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Based on interview and record review, the facility failed for one patient, Patient 16, on dialysis (a system where blood is filtered to remove toxins) was provided in a timely manner. This failure impacted the provision of the medical care provided to the patient and had the potential to negatively contribute to the medical condition of Patient 16.

Findings:

Patient 16 was admitted to the facility on May 8, 2016, at 5:40 p.m., through the Emergency Department, with a diagnosis which included, dialysis dependent kidney disease. A nephrologist (physician who specializes in diseases of the kidneys), wrote an order at 6:40 p.m., on May 8, 2016, for a stat dialysis treatment.

The medical record for Patient 16 was reviewed on May 9, 2016. A consultation note written by the nephrologist indicated, "...I will plan for emergent hemodialysis this evening..." The nephrologist's order indicated, "Please notify [name of dialysis provider] of treatment STAT (as soon as possible) tonight and fax the orders to them. Thank you!" On May 9, 2016, at 00:07 a.m., the dialysis provider was notified of Patient 16's need for stat dialysis (five hours and 27 minutes after the stat order was written). A consent for the dialysis treatment was signed by the patient at 3 a.m. on May 9, 2016, and dialysis started at 3:15 a.m. (three hours and eight minutes after notification to the dialysis provider). Dialysis was initiated eight hours and 35 minutes after the physician's order was written for a stat dialysis treatment.

On May 9, 2016, at 10:07 a.m., Registered Nurse 1 (RN 1) was interviewed. RN 1 stated, the night shift RN for Patient 16, did not report any reason for the delay in the initiation of the dialysis treatment order.