Initial Comments:
Based on the findings of an unannounced on-site state complaint investigation survey conducted on January 30, 2024, and concluded on February 6, 2024, Progress Ave Dialysis was identified to have the following standard level deficiency, and 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:
494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P
Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;
Observations:
Based on review of agency dialysis documents, patient clinical records (CRs), agency policy, and interviews with agency facility administrator, the agency failed to ensure all policies and procedures relative to patient care and safety are adhered to by all individuals who treat patient in the dialysis facility in one (1) out of three (3) patient clinical records reviewed (CR#3).
Findings include:
Review conducted on January 30, 2024, at approximately 8:46 AM, of agency internal event report, File ID 1107170, dated 1/18/24 related to CR#3 fall in bathroom, RN/EF#6 revealed: "With 2 hours and 30 minutes of treatment remaining, patient experienced bowel incontinence. PCT rinsed patient back and assisted her to the bathroom to clean up. PCT instructed patient to ring (help alarm) when she was ready to be transferred back into wheelchair. A few minutes later, PCT discovered patient on the bathroom floor on her knees, both patient and toilet covered in stool. Patient uninjured, denied pain. Patient had disregarded instructions, had attempted transfer (to wheelchair) on her own without assistance when she lost her balance and fell to her knees. Patient ' s cognition seems overall intact, however, she appears to have episodes of confusion. Told patient that we will have to supervise her in the bathroom form here on out."
Review conducted on January 30, 2024, at approximately 11:15 AM to 1:55 PM, of three patient clinical records revealed:
CR#3, start of care 11/28/23, noted documentation of 1/18/24 bathroom fall with no noted injuries due to an bowel incontinence episode; no documentation of family caregiver notification for 1/18/24 fall.
Review conducted on January 30, 2024, at approximately 12:50 PM, of agency "1-03-20A The Patient Fall Prevention Procedure" revealed: "5. If a fall occurs, the following steps must be taken: ... Notify the family or the patient's personal representative of patient's fall."
Interview conducted on February 6, 2024, at approximately 12:45 PM, with FA revealed confirmation of agency staff failure to notify family member of patient fall.
Plan of Correction:V000
The Governing Body of DaVita Progress Ave Dialysis has reviewed the statement of deficiency resulting from a state survey completed on 2/06/24. The Governing Body has approved and respectfully submits this plan of correction.
V715
A Governing Body meeting with the Medical Director, Facility Administrator, Nursing Manager and Regional Operations Director was held to review the results of the survey ending on 2/6/24. The Governing Body reviewed the document Medical Director Qualifications and Responsibilities. The Medical Director acknowledges that he/she is responsible to ensure the facility teammates are trained, follow policy and procedure, and deficiencies identified need to be corrected timely with the support of the facility team. A plan of correction has been developed and initiated to correct identified deficiencies and to sustain compliance. The Facility Administrator took immediate action to address each identified issue. Actions taken included holding an in-seervice on 2/06/24 with the teammates that were there and then again on 2/08/24 with the rest of the teammates that were not in attendance on 2/06/24. Education included a review of Policy 1-03-20A The Patient Fall Prevention Procedure emphasizing if a fall occurs, the following steps must be taken: ... Notify the family or the patient's personal representative of patient's fall. Verification of attendance is evidenced by teammate signature on in-service sheet.
The Facility Administrator or designee will conduct audits to monitor for policy and procedure adherence in instances of any fall patients that may occur. Instances of non-compliance will be addressed immediately.
The Medical Director will review progress of teammate education, results of audits, and adherence to if there were any fall patients, notes made for these fall patients, and if designated family members were notified during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed if applicable to achieve sustained compliance. Supporting documentation will be included in the meeting minutes. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.
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