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The facility failed to ensure the Condition of Participation for Governing Body (GB) was met when contracted hemodialysis treatments (HT) delays were identified by the Chief Nursing Officer (CNO) but not reported to the GB for action. (Refer to A 0084).

The cumulative effect of this systemic practice resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Governing Body.

Based on interview and record review, the Governing Body (GB) failed to monitor and assure contracted hemodialysis treatments (HT) were provided as ordered by the patients' physicians. This failure resulted in delayed HT for 16 of 30 sampled patients.

Findings:

During a concurrent interview and review of the facility's Command Center's (CC- where patient procedures were scheduled) process with the Procedure Scheduler (PS 1), on 8/17/2023 at 4:11 PM, PS 1 stated nursing staff notified the CC via phone to communicate the patients' HT orders. PS 1 stated she was responsible for inputting the patients' HT order as dictated by the nurse onto the computerized spreadsheet, as well as sending a text message to the contracted dialysis provider that included each patient's pertinent data.

PS 1 provided the facility's HT Log and the telephone text message log for review. The HT Log indicated when the nursing staff communicated the new HT order to the CC, as well as when the order was sent to the contracted dialysis provider via text message. The telephone text message log included pertinent patient data (patient's name, room number, dialysis access site and whether there were any isolation precautions).

Review of the text messages to the contracted dialysis provider did not consistently include the patients' HT priority level (such as, STAT) or the date (such as today or tomorrow) for the contracted dialysis provider to provide the patients' HT as ordered.

During a review of the "Governing Body Meeting Minutes," from 2/2023 through 6/2023, there was no documented evidence to show that the facility identified the patients' delayed HT.

During an interview on 8/18/2023 at 9:05 AM, with the CNO, who was a member of the GB, CNO stated she was aware that there were delays in the contracted hemodialysis provider providing physician ordered HT. The CNO stated she had been aware for several months but had not reported the identified concern to the Governing Body (GB).

The facility failed to ensure the Condition of Participation for Patient Rights was met when:

1. Sixteen (16) of 30 sampled patients (2, 3, 4, 5, 6, 7, 8, 9, 14, 16, 17, 18, 21, 22, 27, 28) did not recive hemodialysis treatments (HT) as ordered by the physician. (Refer to A-0145, Finding 1 a-p).

2. Four (4) of 30 sampled patients (21, 22, 26, 28), HT medications, treatment duration, and flow rates were not followed as ordered by the physician. (Refer to A-0145, Finding 2 a-d).

3. Seven (7) of 30 sampled patients (7, 15, 21, 26, 27, 28, 29), HT Records were illegible. (Refer to A-0145, Finding 3 a-g).

On 8/18/2023 at 11:29 AM, the Survey Team called an Immediate Jeopardy situation concerning Patient Rights, in the presence of the facility's CEO, CNO, CFO, and COO.

On 8/18/2023 at 8:15 PM, the CEO and CNO provided the survey team with an IJ Removal Plan.

On 8/21/2023 at 3:15 PM, while onsite after confirming the implementation of the IJ Removal Plan through observations, interviews, and record reviews, the survey team accepted the facility's IJ Removal Plan and removed the IJ in the presence of the CNO.

The cumulative effect of these systemic practices resulted in the facility's inability to be in compliance with the Condition of Participation for Patient Rights.

Based on interview and record review, the facility neglected to ensure:

1. For 16 of 30 sampled patients (2, 3, 4, 5, 6, 7, 8, 9, 14, 16, 17, 18, 21, 22, 27, 28, received hemodialysis treatments (HT) as ordered by the physician.

2. For four (4) of 30 sampled patients (21, 22, 26, 28), HT medication, duration, and flow rates were followed as ordered by the physician.

3. For seven (7) of 30 sampled patients (7, 15, 21, 26, 27, 28, 29), HT Records were legible.

These failures had the potential to cause serious harm or death to the facility's patients who received hemodialysis treatments (HT).

Findings:

1 a. Review of Patient 2's (P2) medical record indicated (P2) was admitted to the facility on 7/17/2023, per the admission History and Physical (H&P). The H&P, dated 7/17/2023, indicated P2's admission diagnoses included End Stage Renal Disease (ESRD, when kidneys no longer function normally) with HT.

Review of P2's physician's orders (PO) indicated:

On 7/17/2023 at 11:25 PM, P2's physician ordered HT, "Tomorrow AM" (7/18/2023).

On 7/25/2023, P2's physician ordered HT, "Tomorrow AM" (7/26/2023).

Registered Nurse 3 (Informatics- RN 3) did not provide documented evidence to show that P2's HT was provided on 7/18/2023 and 7/26/2023, as ordered.

b. Review of P3's medical record indicated P3 was admitted to the facility on 7/24/2023, per the admission H&P. The H&P, dated 7/24/2023, indicated P3's admission diagnoses included ESRD with HT.

Review of P3's PO, dated 7/24/2023 at 6:55 PM, indicated P3's physician ordered a HT, STAT (urgent - within 2 hours per contracted hemodialysis provider).

RN 3 did not provide documented evidence to show that the HT was provided as ordered.

c. Review of P4's medical record indicated P4 was admitted to the facility on 7/15/2023, per the admission H&P. The H&P, dated 7/16/2023, indicated P4's admission diagnoses included ESRD with HT.

Review of P4's PO, dated 7/19/2023, indicated P4's physician ordered HT for 7/20/2023. RN 3 did not provide documented evidence to show that HT was provided on 7/20/2023, as ordered.

d. Review of P5's medical record indicated P5 was admitted to the facility on 7/14/2023, per the admission H&P. The H&P, dated 7/17/2023, indicated P5's admission diagnoses included ESRD with HT.

Review of PO, dated 7/15/2023, indicated P5's physician ordered HT for 7/16/2023.

RN 3 did not provide documented evidence to show that HT was provided on 7/16/2023, as ordered.

e. Review of P6's medical record indicated P6 was admitted to the facility on 8/4/2023, per the admission H&P. The H&P, dated 8/5/2023, indicated P6 admission diagnosis included ESRD with HT.

Review of PO, dated 8/6/2023 at 11:18 PM, indicated P6's physician ordered HT, "Tomorrow AM" (8/7/2023).

RN 3 did not provide documented evidence to show that HT was provided on 8/7/2023, as ordered.

f. Review of P7's medical record indicated P7 was admitted to the facility on 7/28/2023, per the admission H&P. The H&P, dated 7/29/2023, indicated P7's admission diagnoses included ESRD with HT.

Review of P7's PO, dated 7/29/2023 and 7/31/2023, indicated P7's physician ordered HT for 7/30/2023 and 7/31/2023.

RN 3 did not provide documented evidence to show that HT was provided on 7/30/2023 and 7/31/2023, as ordered.

g. Review of P8's medical record indicated P5 was admitted to the facility on 8/10/2023, per the admission H&P. The H&P, dated 8/9/2023, indicated P8's admission diagnoses included ESRD with HT.

Review of P8's PO, dated 8/11/2023 at 9:08 AM, indicated P8's physician ordered HT, STAT.

RN 3 did not provide documented evidence to show that HT was provided STAT on 8/11/2023, as ordered.

h. Review of P9's medical record indicated P9 was admitted to the facility on 8/2/2023, per the admission H&P. The H&P, dated 8/2/2023, indicated P9's admission diagnoses included ESRD with HT.

Review of P9's PO indicated:

On 8/6/2023, P9's physician ordered HT for, "Tomorrow AM" (8/7/2023).

On 8/14/2023, P9's physician ordered HT for, "Tomorrow AM" (8/15/2023).

RN 3 did not provide documented evidence to show HT was provided on 8/7/2023 and 8/15/2023, as ordered.

i. Review of P14's medical record indicated P14 was admitted to the facility on 7/29/2023, per the admission H&P. The H&P, dated 7/29/2023, indicated P14's admission diagnoses included ESRD with HT.

Review of P14's PO, dated 7/29/2023, indicated P14's physician ordered HT for, "Today" (7/29/2023).

RN 3 did not provide documented evidence to show HT was provided on 7/29/2023, as ordered.

j. Review of P16's medical record indicated P16 was admitted to the facility on 8/2/2023, per the admission H&P. The H&P, dated 8/2/2023, indicated P16's admission diagnoses included ESRD with HT.

Review of P16's PO, dated 8/4/2023, indicated P16's physician ordered HT for, "Tomorrow AM" (8/5/2023).

Registered Nurse 4 (Informatics- RN 4) did not provide evidence to show HT was provided on 8/5/2023, as ordered.

k. Review of P17's medical record indicated P17 was admitted to the facility on 7/17/2023, per the admission H&P. The H&P, dated 7/17/2023, indicated P17's admission diagnoses included ESRD with HT.

Review of P17's PO indicated:

On 7/18/2023, P17's physician ordered HT for 7/19/2023.

On 7/21/2023, P17's physician ordered HT for 7/22/2023.

RN 4 did not provide documented evidence to show HT was provided on 7/19/2023 and 7/22/2023, as ordered.

l. Review of P18's medical record indicated P18 was admitted to the facility on 7/21/2023, per the admission H&P. The H&P, dated 7/21/2023, indicated P18's diagnoses included ESRD with HT.

Review of P18's PO, dated 7/21/2023, indicated P18's physician ordered HT for 7/22/2023.

RN 4 did not provide documented evidence to show HT was provided on 7/22/2023, as ordered.

m. Review of P21s (intake CA00851287) medical record indicated P21 was admitted to the facility on 7/5/2023, per the face sheet. P21's diagnoses included ESRD with HT.

Review of P21's PO, dated 7/9/2023, indicated P21's physician ordered HT for, "TOMORROW AM" (7/10/2023).

RN 4 did not provide documented evidence to show HT was provided on 7/10/2023, as ordered.

n. Review of P22's medical record indicated P22 was admitted to the facility on 7/13/2023, per admission H&P. The H&P, dated 7/13/2023, the H&P indicated P22's admission diagnoses included ESRD with HT.

Review of PO, dated 7/13/2023 at 4:46 PM, indicated P22's physician ordered HT STAT.

RN 4 did not provide documented evidence to how HT was provided STAT on 7/13/2023, as ordered.

o. Review of P27's medical record indicated P27 was admitted to the facility on 7/13/2023, per Face Sheet.

Review of P27's H&P, dated 7/16/2023, indicated P27's diagnoses included ESRD with HT.

Review of P27's PO indicated:

On 7/17/2023, P27's physician ordered HT for, "TOMORROW AM." (7/18/2023).

On 7/21/2023, P27's physician ordered HT for, "TODAY" (7/21/2023).

On 7/26/2023, P27's physician ordered HT for, "TODAY." (7/26/2023).

On 7/30/2023, P27's physician ordered HT for, "TOMORROW AM." (7/31/2023).

RN 4 did not provide documented evidence to show HT was provided on 7/18/2023, 7/21/2023, 7/26/2023, and 7/31/2023, as ordered.

p. Review of P28's medical record indicated P28 was admitted to the facility on 7/18/2023, per H&P. The H&P, dated 7/18/2023, indicated P28's diagnoses included ESRD with HT.

Review of P28's PO indicated:

On 7/18/2023, physician ordered HT for, "TODAY" (7/18/2023).

On 7/20/2023, physician ordered HT for, "TOMORROW" (7/21/2023).

RN 4 did not provide documented evidence to show HT was provided on 7/18/2023 and 7/21/2023, as ordered.

During an interview with Charge Nurse 1 (CN 1) on 8/14/2023 at 12:32 PM, CN 1 stated, that STAT orders for HT should have been started within 2 hours.

During an interview with RN 1 on 8/14/2023 at 12:47 PM, RN 1 stated, the nursing staff should have notified the facility's Command Center (CC) of the physicians' orders for HT. RN 1 stated, the CC should have notified the contracted dialysis provider of the HT orders.

During an interview with the contracted dialysis provider's Medical Director (MD 1), on 8/17/2023 at 10:30 AM, MD 1 stated, physicians' orders for HT should have been implemented as ordered.

During a review of the facility's policy and procedure, titled, Verbal/Telephone and Written Orders, approved 3/2022, indicated the purpose of the policy was, "To ensure all physician orders are accurately carried out in a timely manner."

During a review of the facility's contract with the dialysis provider, the contract contained a document titled, "Exhibit B Schedule of Services and Fees," and indicated, "STAT Hemodialysis Procedure (within 2 hours of request)."

2 a. Review of P21s medical record indicated P21 was admitted to the facility on 7/5/2023, per the face sheet. P21's diagnoses included ESRD with HT.

Review of P21's PO for HT and HT Records indicated the HT nurse did not carry out HT according to the physician's order:

On 7/13/2023, HT order, "Bath (a solution of pure water, electrolytes and salts, such as bicarbonate and sodium) K+ (potassium - an electrolyte) 1 mEq L (milliequivalent - amount per liter)."

On 7/13/13, the HT Record indicated a K+ 2 mEq L was used during the treatment.

b. Review of P22's medical record indicated P22 was admitted to the facility on 7/13/2023, per admission H&P. The H&P, dated 7/13/2023, the H&P indicated P22's admission diagnoses included ESRD with HT.

Review of P22's PO for HT and HT Records indicated the HT nurse did not carry out HT according to the physician's order:

On 7/14/2023, HT order, "DURATION 2 hours..."and the HT Record indicated P22's HT duration was 3 hours long.

c. Review of P26's medical record indicated P26 was admitted to the facility on 7/13/2023, per the face sheet.

Review of the admission H&P indicated P26's diagnoses included ESRD with HD.

Review of P26's PO for HT and HT Records indicated the HT nurse did not carry out HT according to the physician's order:

On 7/21/2023, HT order, blood flow rate (BFR) 350 ml/min (milliliters per minute); Dialysate flow rate (DFR- the part of a mixture which passes through the membrane in dialysis) 700 ml/min. P26's HT Record indicated a BFR of 200-300 ml/min, and a DFR of 500 ml/min were used.

d. Review of P28's medical record indicated P28 was admitted to the facility on 7/18/2023, per H&P. The H&P, dated 7/18/2023, indicated P28's diagnoses included ESRD with HT.

Review of the PO for HT, and the HT Records indicated the HT Nurse did not carry out HT according to the physician's order:

On 7/27/2023, HT order, "Bath K+ 2.5 mEq/L." P26's HT Record indicated a 2 K+ bath was used.

During a review of the facility's policy and procedure, titled, Verbal/Telephone and Written Orders, approved 3/2022, indicated the purpose of the policy was, "To ensure all physician orders are accurately carried out in a timely manner."

During an interview with the contracted dialysis Medical Director (MD 1), on 8/17/2023 at 10:30 AM, MD 1 stated the HT Nurse should have clarified orders with the ordering physician in cases where the HT Nurse determined the order did not match the patient's current condition. MD 1 stated physicians' orders for dialysis treatments should be carried out as ordered.

3 a. Review of P7's medical record indicated P7 was admitted to the facility on 7/28/2023, per the admission H&P. The H&P, dated 7/29/2023, indicated P7's admission diagnoses included ESRD with HT.

Review of P7's HT Record, dated 7/31/2023, indicated the record had illegible documentation for times when vital signs (heart rate and blood pressure) were measured.

b. Review of P15's medical record indicated P!5 was admitted to the facility on 7/25/2023, per the admission H&P. The H&P, dated 7/25/2023, indicated P15 had a diagnosis which included ESRD with HT.

Review of P15's HT Records for P15, dated 7/25/2023 and 7/28/2023, indicated the records had illegible documentation for times when vital signs were measured.

c. Review of P21s medical record indicated P21 was admitted to the facility on 7/5/2023, per the face sheet. P21's diagnoses included ESRD with HT.

Review of P21's HT Records, dated 7/11/2023 and 7/13/2023, indicated the documentation for the nursing assessment, nursing notes, and vital sign measurements were illegible.

d. Review of Patient 26's medical record indicated P26 was admitted to the facility on 7/13/2023, per the admission H&P. The H&P indicated P26 had a diagnoses included ESRD with HT.

Review of P26's HT Record, dated 7/20/2023,indicated the documentation for the nursing assessment, nursing notes, and vital sign measurements were illegible.

e. Review of Patient 27's medical record indicated P27 was admitted to the facility on 7/13/2023, per the face sheet.

Review of P27's admission H&P, indicated P27's diagnoses included ESRD with HT.

Review of P27's HT Record, dated 8/1/2023, indicated the documentation for the nursing assessment, nursing notes, and vital sign measurements were illegible.

f. Review of P28's medical record indicated P28 was admitted to the facility on 7/18/2023, per H&P. The H&P, dated 7/18/2023, indicated P28's diagnoses included ESRD with HT.

Review of P28's HT Records, dated 7/27/2023 and 7/29/2023, indicated the documentation for the nursing assessment, nursing notes, and vital sign measurements were illegible.

g. Review of P29's medical record indicated P29 was admitted to the facility on 8/8/2023, per the admission H&P, dated 8/8/2023. P29's admission diagnoses included ESRD with HT.

During a review of P29's HT Record, dated 8/12/2023, indicated the documentation for the nursing assessment, nursing notes, and vital sign measurements were illegible.

During an interview with the contracted dialysis Administrator (ADM 1), on 8/17/2023 at 10 AM, ADM 1 stated HT Records should have been legible for continuity of patient care.

Review of the contracted dialysis policy and procedure (P&P), titled, Documentation, dated 2/15/2018, the P&P indicated, "Each entry should be legible..."

Review of the facility's Legal Record Policy: Definitions and Standards P&P, dated 3/2022, the P&P indicated, "...All entries in the Medical Record must be legible to individuals other than the author."

The facility failed to ensure the Condition of Participation Quality Assessment and Performance Improvement Program (QAPI) was met when the Chief Nursing Officer (CNO) identified delayed patient hemodialysis treatments (HT) but did not report the delays to the QAPI Program for action. (Refer to A-0283)

The cumulative effects of this systemic practices resulted in the facility's inability to be in compliance with the QAPI Program Condition of Participation.

Based on interview and record review, the facility failed to maintain an effective Quality Assessment and Performance Improvement Program (QAPI) Program when the Chief Nursing Officer (CNO) failed to report identified delays in patient hemodialysis treatments (HT) to the facility's QAPI Program Committee for action. This failure resulted in delayed HT for 16 of 30 sampled patients.

Findings:

During an interview with the CNO, who was a member of the facility's QAPI Program Committee, on 8/18/23 at 9 AM, the CNO stated she had been aware of delayed patient HT for months and had not reported the identified concern to the facility's QAPI Program Committee for action.

During a review of the facility's QAPI Program with Registered Nurse 5, on 8/18/23 at 11:57 AM, the QAPI Program records failed to show documented evidence of the delayed HT for the facility's patients.