical record.
Applicability: This policy applies to all teammates involved in the documentation of any information in a medical record...
Procedure...2. Erroneous Entries-All charting errors and charting corrections or clarifications must be handled properly to avoid loss of information, the appearance of impropriety...

On December 6, 2021 at approximately 3:55 PM, review of facility policy 3-02-15, titled "Hemodialysis Daily/Monthly Reconciliation Audit and Close Process" revealed the following:
Policy...7. Corrections, addendums, additions or late entries needed on a flowsheet, or post-treatment report, as a result of the reconciliation/audit process must be completed by the teammate who provided the service...based on their recollection of the event and must be in accordance with proper documentation guidelines. Exception: If the teammate who provided the service...is unable to, and will not be available to for an extended period, document the needed correction or addendum, another teammate who is knowledgeable is what occurred during the patient's treatment may document to verify medical record accuracy reflects the services provided. If the teammate who provided the services...will be able to make corrections or addendums prior to the month end close for the month the services were administered, the above exception would not apply...
10. The "Day Closer" and "Period Closer" are optional roles that an FA (facility administrator) may grant a teammate...If the daily audit indicates errors or omissions, the errors are flagged and given to the FA or licensed designee. The FA or licensed designee is responsible for notifying the teammate of the error. The appropriate teammates(s) will make the change...

Patient #1: Review of the medical record on November 22, 2021 at approximately 10:55 AM, November 24, 2021 at approximately 1:32 PM, November 29, 2021 between the approximate times of 10:30 AM and 2:42 PM and December 8, 2021 at approximately 8:50 AM revealed chronic ICHD treatments were initiated on August 3, 2021 and that the patient was 69 years old as documented on the CMS-2728-U3 form titled "End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration".
Review of the ICHD "Post Treatment" sheet dated 09/28/2021 revealed the following was documented under Intradialytics (during treatment) Patient Statistics:
-8:31 AM: The "Notes" column entry revealed the registered nurse (RN-employee #1) documented the following assessment findings: Patient moaning, patient "feels fine", UF was turned off and that 100 cc of NSS was administered.
-10:33 AM: The "Notes" column entry revealed the RN (employee #1) documented the following assessment findings: Patient reported that the patient felt fine and patient offers no complaints.
-Post Treatment Data Collection and Assessment: 10:35 AM (Assessment): Patient was alert/oriented, ambulated with walker, tolerated treatment well but suffered fall after treatment and was transported to the hospital as documented by RN (employee #1).
Review of the Post Treatment-Flowsheet History tracking form dated 09/28/2021 revealed the following:
-8:31 AM: There were no "Notes" entered by the RN (employee #1) under the "New Value" column.
-8:33 AM: The "Notes" entered by the CCHT (employee #2) at 8:42 AM under the "New Value" column were as follows: Patient moaning, patient states the patient feels fine, UF off, 100 cc NSS administered and oxygen administered at 3 liters per minute.
-10:33 AM: There were no "Notes" entered by the RN (employee #1) under the "New Value" column.
-10:35 AM: The "Notes" entered by the PCT (employee #5) at 10:47 AM in under the "New Value" column were as follows: Patient feeling much better. Patient offers no complaints.
-At 2:06 PM on 09/28/2021, the RN (employee #1) modified the above referenced entry documented by the CCHT (employee #2) to read patient moaning, patient "feels fine", UF off and that 100 cc NSS was administered which was the entry included the "Post Treatment" flowsheet at 8:31 AM.
-At 3:14 PM on 09/28/2021, the RN (employee #1) modified the above referenced entry documented by the PCT (employee #5) to read patient feels fine and patient offers no complaints which was the entry included the "Post Treatment" flowsheet at 10:33 AM.
During telephone interview conducted on December 6, 2021 at approximately 2:54 PM, the CCHT (employee #2) reported that the oxygen concentrator had been transported to the patient's hemodialysis station on 09/28/2021 and that CCHT thinks that oxygen may have been applied. The CCHT reported that oxygen may have been discontinued at the direction of the RN (employee #1) because the patient's pulse oximetry reading was normal. The CCHT confirmed that CCHT did not modify the entry which was documented by the CCHT on 09/28/2021 at 8:42 AM.
During telephone interview conducted on December 6, 2021 at approximately 2:29 PM, the RN (employee #1) reported that the RN can make corrections to the "Post Treatment" sheet entries after consultation with clinical staff. The RN reported that the RN corrected the entry completed by the CCHT (employee #2) because oxygen was not administered to the patient. The RN was unable to provide an explanation as to why the RN (employee #1) corrected the entry instead of the documenting clinician/CCHT (employee #2). The RN (employee #1) confirmed the RN corrected the entry made by the PCT (employee #5) because the patient did not state that the patient felt "bad". The RN was unable to provide an explanation as to why the RN (employee #1) corrected the entry instead of the documenting clinician/PCT (employee #5).
There was no documentation in the medical record which provided evidence that the RN (employee #1) had notified the CCHT (employee #2) and the PCT (employee #5) that a documentation error on the 09/28/2021 "Post Treatment" sheet was identified nor that the CCHT (employee #2) and the PCT (employee #5) had completed the correction of the errors identified by the RN (employee #1) on 09/28/2021.

On December 8, 2021 at approximately 8:18 AM, review the email from the administrator dated 12/06/2021 revealed the CCHT (employee #2) and the PCT (employee #5) worked from 5:00 AM to 4:00 PM on 09/28/2021. Comparison of the times included in the administrator's email and the Post Treatment-Flowsheet History tracking form entries revealed employee #2 and employee #5 were on duty when the RN (employee #1) made the corrections to patient #1's medical record on 09/28/2021.

During telephone interview conducted on December 6, 2021 at approximately 3:09 PM, the medical director reported that the documenting clinician should complete medical record corrections but that the RN overseeing patient care may make corrections if the documenting clinician is unable to complete the correction.

During telephone interview conducted on December 8, 2021 at approximately 2:01 PM, the facility administrator, regional operations director and manager of clinical services confirmed that medical record corrections were not completed by the documenting clinicians on the day a documentation error was identified for the above referenced patient.













Plan of Correction:


The Facility Administrator or designee will hold mandatory in-service(s) for all clinical teammates starting 12/13/21. Surveyor observations will be reviewed. Education will include: 1) a review of Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment emphasizing accurate documentation of all assessment and that patient pre-treatment data will be obtained and documented by the PCT or a licensed nurse. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. All findings and interventions will be documented accurately in the patient medical record. 2) A review of Policy 3-02-15 Hemodialysis Daily/Monthly Reconciliation, Audit and Close Process emphasizing their responsibility to review Daily Audit Report for accuracy of treatments, events, and medical justification. If manual flowsheets were used, then compare the Flowsheet and Daily Audit Report for 100% accuracy, legibility and completeness and review the Flowsheet and Daily Audit Report against one another for consistency. If an error in documentation is found, the FA or licensed designee is responsible for notifying the teammate of the error who should correct the error in a timely manner and/or document as a late entry if needed. The appropriate teammates(s) will make the change. Verification of attendance is evidenced by teammate signature on in-service sheet.
The Facility Administrator or designee will perform audits on twenty five percent (25%) of the flow sheets daily for two (2) weeks, then once weekly for 2 weeks then on ten percent (10%) during monthly medical records audits to verify accuracy with documentation. In addition, daily reconciliation will be reviewed weekly for four (4) weeks then monthly for two (2) months to verify compliance. Instances of non-compliance will be addressed immediately. The results of the audits to be reviewed with teammates during homeroom meetings and with the Medical Director during Quality Assurance and Performance Improvement meetings known as Facility Health meetings with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction