HospitalInspections.org

Based on record review, policy review and staff interview the facility failed to ensure dialysis staff monitored one [#4] of one hemodialysis patient of four records reviewed in accordance with the hospital's policy.

Finding included:

A review of the facility policy, "Intradialytic Assessment and Monitoring," #7063, Rev. 08/24/2017 states, The dialysis services staff shall be responsible for evaluating the patient's response to the dialysis treatment, performing patient assessment, including blood pressure [B/P], fluid status, pulse and respiration shall be completed and documented in the dialysis flowsheet every thirty [30] minutes, unless more frequent monitoring is required due to the condition of the patient or if the patient is in Critical Care, Operating Room, Emergency Room or Recovery areas, the documentation is every fifteen [15] minutes.


A review of Patient #4 medical record, specifically the facility face sheet, physician's history and physical assessment notes, physician progress notes, nursing notes and hemodialysis flow sheets documented the patient was admitted to the facility on 12/18/2013. A review of the dialysis flow sheets documented the physician's dialysis prescription including the Dialysate bath, blood flow rate, dialysis flow rate and treatment length.
A detailed review of treatment date 07/06/2018 document the following:
11:34 AM - B/P - 136/56 - Treatment started
12:32 PM - B/P - 134/56 - No documentation why patient's vital signs and safety check not documented every 30 minutes per policy.
13:02 PM - B/P 133/42
13:31 PM - B/P 153/43
14:01 PM - B/P 123/53
14:31 PM - B/P 122/48
15:01 PM - B/P 129/51
15:30 PM - B/P 142/56
16:06 PM - B/P 140/50 - Treatment completed, No documentation why patient's vital signs and safety check not documented every 30 minutes per policy.

A detailed review of treatment date 07/09/2018 documents the following:
14:45 PM - B/P 137/59 Treatment started
15:00 PM - B/P 138/42
15:36 PM - B/P 149/56 - No documentation why patient's vital signs and safety check not documented every 30 minutes per policy.
16:03 PM - B/P 141/64
16:31 PM - B/P 154/64
17:03 PM - B/P 147/57 - No documentation why patient's vital signs and safety check not documented every 30 minutes per policy.
17:30 PM - B/P 158/52
17:59 PM - B/P 171/55
18:16 PM - B/P 134/55
18:30 PM - B/P 140/52
18:50 PM - B/P 129/46 - Treatment completed

An interview with the Director of Education on 07/11/2018 at 10:30 AM confirmed the above findings.