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Based on findings from document review and interviews, policies and procedures (P&Ps) used by nursing staff for the care of patients receiving continuous ambulatory peritoneal dialysis (CAPD) lacked indication that the policies were approved for use in this hospital. Additionally, even though Patient A was provided continuous cycler-assisted peritoneal dialysis (CCPD), the hospital lacked a policy addressing the procedure.

Findings include:

--Per review of the hospital policy titled "CAPD Management Protocol," last revised 01/2008, it describes procedures for performing a CAPD exchange using a Baxter disposable Ultra bag, adding medications to the peritoneal dialysis solution, daily care of the peritoneal dialysis catheter site, effluent sampling and drawing samples of effluent for cell count with differential, routine and anaerobic cultures. The policy contained another hospital's letterhead and lacked documentation that it was approved for use by staff in this hospital.

--Per review of the hospital policy titled "Guidelines for Completion of the Inpatient Continuous Ambulatory Peritoneal Dialysis Daily Record Sheet, last revised 09/2011, it also contained another hospital's letter head and lacked documentation that it was approved for use in this hospital.

--During interview with the Manager of Inpatient Unit / Respiratory Therapy on 5/30/13 at 1:30 pm, he/she acknowledged that the CAPD P&P used by staff at this hospital was developed by another hospital and was not adapted and approved for use at this hospital.

--Review of Patient A's medical record (MR) reveals that on 5/11/12 this female, with a medical history of end-stage renal disease on peritoneal dialysis, was admitted to the hospital for rehabilitation. At 11:40 am the same day, the Attending Physician (Physician #1) wrote orders for continuous peritoneal dialysis using 2.5% dextrose for 11 hours daily. At 21:30, Registered Nurse (RN) #1 initiated this dialysis using a dialysis cycler (CCPD). Each night the patient received the nightly CCPD until transfer to another hospital on 05/15/12.

--Per interview with the hospital's Chief Nursing Officer (CNO) on 5/30/13 at 2:40 pm, nursing staff were presently in the process of reviewing hospital nursing policies, making sure all were adapted to the hospital's own standards. He/she acknowledged that the policy used by the hospital for patients undergoing CAPD did not address the automated cycler use procedure (CCPD).

Based on findings from medical record review, the medical care provided was not consistent with generally accepted standards of medical practice. Specifically, on 05/15/12, when there was a strong suspicion for infection and peritoneal sepsis in Patient A, a cell count and cultures of her peritoneal fluid were not obtained prior to initiation of antibiotics and transfer to a higher level of care hospital.

Findings include:

--Review of the MR for Patient A reveals she was a 72 year old with multiple medical issues including end stage renal disease (on peritoneal dialysis), hypertension, coronary artery disease, atrial fibrillation (on chronic anticoagulation), diabetes mellitus, and morbid obesity, and was status post laminectomy. She had undergone a right below the knee amputation (BKA) for gangrene at another hospital and was admitted to a swing bed at this hospital for rehabilitation. After admission to this hospital the patient's continued postoperative course was complicated by hyperglycemia and elevated INR (international normalized ratio) levels of 3.6 to 4.2. She received peritoneal dialysis and wound care for stump and coccyx wounds present on admission.

During this swing bed admission (05/11/12 to 05/15/12) Patient A experienced increased abdominal pain and an elevated white blood cell (WBC) count: 19,000 with 90% segs (neutrophils). Patient A was started on vancomycin and ceftazidime (broad spectrum antibiotics) and was transferred from this hospital to a tertiary care facility on 05/15/12.

--Review of Patient A's MR by a physician board-certified in internal medicine has identified the following lapses in care:

Prior to transfer on 05/15/12, there was strong suspicion for peritoneal sepsis based on worsening pain and a newly elevated WBC in a high risk patient. Blood cultures were obtained on 05/15/12 and were reported as "no growth." In peritoneal dialysis-related peritonitis, blood cultures are generally negative, and therefore it is critical to obtain peritoneal fluid cell count and cultures to rule out acute peritonitis. This was not done prior to initiating broad spectrum antibiotics. The omission was a missed opportunity that did not meet standards of care.

Based on findings from document reviews and interviews, 3 of 3 nursing personnel files (for Registered Nurses #1, #2, #3) lacked documentation indicating the nursing staff were trained in the use of automated peritoneal cyclers for providing continuous cycler-assisted peritoneal dialysis (CCPD) to patients.

Findings include:

--Per review of training records for 3 nursing staff who provided or assisted with CCPD during Patient A's hospitalization from 05/11/12 to 05/15/12, each attended a training session titled "CAPD Overview" on 02/22/12, and each signed a Competency Validation Checklist for Continuous Ambulatory Peritoneal Dialysis (CAPD) form indicating they agreed (along with the validator) that they were competent to perform CAPD. However, the competency checklist does not indicate that the staff were trained in and demonstrated competency to perform CCPD, a specific type of ambulatory peritoneal dialysis done at the hospital.

--Per interview of the hospital's Director of Education on 5/30/13 at 8:45 am, registered nurses (RNs) at this hospital were trained in peritoneal dialysis by trainers from another hospital in 2011 and 2012. He/she thought that staff received peritoneal dialysis training using automated peritoneal dialysis cyclers, but was not certain.

--Per interview with RN #2 on 06/11/13 at 10:50 am, he/she received training on automated cycler use during staff training in 2012.

--During interview with the Chief Nursing Officer on 08/28/13 at 8:40 am, he/she acknowledged the lack of documentation regarding nursing staff's competency to perform CCPD specifically.