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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. The facility failed to assess patients in accordance with physician orders and facility policy. In addition, the facility failed to ensure patient weights along with fluid intakes and outputs were measured and documented as ordered in 4 of 11 medical records reviewed (Patients #2, #4, #10 and #11). This failure created the potential for the patient's medical needs to not be addressed. In addition, this failure resulted in a longer than expected patient hospitalization and emergent dialysis for 1 of 11 patients (Patient #4).

Based on interviews and document review, the facility failed to assess patients in accordance with physician orders and facility policy. In addition, the facility failed to ensure patient weights were measured and documented as ordered in 4 of 11 medical records reviewed (Patient #2, #4, #10 and #11).

This failure created the potential for the patient's medical needs to not be addressed. In addition, this failure resulted in a longer than expected patient hospitalization and emergent dialysis for 1 of 11 patients (Patient #4).

FINDINGS

POLICY

According to the policy, Patient Assessment and Reassessment, the Registered Nurse (RN) will perform a physical assessment including weight. Physical reassessment will be conducted at a minimum every shift and will include vital signs, diagnosis or signs/symptoms, and a review of systems including renal.

According to policy, Pre and Post Treatment Assessment and Data Collection, pre and post dialysis treatment data collection includes a weight.

According to policy, Dialysis Performed on a Nursing Unit, the unit nurse assesses the patient prior to the start of the scheduled dialysis. Weigh and record weight prior to dialysis.

REFERENCE

According to the contracted dialysis company's policy, Dialysis Performed on a Nursing Unit, obtain pre treatment hand off report from the patient's primary nurse to include but not limited to vital signs, including weight, scale type and time obtained. Post treatment vital signs to include weight (if ordered by the nephrologist).

1. Nursing staff failed to identify and alert medical providers in regards to Patient #4's chronic medical condition and hemodialysis needs.

a) Review of a Consultation Note on 02/05/17 at 3:32 p.m. revealed Patient #4 presented to the facility on 02/01/17 for a procedure to place an Implantable Cardioverter Defibrillator (ICD), a small device placed in the chest or abdomen used to treat abnormal heartrate. The procedure was delayed until 02/02/17. Documentation stated the procedure went well but the patient was unable to leave the facility due to other issues of concern, specifically related to the patient's history of end stage renal disease (ESRD) and the need for hemodialysis.

Review of the patient's medical record showed the following documentation:

On 02/01/17 at 3:35 p.m., a Nursing Admission History documented Patient #4 had a history of kidney failure and received hemodialysis on Mondays, Wednesdays and Fridays. At 4:05 p.m., the patient's weight was documented at 70.94 kilograms (kg) or 156 pounds (lbs). At 6:31 p.m., nursing documentation noted Patient #4's ICD placement procedure was delayed to the next morning due to 2 emergencies. Documentation further stated the patient was on a renal diet.

On 2/01/17 at 11:39 p.m., nursing documentation revealed an assessment of Patient #4's fistula (access for dialysis) located in the right upper extremity. Documentation further stated Patient #4 last received dialysis on 1/31/17, one day prior to presenting for the outpatient procedure.

A review of the Medication Discharge Summary revealed Patient #4 was receiving Renvela (a medication used by dialysis patients to lower phosphorus levels in the blood) beginning on 02/02/17. According to the Discharge Report, Renvela was ordered on 02/02/17 at 8:45 a.m.

On 02/02/17 at 9:00 a.m., nursing documentation revealed Patient #4 was a dialysis patient and an assessment of the patient's fistula was conducted.

On 02/03/17 at 1:25 a.m., nursing documentation revealed Patient #4 was a dialysis patient and an assessment of the patient's fistula was conducted. The patient's blood pressure was assessed in his/her right arm, which was the same arm the fistula was located at. Additionally, the RN documented the patient received dialysis one-day prior, which indicated 02/02/17. This was in contrast to the nursing admission history on 2/01/17, which stated the patient last received dialysis on 01/31/17.

On 02/03/17 at 10:00 a.m. and at 8:00 p.m., as well as on 02/04/17 at 8:30 a.m., nursing documentation revealed Patient #4 was a dialysis patient and an assessment of the patient's fistula was conducted. However, there was no documentation the facility identified Patient #4 was not receiving his/her routine dialysis treatments.

On 02/04/17 at 10:18 a.m., a Cardiology Progress note documented Patient #4 was weak and that the patient did not feel ready for discharge. Physician documentation noted the plan for the patient's weakness was for physical therapy and case management to see the patient. Patient #4's documented intake was noted on 02/03/17 at 7:00 p.m. to be 1260 ml's and zero mls of fluid output. Further review of the Progress Note revealed no indication the patient had ESRD or was a hemodialysis patient.

On 02/04/17 at 8:00 p.m., nursing documentation revealed Patient #4 was a dialysis patient, 3 days after the patients admission to the facility. There was no documentation the facility identified the patient had not received dialysis since 01/31/17.

On 02/05/17 at 10:28 a.m., nursing documentation revealed Patient #4 was a dialysis patient and an assessment of the patient's fistula was conducted.

On 02/05/17 at 2:45 p.m., the RN documented s/he notified the patient's cardiologist that the patient was a chronic dialysis patient and had not had dialysis since before admission. The RN further documented the patient appeared to be jaundiced (yellow in color) and had not been feeling well. Per the documentation, the physician ordered immediate lab work and a nephrology consultation (a physician who specialized in patients with ESRD). At 5:12 p.m., the Patient #4's weight was documented at 79.9 kg (176.5 lbs). This was a 20.5 lb weight increase from Patient #4's weight of 156 lbs documented on 02/01/17.

A review of the Lab Discharge Summary Report documented the laboratory results from tests drawn on 02/01/17 at 10:45 a.m. and repeated on 02/05/17 at 2:58 p.m. Results from the tests revealed critical levels including the potassium level increased from 4.3 to 6.8 (normal range 3.5-5.0), the blood urea nitrogen (BUN) level increased from 31 to 122 (normal range 7-18), and the creatinine level increased from 4.5 to 14.1 (normal range 0.6-1.1).

On 02/05/17 at 7:47 p.m., a Nephrology Progress Note documented the patient had a history of receiving dialysis treatments at an out patient dialysis center on Mondays, Wednesdays and Fridays with the last dialysis treatment on 01/31/17. Patient #4's plan was to receive emergent dialysis on 02/05/17, (6 days after the patient's last documented dialysis treatment). The physician additionally planned for Patient #4 to receive emergent dialysis again the next morning. The physician noted the patient to have a weight increase and requested to have the patient always admit to medicine on future admissions.

A physician order was placed for Patient #4 to receive hemodialysis on 02/05/17 at 8:28 p.m. Patient #4 received 2 hours of dialysis beginning at 8:08 p.m. on 02/05/17.

On 02/06/17 at 4:02 p.m., a Pulmonary Consultation Note documented Patient #4 was admitted on 02/01/17 for a placement of an automatic implantable cardioverter-defibrillator (AICD) which was delayed until 02/02/17. The physician noted during this time noted the patient had progressive weakness, shortness of breath and was noted to have an enlarging left sided pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest). During the hospitalization Patient #4 had gained about 9 kilograms (kg) (19.8 pounds). Further documentation revealed the physician suspected the buildup of fluid on the patient lungs, the patient weight gain and slow appearance of pleural effusion (buildup of fluid between the lungs and the chest) over subsequent days were due to missing several sessions of hemodialysis.

Review of a Bedside Post Procedure Report revealed on 02/06/17 at 7:10 p.m., Patient #4 underwent a thoracentesis (insertion of a needle in the space between the lungs and the chest in order to remove excess fluid). The report documented a total of 1.2 Liters of fluid was removed during the procedure.

b) On 04/26/17 at 2:27 p.m., an interview was conducted with Registered Nurse (RN) #8 who stated s/he cared for ESRD patients on the Telemetry Unit. RN # 8 verified the medication Renvela was administered to dialysis patients in order to lower the amount of phosphorus levels in the blood. RN #8 stated the risk of taking a blood pressure on an arm with a fistula present could result in damage or the need to replace the fistula. RN #8 further stated the risk of missing dialysis treatments could result in confusion, swelling, and cardiac issues.

c) On 04/26/17 at 5:05 p.m., an interview with RN #3 was conducted. RN #3 stated s/he was notified of a patient's history of requiring hemodialysis either during report from the patient's previous nurse, by looking at the medical record for the patient's history, or from assessing the patient to see if a fistula was present.

d) On 04/27/17 at 11:11 a.m., an interview was conducted with Nurse Manager of the Intensive Care Unit and the Telemetry Unit (Manager #5). Manager #5 stated s/he was familiar with Patient #4 and confirmed dialysis was not conducted on the patient for several days after s/he presented to the facility. Manager #5 stated the patient was transferred from an observation status to an inpatient status and was planned to be discharged earlier; however, the patient was not feeling well so s/he stayed in the unit for a longer amount of time than planned. This resulted in the patient missing orders for hemodialysis.

Manager #5 then stated the facility sent letters to the RNs involved in Patient #4's care discussing the importance of communication between staff regarding patient care needs. Manager #5 stated s/he had not conducted any further education with the rest of the nursing staff or implemented any practice changes to avoid similar outcomes because s/he was waiting for results from an internal analysis of the incident.

e) On 04/27/17 at 10:20 a.m., an interview was conducted with Physician #6, a nephrologist who specialized in renal patients. Physician # 6 stated hemodialysis was used when patients' kidneys were not working. Dialysis took over and got rid of fluid and waste products. Dialysis was important because the waste products would build up and become life threatening if not removed.

2. Nursing staff failed to obtain patient weights as ordered by the physician.

a) On review of Patient #2's History and Physical, dated on 03/06/17 at 9:09 a.m., Patient #2 presented to the Emergency Department (ED) for emergent dialysis.

On 03/06/17 at 11:30 a.m., an order was placed by the physician to obtain the patient's weight prior to each procedure and at the completion of dialysis. The patient's weight was documented in the Nursing Admission Assessment note at 12:25 p.m. at 53.97 kg (118.73 lb) and on the Acute Hemodialysis Flow Sheet (flow sheet) as pre weight of 54.0 kg and post weight of 51 kg.

The patient received dialysis again on 03/07/17 at 7:05 a.m. On review of the nursing documentation and the Hemodialysis Flow Sheet, there was no further documentation of the patient's weight prior to or at the completion of the dialysis treatment.

b) Review of a Consultation Note on 02/05/17 at 3:32 p.m. revealed Patient #4 presented to the facility on 02/01/17 for a procedure to place an Implantable Cardioverter Defibrillator (ICD), a small device placed in the chest or abdomen used to help treat an abnormal heartrate. The procedure was delayed until 02/02/17.

Admission orders dated 02/02/17 at 7:38 a.m., instructed nursing staff to obtain Patient #4's daily weights. Nursing documentation on 02/01/17 at 4:05 p.m. revealed the patient's weight was 70.94 kg (156 lbs). The next weight was documented 4 days later on 02/05/17 at 5:12 p.m. at 79.9 kg (176.5 lbs), which was a 20.5 lb increase.

A physician order for Patient #4 to receive hemodialysis was placed on 02/05/17 at 8:28 p.m. An additional order at 8:28 p.m. instructed staff to measure the patient's weight prior to each procedure and at the completion of dialysis. The patient underwent dialysis treatment on 02/05/17 at 8:08 p.m.; however, there was no documented patient weight at the completion of the treatment.

c) Review of Patient #10's Emergency Provider Report revealed the patient presented to the ED on 01/10/17 at 10:00 a.m. after the patient's spouse found the patient on the floor unarousable. A physician order dated 01/10/17 at 2:57 p.m., instructed nursing staff to obtain daily weights on the patient.

On 01/10/17 at 4:03 p.m., Patient #10's weight was documented at 80.29 kg (177 lbs). The weight source was documented as reported by the patient.

On 01/11/17 at 5:42 a.m., the patients weight was documented at 85.72 kg and the weight source was documented as obtained by the patient's bed scale. This was 5 kg (11 lbs) higher than the previous day.

On review of documentation for 01/12/17, 01/13/17 and 01/14/17 (the date of discharge), there was no documentation of the patient's weight, which was in contrast to the physician's order for daily weights.

d) Review of Patient #11's Emergency Provider Report revealed the patient presented to the ED on 01/11/17 at 3:26 p.m. with a chief complaint of general malaise and a history of chronic kidney disease. A review of Patient #11's orders for 01/11/17 at 10:30 p.m. revealed a physician order to obtain daily weights for the patient. The patient's weight was documented in a Rapid Assessment Note at 3:30 p.m. at 89.81 kg and then again in a Clinical Documentation note at 10:54 p.m. at 98.70 kg (a difference of 8.89 kg). This was the only documented patient weight, although the patient was in the facility until 01/16/17.

e) On 4/26/17 at 1:54 p.m., an interview was conducted with RN #1, who revealed s/he was contracted with the facility to conduct dialysis treatments for patients. RN #1 explained all patients receiving dialysis were expected to have weights obtained and documented prior to and after each treatment. RN #1 stated s/he would obtain patient weights either from the patient's bed scale, from the medical record or on a scale located in the dialysis unit. RN #1 then stated the scale used for patients in the dialysis unit was currently broken s/he and was unsure how long the scale had been broken. RN # 1 stated s/he had been getting weights from the patients' medical record in the computer.

f) On 04/27/17 at 11:11 a.m., an interview was conducted with Nurse Manager #5 who stated monitoring patient weights was an important assessment for many types of diagnoses and that RN's were expected to follow physician orders with weighing patients. Manger #5 also identified a 2-pound weight change in a 24-hour period would be important to notify a physician due to possible fluid overload.

g) 04/26/17 2:11 p.m., an interview was conducted with Clinical Education Specialist (CES #4), who was in charge of staff education for the hospital units for the facility. CES #4 stated daily weights in renal patients were important to monitor for fluid retention and anything over 5-8 pounds was a significant weight gain for a renal patient. CES #4 further stated s/he was unsure if staff had access to a policy offering guidance on obtaining patient weights and notifying physicians of abnormal weight findings.