Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted August 9, 2021 through August 11, 2021, Fresenius Medical Care Fogelsville 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 conducted on August 9, 2021 through August 11, 2021, Fresenius Medical Care Fogelsville 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, observational tour, and an interview with the facility administrator and director of operations, the facility failed to follow it's policy for reporting and documentation of abnormal findings pre, post, and during dialysis for four (4) of five (5) medical records reviewed (MR #2, MR #3, MR #4, and MR #5).
Findings include:
A review of policy titled "Patient Assessment and Monitoring" at approximately 10:00 AM states for "During Treatment", "The Registered Nurse will assess/reassess any findings addressed pre or during treatment as needed." Policy states for "Post Treatment", "If any changes or abnormal findings in the patient's condition, vital signs, or vascular access are observed or reported by the patient, 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." Policy states for "Monitoring During Treatment", "Report to the Nurse: systolic blood pressures greater than 180 mm/Hg; diastolic blood pressure greater than 100 mm/Hg; blood pressure less than or equal to 100 mm/Hg systolic."
A review of medical records was conducted on August 10, 2021 between approximately 1:30 PM and 2:30 PM.
A review of dialysis treatment records between July 28, 2021 and August 9, 2021 was conducted on August 11, 2021 between approximately 9:30 AM and 11:00 AM.
MR #2, Start of Care: 6/4/2021, Dialysis treatment orders from 6/9/2021: Estimated Dry Weight (EDW) (estimated dry weight): 75.5 kg; Frequency: Monday-Wednesday-Friday; Dialyzer: Optiflux 160NRe; Dialysate: 2.0 K, 2.5 Ca, 35 HCO3, 140 Na; Blood Flow Rate (BFR) (blood flow rate): 450; Dialysate Flow Rate (DFR) (dialysate flow rate): Manual 800; Treatment Duration: 4 hours.
Treatment record for 7/28/2021:
09:33 AM: B/P 220/135, "Resting comfortably" documented by PCT. No follow-up note from RN addressing blood pressure after documentation or in discharge note.
Treatment record for 7/30/2021:
07:36 AM B/P 214/104, "Denies complaints; resting comfortably" documented by PCT.
No follow-up note addressing blood pressure from RN after PCT documentation or in RN discharge note.
Treatment record for 8/4/2021:
07:38 AM, B/P 130/29, "Green AMP light; patient alert; pt bp drop nss given Vomited up undigested food" documented by RN.
07:56 AM, B/P 204/125, documented by RN without comments.
08:02 AM, B/P 201/110, "UF on; Green AMP light; Patient Alert" documented by PCT.
08:34 AM, no B/P recording, "UF on; Resting comfortably; access visible; sleeping; green AMP light; denies complaints" documented by PCT.
09:05 AM, B/P 181/105, documented by PCT without comments.
09:29 AM, B/P 186/94, documented by PCT without comments.
No follow-up note addressing blood pressure from RN after PCT documentation or in RN discharge note.
MR #3, Start of Care 4/5/2021, Dialysis treatment orders from 6/7/2021: EDW 89.5 kg; Frequency: Monday-Wednesday-Friday; Dialyzer: Optiflux 180 NRe; .Dialysate: 2.0 K, 2.5 Ca, 35 HCO3, 137 Na; BFR: 400; DFR: Autoflow 1.5; Treatment Duration: 4 hours.
Treatment record for 7/26/2021:
11:34 AM, B/P 210/111, documented by PCT without comments.
11:34 AM, B/P 192/100, "UF on; access visible, green AMP light, denies complaints; patient alert" documented by PCT.
11:48 AM, B/P 205/116, "Access visible; green AMP light, denies complaints; UF Off; patient alert; treatment discontinued without problem; bfr to 200 for blood return, system and dialyzer clear" documented by PCT.
11:48 AM, Post B/P sitting 145/95, post B/P standing 192/104 documented by PCT. RN note for discharge states, "pt stable upon d/c." No follow-up note addressing blood pressure from RN after PCT documentation or in RN discharge note.
Treatment record for 8/9/2021:
08:01 AM, B/P 202/114, "Green AMP light; resting comfortably" documented by PCT.
08:32 AM, B/P 193/105, "UF on; resting comfortably; access visible; green AMP light; denies complaints; patient alert; profile A" documented by RN
09:05 AM, B/P 205/111, "UF on; resting comfortably; access visible; green AMP light; denies complaints; patient alert; profile C" documented by RN.
10:02 AM, B/P 205/162, "Green AMP light, patient alert; PT IN PROFILE C ON CRITLINE GIVEN NSS" documented by PCT.
10:37 AM, B/P 208/124, "Resting comfortably; green AMP light; denies complaints; patient alert" documented by PCT.
11:02 AM, B/P 211/126, "UF on; resting comfortably; access visible; green AMP light, denies complaints; patient alert; profile B; BP elevated, asymptomatic at this time, will take BP meds at home" documented by RN.
11:31 AM, B/P 225/114, "Resting comfortably, green AMP light, denies complaints; UF off; patient alert; treatment discontinued without problem; PT REINFUSED DIALYZER CLEARED FAIR" documented by PCT.
11:29 AM, Post B/P sitting 218/111, post B/P standing "Cannot Assess" documented by PCT.
No follow-up note addressing blood pressure or rationale for fluid given with high blood pressure reading from RN after PCT documentation.
MR #4, Start of Care: 5/31/2021, Dialysis Treatment Orders from 7/26/2021: EDW: 65.5 Kg. Frequency: Monday-Wednesday-Friday; Dialyzer: Optiflux 160 NRe; Dialysate: 3 K, 2.5 Ca, 35 HCO3, 140 NA; BFR: 450; DFR: Manual 800; Treatment Duration: 4 hours.
Treatment record for 7/28/2021:
10:01 AM, B/P 83/45, "Resting comfortably; lines reversed; green AMP light; denies complaints; patient alert" documented by PCT.
10:32 AM, B/P 72/40, documented by PCT without comments.
10:33 AM, B/P 75/43, "Resting comfortably; lines reversed; green AMP light; denies complaints; patient alert" documented by PCT.
10:52 AM, B/P 63/38, "Resting comfortably; access visible; UF off; patient alert; green AMP light; denies complaints; treatment ended" documented by RN.
10:53 AM, Post B/P sitting 101/48, post B/P standing "Cannot Assess" documented by PCT.
No follow-up note addressing blood pressure from RN after PCT documentation or in discharge note.
MR #5, Start of Care: 5/14/2021, Dialysis Treatment Orders from 6/25/2021: EDW: 111 Kg. Frequency: Monday-Wednesday-Friday; Dialyzer: Optiflux 180 NRe; Dialysate: 3 K, 2.5 Ca, 33 HCO3, 140 NA; BFR: 400; DFR: Autoflow 1.5; Treatment Duration: 4 hours.
Treatment record for 7/28/2021:
11:06 AM, B/P 72/59, "UF AT MINIMUM" documented by PCT.
11:31 AM, B/P 103/72, "Resting comfortably; lines reversed; denies complaints; UF off; patient alert; treatment discontinued without problem; PT REINFUSED DIALYZER CLEARED FAIR" documented by PCT.
No follow-up note addressing blood pressure from RN after PCT documentation or in discharge note.
An interview with the facility administrator and director of operations on August 11, 2021 at approximately 1:00 PM confirmed the above findings. Facility administrator made copies of treatment records to do inservice with in-center team.
Plan of Correction:To ensure compliance the clinic manager (CM) or designee will in-service all the direct patient care (DPC) staff on policy:
Patient Assessment and Monitoring
Emphasis will be placed on ensuring that a follow up note for any treatment interventions and /or abnormal blood pressures (BP) are documented by the Registered Nurse(RN) either in the clinical notes or in the discharge note.
In-servicing was completed by August 16, 2021. All training documentation is on file at the facility.
The CM or designee will perform daily flowsheet audits for two (2) weeks- August 23- September 4, 2021. At the time if compliance is observed the audits will then be completed 2 times/ week to ensure that compliance is maintained- September 6- September 18, 2021. 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 audits and report the findings to the QAI Committee at the monthly meeting. The QAI committee will be responsible for further guidance and ongoing oversight.
Completion date: September 24, 2021
|