QA Investigation Results

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


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Initial Comments:


Based on the findings of an onsite unannounced Medicare complaint survey concluded on March 4, 2021, Cheltenham Dialysis was identified to have the following standard level deficiency that was determined to be in substantial compliance with the 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 review of facility policy, clinical records (CR), facility grievance documentation, Governing Body Meeting minutes, and staff interviews, the facility did not follow its policy regarding blood pressure management for five (5) of six (6) CR's (CR#1, 2, 3, 4, and 6.) and did not follow its policy regarding vitals signs and treatment monitoring for one (1) of six (6) CR's, (CR #3.)

Findings include:

A review of policy 1-03-08 "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" on 3/4/2021 at approximately 11:30 AM states: "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 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 ...2. Intradialytic BP in the sitting/reclined or supine position ...v. Patients ' report of well-being, level of pain or discomfort, complaints, ...2. The nursing assessment will be performed and documented by a licensed nurse ...Pre-Treatment Data Collection/Assessment: 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to " Abnormal Findings " section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient ' s condition. 6. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The physician will be notified of any concerns that may preclude the initiation of dialysis ...Intradialytic Data Collection/Assessment: ...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring. i. For non-nocturnal treatments is completed at least every thirty (30) minutes ...b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate ...vi. Patient subjective statement(s) i.e., patient report on overall health, any complaints ...11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to " Abnormal Findings " section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary ...13. All findings, interventions, and patient response will be documented in the patient ' s electronic health record. 14. Additional documentation if applicable includes the following: a. All medications including time administered, dose, route, and initials of person administering the medication. b. Indication and patient response to PRN medication ...Post Treatment Data Collection/Assessment: 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. Licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician is necessary prior to discharge of the patient from the facility. Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient ' s electronic health record. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient ' s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time ...Blood Pressure: Pre dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg, Diastolic greater than or equal to 100 mm/Hg. Blood Pressure: Intradialytic: Difference of 20 mm/Hg increase or decrease from patient ' s last intradialytic treatment BP reading ...Blood Pressure: 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. If patient is not able to stand, document reason and sitting BP. Sitting BP for patient ' s that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg, Sitting diastolic BP greater that 90 mm/Hg or less than 50 mm/Hg ... "

A review of CR's was conducted on 3/4/2021 from approximately 9:45 am to 11:30 am.

CR #1 Admission date: 5/15/15. Medication order for blood pressure: Clonidine 0.1 milligrams by mouth, give if systolic blood pressure is greater than or equal to 170. Can repeat times one only if heart rate is greater than or equal to 70. Document blood pressure and that Clonidine was offered. Document if patient accepts or refuses Clonidine.

Review of treatment sheets revealed the following:

Treatment record for 2/1/2021:
07:05 am BP 164/80 HR 73 " no complaints " documented by PCT
07:34 am BP 171/68 HR 78 " eyes closed resting comfortably hypertension " documented by PCT
08:04 am BP 161/90 HR 83 " no complaints " documented by PCT
08:34 am BP 165/79 HR 79 " patient watching television " documented by PCT
09:04 am BP 184/79 HR 81 " patient going up patient stable " documented by PCT
09:06 am BP 179/86 HR 82 " no complaints " documented by PCT Medication record documents blood pressure medication Clonidine 0.1 milligrams (mg) with status stating " given " by mouth to patient by nurse at 09:08 am for BP of 179/86 HR 82. Medication note states " give Clonidine 0.1 mg to patient if systolic blood pressure (SBP) is greater than or equal to 170. Can repeat times 1 (one) only if heart rate (HR) is greater than or equal to 70. Document BP and that Clonidine is offered. Document if patient accepts or refuses Clonidine. "
09:34 am BP 189/81 HR 80 " no complaints " documented by PCT 09:48 am BP 173/82 HR 82 " treatment ended with 300 normal saline (NSS) rinse " by PCT.
Post-treatment standing BP of 173/82 HR 65 is documented at 09:50 am by PCT.
No post-treatment data collection or assessment is documented by the PCT or the nurse.
Discharge status: discharged to home or self-care.

There is no documentation stating the nurse was notified of abnormal findings and no documentation that a second dose of Clonidine was offered to patient for continued documented high blood pressure.

Treatment record for 2/3/2021:
08:04 am BP 173/75 HR 75 " patient watching television " documented by PCT
08:34 am BP 172/82 HR 76 " clonidine given at request " documented by nurse.
Medication record documents Clonidine 0.1 mg given at 08:40 am by nurse. No BP recorded on medication record.
09:04 am BP 180/87 HR 83 " no complaints " documented by PCT
09:33 am BP 185/83 HR 89 " treatment terminated with 250 ml normal saline rinse back " documented by PCT
Post-treatment standing BP 176/75 HR 81documented by PCT
No post-treatment data collection or assessment is documented by PCT or nurse.
Discharge status: Discharged to home or self-care.

There is no documentation stating the nurse was notified of abnormal findings and no documentation that a second dose of Clonidine was offered to patient for continued documented high blood pressure.

Treatment record for 2/10/2021:
06:35 am BP 150/74 HR 74 " patient watching television " documented by nurse
Medication record documents Clonidine 0.1 mg given at 06:39 am by nurse. No BP recorded on medication record.
07:35 am BP 170/80, HR 64 " no complaints " documented by PCT
08:05 am BP 188/78 HR 76 " eyes closed resting comfortably " documented by PCT
08:35 am BP 178/75 HR 75 " rechecking BP " documented by PCT
09:04 am BP 191/84 HR 77 " hypertension, RN aware, patient stable no complaints " documented by PCT
Medication record documents Clonidine 0.1 mg given at 09:07 am by nurse. No BP recorded on medication record.
09:35 am BP 201/71 HR 76 " patient on cell phone " documented by PCT
09:39 am BP 185/85 HR 78 " treatment terminated with 300 ml normal saline rinse back " documented by PCT
Post-treatment standing BP 185/65 HR 65 was documented at 09:39 am by PCT
No post-treatment data collection is documented by PCT.
Nursing post-treatment assessment is documented at 06:10 am (same as pre-treatment assessment).
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of all abnormal findings and no documentation that a second dose of Clonidine was offered to patient for continued documented high blood pressure.

Treatment record for 2/12/2021:
06:35 am BP 168/81 HR 70 " patient watching television " documented by PCT
Nursing assessment documented at 06:35 am.
07:05 am BP 166/80 HR 73 " patient watching television " documented by PCT
07:08 am BP 164/67 HR 66 " patient watching television " documented by PCT
07:35 am BP 167/75 HR 66 " requested UF back on. Cramps subsided " documented by nurse
08:05 am BP 178/84 HR 75 " patient watching television " documented by PCT
08:35 am BP 174/77 HR 78 " patient watching television " documented by PCT
Medication record documents Clonidine 0.1 mg given at 08:24 by nurse, BP is documented as 178/84 and HR 75.
08:55 am no BP documented " treatment paused, patient complains of cramping " documented by PCT
09:05 am BP 173/82 HR 72 " patient on phone, no complaints " documented by PCT
09:32 am BP 181/82 HR 76 " treatment terminated with 300 ml normal saline back documented by PCT
Post-treatment Sitting BP 181/82, Standing BP 190/88 HR 76 is documented at 09:32 am by PCT
09:55 am BP 190/88 HR 80 " BP high standing, nurse aware " documented by PCT
Post-treatment data collection is documented by PCT at 09:58 am.
No post-treatment assessment is documented by nurse.
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of all abnormal findings and no documentation that a second dose of Clonidine was offered to patient for continued documented high blood pressure.

CR #2 Admission date: 4/11/15. Review of treatment sheets revealed the following:
Treatment record dated 2/19/2021:
Treatment was initiated at 06:18 am by PCT, no BP or HR documented 07:02 am BP 80/45 HR 76 " no complaints " documented by PCT
07:04 am BP 82/52 HR 79 " no complaints " documented by PCT
07:32 am BP 91/52 HR 81 " no complaints " documented by PCT
08:02 am BP 74/39 HR 82 " BP low, patient complains she felt lightheaded, stopped pulling fluid " documented by PCT
08:03 am BP 77/41 HR 83 " BP low, UF off " documented by PCT
08:05 am BP 83/45 HR 81 " BP increased, patient watching tv " documented by PCT
08:17 am BP 115/65 HR 83 " patient watching television, patient says that she feels fine " documented by PCT
08:32 am BP 127/64 HR 81 " no complaints " documented by PCT
09:10 am no BP or HR recorded " treatment ended with 200 NSS rinse " documented by PCT
No post-treatment assessment documented by nurse.
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of abnormal findings.

Treatment record dated 2/22/2021:
08:32 am BP 84/48 HR 83 " BP dropped, patient complains of cramping, NSS given " documented by PCT
08:40 am BP 126/64 HR 85 " patient still complains of cramping, NSS given " documented by PCT
No post-treatment nursing assessment was documented.
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of abnormal findings.

Treatment record dated 2/26/2021:
06:32 am BP 96/55 HR 81 " no complaints " documented by PCT
07:03 am BP 86/50 HR 84 " BP low, patient alert " documented by PCT 07:07 am BP 73/41 HR 84 " retaking BP " documented by PCT
07:08 am BP 88/47 HR 84 " BP low, will check " documented by PCT 07:12 am BP 90/49 HR 84 " BP increased, patient alert " documented by PCT
07:32 am BP 89/49 HR 83 " BP low, UF turned off, RN notified, patient alert " documented by PCT
07:33 am BP 82/50 HR 83 " patient complains of cramps, 200 ml NSS given " documented by PCT
08:02 am BP 102/50 HR 82 " patient stable " documented by PCT
08:32 am BP 88/50 HR 80 " patient complains of cramping, NSS given " documented by PCT
09:02 am BP 91/50 HR 77 " no complaints " documented by PCT
09:29 am BP 85/43 HR 79 " treatment terminated with 200 ml normal saline rinse back " documented by PCT
Post-treatment standing BP 94/54 HR 79 documented at 09:33 am by PCT No post-treatment nursing assessment is documented. Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of all abnormal findings.

CR #3 Admission Date: 12/16/13. Review of treatment sheets revealed the following:
Treatment record for 2/8/2021:
08:01 am BP 184/83 HR 73 " patient complains of pain in chest, notified RN, UF off, refused oxygen " documented by PCT
08:08 am BP 219/95 HR 85 " patient complains of chest pain, refused oxy and nitro, request NSS only. 100 ml NSS given " documented by nurse 08:31 am BP 214/90 HR 78 " no complaints " documented by PCT
08:33 am BP 213/84 HR 79 " patient has no complaints feels better after NSS given " documented by PCT
Medication record documents acetaminophen 325 mg given at 08:46 am by nurse for headache and hand pain.
09:01 am BP 211/83 HR 79 " BP elevated, patient complains of chest pain refuses hospital, refuses oxygen " documented by PCT
09:03 am BP 212/84 HR 81 " patient talking to NP, complains of chest pain " documented by PCT
09:11 am BP 244/114 HR 88 " with 200 ml NSS rinse back " documented by PCT
Post-treatment sitting BP 193/83 HR 86 documented at 09:11 am by PCT No post-treatment assessment documented by nurse.
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of all abnormal findings.

Treatment record for 2/10/2021:
06:31 am BP 171/84 HR 72 " no complaints " documented by PCT
09:01 am BP 192/83 HR 70 " patient request goal increased to .700 " documented by PCT
09:31 am BP 194/75 HR 67 No note documented,
09:38 am BP 190/80 HR 68 " treatment terminated with 250 ml NSS rinse back " documented by PCT
Post-treatment standing BP 188/90 HR 68 documented at 09:38 am by PCT
No post-treatment assessment documented by nurse.
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of abnormal findings.

Treatment record for 2/24/2021:
Pre-treatment data collection standing BP 175/79 HR 90 was documented by PCT at 06:06 am.
06:06 am BP 174/78 HR 90 "treatment initiated" documented by PCT 06:29 am BP 148/71 HR 81 " patient watching television " documented by PCT
No vital signs were recorded between 06:29 am and 07:35 am.
07:35 am BP 191/78 HR 92 " patient watching television " documented by PCT
08:00 am BP 175/69 HR 92 " no complaints " documented by PCT
08:29 am BP 171/75 HR 84 " patient complains not feeling good " documented by PCT
08:59 am BP 189/82 HR 85 " no complaints " documented by PCT
09:32 am BP 205/85 HR 90 " treatment terminated with 250 ml NSS rinse back " documented by PCT
Post-treatment standing BP 181/88 HR 90 documented at 09:36 am by PCT
No post-treatment assessment documented by nurse.
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of abnormal findings.

Treatment record for 2/26/2021:
07:29 am BP 175/87 HR 89 " no complaints " documented by nurse 07:59 am BP 180/83 HR 87 " patient watching television " documented by PCT
08:26 am BP 191/89 HR 88 " retake BP " documented by PCT
08:29 am BP 196/57 HR 86 " patient watching television " documented by PCT
08:59 am BP 187/85 HR 85 " patient on phone " documented by PCT 09:29 am BP 186/77 HR 84 " no complaints " documented by PCT
09:51 am BP 206/86 HR 88 " treatment terminated with 250 ml NSS rinse back " documented by PCT
Post-treatment sitting BP 206/86 HR 88 documented at 09:51 am by PCT No post-treatment assessment documented by nurse.
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of abnormal findings.

CR #4 Admission Date: 12/20/16. Review of treatment sheets revealed the following:
Review of treatment record for 3/2/2021:
Pre-treatment data collection standing BP 184/94 HR 67 was documented by PCT at 10:30 am
Treatment was initiated at 10:35 am with no BP or HR documented by PCT
10:36 am BP 191/98 HR 67 " Patient watching television " documented by PCT
11:01 am BP 173/79 HR 64 " no complaints " documented by PCT
11:32 am BP 171/82 HR 65 " no complaints " documented by PCT
No post-treatment nursing assessment was documented.
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of abnormal findings.

CR #6 Admission date: 11/30/12. Review of treatment sheets revealed the following:
Treatment record for 2/18/2021:
Pre-treatment data collection with standing BP 195/101 HR 75 was documented at 07:45 am by PCT
Treatment was initiated at 07:49, no BP or HR recorded by PCT
08:02 am BP 185/115 HR 80 " no complaints " documented by PCT 08:32 am BP 212/119 HR 81 " BP high rechecking " documented by PCT 08:34 am BP 189/112 HR 81 " No complaints " documented by PCT 09:02 am BP 178/107 HR 85 " eyes closed, resting comfortably " documented by PCT
09:32 am BP 178/110 HR 89 " eyes closed, resting comfortably " documented by PCT
10:02 am BP 178/106 HR 89 " Patient watching television " documented by PCT
10:30 am No BP or HR documented " treatment ended with 300 NSS rinse " documented by PCT
Post-treatment data collection with standing BP 111/60 HR 74 documented by PCT at 10:35 am
No post-treatment nursing assessment is documented.

There is no documentation stating the nurse was notified of abnormal findings.

Treatment record for 3/2/2021:
Pre-treatment data collection with standing BP 179/106 HR 82 was documented by PCT at 06:18 am
Treatment was initiated with no BP or HR recorded by PCT at 06:49 am 07:02 am BP 174/97 HR 80 " no complaints " documented by PCT
07:29 am BP 144/114 HR 46 " no complaints " documented PCT
07:59 am BP 176/110 HR 83 " patient watching television " documented by PCT
08:22 am BP 194/171 HR 83 " patient complains of nausea UF off no NSS/advised legs Trendelenburg " documented by PCT
08:42 am BP 174/98 HR 81 " eyes closed resting comfortably " documented by PCT
08:59 am BP 155/89 HR 81 " eyes closed resting comfortably " documented by PCT
09:33 am BP 178/98 HR 82 " no complaints " documented by PCT
09:54 am BP 185/106 HR 82 " treatment terminated " documented by PCT
Post-treatment data collection with standing BP 182/101 HR 82 was documented by PCT at 10:05 am
No post-treatment nursing assessment is documented.
Discharge status: discharge to home or self-care.

There is no documentation stating the nurse was notified of abnormal findings.

An interview with the administrator on 3/4/2021 at 1:00 PM confirmed the above findings.






Plan of Correction:

POC: The Facility Administrator (FA) held a mandatory in-service with clinical teammates from 3/8/21-3/12/21. Education included, but not limited to, the review of policy 1-03-08 "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment." Teammates were instructed using surveyor observations as examples, with emphasis on, but not limited to: 1) Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse, 2) 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..., 2. Intradialytic BP in the sitting/reclined or supine position... v. Patients' report of well-being, level of pain or discomfort, complaints..., 3) The nursing assessment will be performed and documented by a licensed nurse..., 4) Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately report to the licensed nurse (refer to "Abnormal Findings" section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis, 5) The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient's condition, 6) The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The physician will be notified of any concerns that may preclude the initiation of dialysis..., 6) Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring i. For non-nocturnal treatments is completed at least every thirty (30) minutes... b. At a minimum, obtain and document the following i. Blood pressure ii. Heart or pulse rate vi. Patient subjective statement(s) i.e., patient report on overall health, any complaints..., 7) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to "Abnormal Findings" section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary..., 8) All findings, interventions, and patient response will be documented in the patient's electronic health record, 9) Additional documentation if applicable includes the following: a. All medications including time administered, dose, route, and initials of person administering the medication. b. Indication and patient response to PRN medication..., 10) Post Treatment Data Collection/Assessment; The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings, 11) If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge, 12) Licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician is necessary prior to discharge of the patient from the facility, 13) Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's electronic health record. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient's condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time... Blood Pressure: Pre dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg, Diastolic greater than or equal to 100 mm/Hg. Blood Pressure: Intradialytic: Difference of 20 mm/Hg increase or decrease from patient's last intradialytic treatment BP reading... Blood Pressure: 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. If patient is not able to stand, document reason and sitting BP. Sitting BP for patient's that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg, Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg.....Verification of attendance at in-service is evidenced by signature sheet. The FA or designee will audit 10% of post treatment flow sheets each shift daily x 2 weeks and then 10% post treatment flow sheets weekly x 2 to verify that nurse is notified for abnormal findings and documented per policy. Ongoing compliance will be monitored by 10% of flow sheets monthly per the medical record audit. Results of audits will be reviewed with Medical Director during monthly QAPI meeting, known as the Facility Health Meeting (FHM). The FA is responsible for ongoing compliance with this Plan of Correction (POC).