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Based on observation, interview, record review and policy review, the facility failed to initiate actions to ensure hemodialysis treatment (a blood cleansing procedure using a special machine to remove waste and excess water from the blood and used as an artificial replacement for lost kidney function) was available for one patient (#10) of three patients who required treatment due to kidney failure. The facility also failed to ensure nursing staff assessed, supervised and evaluated nursing care for two patients (#7 and #15) of two patients reviewed with skin and wound care issues.
These failures had the potential to cause harm to all patients needing hemodialysis (dialysis) and to any patients with skin or wound care issues.
The facility census was 100.

Findings included:

1. Record review of the facility policy titled, "HSI Hemodialysis Services, Inc. Hemodialysis Services", revised 06/2014 showed that Hemodialysis Services is an acute service that provides emergency hemodialysis treatment on an as needed basis to acute care hospitals and long term acute care facilities. Equipment and disposable supplies for the hemodialysis treatment and staff are provided.

2. Record review of Patient #10's History & Physical (H&P) showed the patient was admitted to the facility on 11/23/15 for decreased level of consciousness which resulted from Chronic Renal Failure.

Record review of physician orders showed:
- On 12/07/15 an order for dialysis.
- A telephone order dated 12/11/15 at 4:00 PM by Staff MM, Attending Physician, "May remain at this facility". (The facility had been informed that dialysis services would not be available on 12/12/15.)
- Staff MM, wrote an order dated 12/14/15 at 2:15 PM to transfer the patient to a facility for dialysis.
- Staff II, Nephrologist, wrote an order dated 12/14/15 at 3:08 PM to arrange a facility for the patient to receive dialysis.
- Staff MM, wrote an order dated 12/14/15 at 4:31 PM to send the patient to Hospital B.
The patient was transferred on 12/14/15.

During an interview on 12/14/15 at 4:45 PM, Staff LL, Director of Nursing (DON), stated that:
-Dialysis was provided on Tuesday,Thursday and Saturdays by a contracted source which was ending on 12/23/15.
-The dialysis provider had informed her on Friday (12/11/15) that they had no staff to provide dialysis on Saturday.
-She had tried to call the provider numerous times but did not get a response to her calls.
-Admissions for dialysis patients had not been stopped.
-There were three patients receiving dialysis at that time with one patient who had been admitted with worsening renal function. (Record review showed only two patients received dialysis and one of those patients was transferred to another facility on 12/12/15.)
-Primary physicians had been called about each of their dialysis patients with orders to transfer one patient and two patients could wait until Monday for their dialysis.
-An order or progress note had not been written after speaking with the physicians.
-A dialysis nurse had been hired two weeks ago and "last week" (week of 12/07/15) equipment and supplies had been ordered.
-The provider stated that they could not find staff to provide dialysis for the remainder of their contract.

During an interview on 12/16/15 at 7:42 AM, Staff Z, Chief Operating Officer/Chief Nursing Officer (COO/CNO), stated that although equipment and supplies had been ordered, he did not think that dialysis services would be available for two to three months.

During an interview on 12/15/15 at 9:00 AM, Staff LL, stated that the Emergency Medical System (EMS) had been notified as of today that the facility would no longer admit dialysis patients.

During an interview on 12/15/15 at 9:30 AM, Staff N, Emergency Room (ER) Paramedic, stated that she was not aware that dialysis patients were not to be admitted.

During an interview on 12/15/15 at 9:26 AM, Staff P, ER Physician, stated that the facility had not informed him not to admit patients who needed dialysis. He stated that if someone came to the ER, they would be admitted and provided dialysis.

3. Record review of the facility's policy titled, "Admission Assessment and Process", dated 07/2014, showed the following directives:
- Registered Nurses (RNs) conducted a comprehensive and complete physical assessment of all patients admitted to the medical/surgical unit (MS Unit, where patients who had medical and/or surgical care needs were placed) ) within four hours of admission.
- RNs notified the admitting physician if physician orders were warranted for additional patient care needs based on the patient's assessment findings.
- Discharge/transfer needs were assessed by the nurse at the time of the initial assessment and throughout the patient's admission.

Record review of the facility's policy titled, "Skin Integrity: Assessment, Plan, Intervention and Documentation", dated 02/2015 showed the following staff directives:
- The nurse was responsible for the assessment of patients' skin integrity upon admission.
- The nurse conducted a wound assessment and documented the findings on a body gram (a blank picture outline of a body) on admission, daily and each shift.
- The body gram documentation included a description of each wound identified.
- Each wound was described by of the size, depth, color, wound bed/wound edges, drainage, appearance of the surrounding skin, odor, pain, bandages, products used for care and evaluation of the patient's response to treatment.
- Notification of assessment findings related to a patient's impaired (less than perfect, damaged or weakened) skin integrity to the physician was the responsibility of the nurse.
- When necessary to provide skin care treatments and or interventions beyond the scope and authority of a nurse, the nurse was required to request physician orders.
- Nurse documented assessments in the medical record.

4. Observation on 12/15/15 at 2:38 PM on the MS Unit, showed Patient #15 sitting on the side of the bed with a sock on the right foot. On the top of the sock, near the toes was a circular area, approximately two inches in circumference, of a wet liquid stain that had soaked through the sock. Three areas, approximately one inch in circumference, of amber colored stains were on the sheet at the foot of the patient's bed.

Observation of wound care on 12/15/15 at 3:05 PM of Patient #15, conducted with Staff K, Clinical Coordinator, showed Staff S, RN, removed the sock and a bandage from the patient's right foot and showed a grotesquely swollen right third toe with a wound that was purple to dark red and had dark purplish color skin surrounding the wound. The bandage was soaked with amber and tan drainage. Staff S provided wound care to the patient's right foot. Observation of the patient's left foot had multiple areas of broken skin located in the crevices on the bottom of the foot where the toes project from the foot and one healing wound about one half inch in circumference near the ball of the foot.

During an interview on 12/15/15 at 3:05 PM, Patient #15 stated that she did not have any "feeling" in her feet, was not able to feel pain or know if a new sore developed on her feet. She stated that she did not realize she had the infected sore on her right foot until a family member saw it and told her it was infected. She further stated that no nurse had assessed her left foot for wounds.

Record review of Patient #15's medical record on 12/15/15 showed two photographs of the patients right foot wound. The photos were dated 12/05/15 and 12/10/15. Both photos showed the right toe was red and slightly swollen. There was no wound assessment documentation in the medical record per the facility policy.

During an interview and concurrent medical record review on 12/15/15 at 3:30 PM, Staff S, and Staff K, stated that Patient #15's right foot wound looked like it had deteriorated since the photos were taken on 12/05/15 and 12/10/15. Staff S and K, agreed no nurse assessed the ongoing condition of the patient's wound and that there was no documentation of impaired skin integrity of the left foot.

During an interview on 12/16/15 at 8:50 AM, Staff Y, Physician, stated that he provided care and oversight to most patients with wounds and/or skin impairment which included Patient #15. He stated that diagnostic tests showed she had a bone infection, required long-term antibiotic treatment and that she was at a high risk for the amputation of her right foot. He further stated that he was not aware that the patient had wound drainage or that the left foot had impaired skin integrity. He stated that he had ongoing concerns about the nurses' lack of patient wound assessments, lack of wound care and notification of the patients' response to treatment. He stated that he expected the nurses to follow the facility's policy.

5. Observation on 12/14/15 at 2:35 PM on the MS Unit of Patient #7 showed:
- Both lower legs were extremely large and swollen.
- Approximately five inches of exposed skin just below the knees were a purplish/red color, had deep crevices, deep dimpling and had multiple scattered fluid filled sacs on the surface of the skin. Approximately five inches below both knees, elastic bandages were loose and unevenly wrapped.
- Multiple areas of greenish/tan colored stains, that looked dried and hardened, as well as wet areas, were scattered throughout the bandages on both legs.
- A foul odor emitted from the patient.

During an interview and concurrent observation of Patient #7 on 12/14/15 at approximately 2:35 PM, Staff J, Infection Prevention Coordinator, stated that:
- The discoloration on Patient #7's lower leg bandages looked "bad".
- What looked like drainage from wounds had soaked through to the outside of the bandages.
- The patient had a foul odor and the odor could have come from the wounds.
- Nurses were responsible for notifying the physician of draining wounds.

During an interview on 12/14/15 at 2:50 PM, Patient #7 stated that:
- His legs were infected, painful and swollen more than they had ever been.
- No one looked at his leg wounds, provided wound care or changed the leg bandages since he was admitted.
- It had been four days since he was admitted and he felt worse than ever.

During an interview on 12/14/15 at approximately 4:00 PM, Staff L, RN, who was assigned to the care of Patient #7, stated that:
- It was the end of her shift and she had provided care to the patient for the entire shift.
- She was not aware of the patient's lower extremity wounds.
- Because she had not conducted the appropriate wound/skin assessments, and she was not aware of previous wound/skin assessments, she was not able to evaluate the patients response to treatment.
- She could not determine if the patient's status had deteriorated (gotten worse) or improved since he was admitted.

During an interview on 12/14/15 at 4:00 PM, Staff K reviewed Patient #7's medical record and stated that:
- On 12/10/15, the patient was admitted for right lower extremity cellulitis (a serious skin infection that happens when bacteria spread through the skin to deeper tissues).
- No evidence a nurse conducted an initial skin integrity assessment or ongoing assessments of the lower leg wounds.
- No evidence a nurse provided wound care to the lower leg wounds.
- No evidence a nurse notified a physician of the patient's impaired skin integrity.
- No evidence a nurse evaluated the patient's response to treatment for actual and/or potential risk factors associated with lower leg cellulitis.















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Based on observation, interview, record review and policy review the facility failed to ensure Care Plans were initiated, individualized and/or revised for four current patients (#7, #15, #6 and #16) and one discharged patient (#23) of 12 care plans reviewed. This had the potential to affect all patients, when the patients' needs go unidentified and may lead to medical needs not being met and could result in poor patient outcomes. The facility census was 100.

Findings included:

1. Record review of the facility policy titled, "Interdisciplinary Plan of Care", revised 06/2015, showed the following direction:
-To provide an organized plan of care that identifies problems and coordinates interdisciplinary goals in meeting the patient needs.
-To provide an effective method of communicating pertinent information to all personnel involved in the care of the patient.
-An individualized patient plan for healthcare services be written as part of the admission process and revised/updated as appropriate.
-The patient's problems are identified when the patient is admitted based on abnormal "assessment parameters" and the nursing process
-The Plan of Care is to be initiated at the time of admission to the medical/surgical unit.

2. Observation on 12/14/15 at 2:35 PM on the medical/surgical unit of Patient #7 showed:
- Both lower legs were extremely large and swollen.
- Approximately five inches of exposed skin just below the knees was purplish/red color, had deep crevices, deep dimpling and had multiple scattered fluid filled sacs on the surface of the skin. Approximately five inches below both knees, elastic bandages were loose and unevenly wrapped.

During an interview on 12/14/15 at 2:50 PM, Patient #7 stated that:
- Prior to admission, a doctor at a wound clinic told him to go to an Emergency Department because his legs were infected.
- His legs were painful and swollen more than they had ever been. No one looked at his leg wounds, provided wound care or changed the leg bandages since he was admitted.

During an interview and concurrent review of the medical record for Patient #7 on 12/14/15 at approximately 4:00 PM, Staff L, Registered Nurse (RN) assigned to the care of the patient, stated that:
- There was no care plan developed for the patient's wound care or skin integrity.
- She had not assessed or performed wound care to the patient's lower extremity wounds.
- She did not evaluate or provide specific nursing interventions to his leg wounds because she didn't know he had the wounds.

Record review of Patient #7's medical record, conducted with Staff K, Clinical Coordinator, on 12/14/15, showed:
- On 12/10/15, the patient was admitted for right lower extremity cellulitis (a serious skin infection that happens when bacteria spread through the skin to deeper tissues) .
- No care plan was developed to address the patient's problems related to the lower extremity wounds.
- No nursing assessment, interventions or nursing evaluation was documented about of the patient's lower extremity wounds or transfer to another facility.
- A fall-risk care plan included an intervention for the use of a chair/bed alarm (an alarm placed on surfaces to alert nursing staff if a patient got out of bed or up from a seated position in a chair. No alarm was observed in the patient's room.)

During an interview on 12/14/15 at approximately 4:05 PM, Staff K stated that Patient #7's medical record did not include documentation of the nursing process or care plan that addressed the patient's current problems and needs related to the leg wounds or transfer. She further stated that all care plans for fall risks automatically included the use of a bed/chair alarm. However, Patient #7 did not need a bed/chair alarm and the intervention was not updated and the use of a bed/chair alarm was not removed from the care plan.

3. Observation on 12/15/15 at 2:38 PM, showed Patient #15 sitting on the side of the bed with a sock on the right foot. On the top of the sock, near the toes was a circular area, approximately two inches in circumference, of a wet liquid stain that had soaked through the sock. Three areas, approximately one inch in circumference, of amber colored stains were on the sheet at the foot of the patient's bed.

Observation of wound care on 12/15/15 at 3:05 PM of Patient #15, conducted with Staff K, Clinical Coordinator, showed Staff S, RN, removed the sock and a bandage from the patient's right foot and showed a grotesquely swollen right third toe with a wound that was purple to dark red and had dark purplish color skin surrounding the wound. The bandage was soaked with amber and tan drainage. Staff S provided wound care to the patient's right foot. Observation of the patient's left foot had multiple areas of broken skin located in the crevices on the bottom of the foot where the toes project from the foot and one healing wound about one half inch in circumference near the ball of the foot.

During an interview and concurrent observation of wound care on 12/15/15 at 3:05 PM, Patient #15 stated that she did not have any "feeling" in her feet, was not able to feel pain or know if a new sore developed on her feet. She further stated that no nurse had assessed her left foot for wounds.

During an interview and concurrent medical record review on 12/15/15 at 3:30 PM, Staff S, and Staff K, stated that Patient #15's medical record did not contain a care plan or documentation of the nursing process for the patient's foot wounds or impaired ability to identify pain in her feet.

During an interview on 12/16/15 at 8:50 AM, Staff Y, Physician, stated that he provided care and oversight to most patients with wounds and/or skin impairments and included Patient #15. He stated that diagnostic tests showed she had a bone infection, required long-term antibiotic treatment and that she was at a high risk for amputation (surgically remove) of her right foot if the wound was not carefully monitored and treated. He stated that he expected the nurses to follow the facility's policies and develop a plan to meet the patient's needs.

4. Record review of current Patient #6's medical record showed:
- Documentation on the H&P that the patient was admitted on 12/02/15 for complaints of a fall and swollen lower legs.
- A care plan for a the patient's high fall-risks included the placement of a bed and/or chair alarm and patient education to inform the patient he was not to stand or walk without assistance.
- Nursing care plan interventions to frequently reinforce the patient's need to call nursing staff for assistance to stand and walk was also included.

Observation and concurrent interview on 12/14/15 at 3:00 PM of Patient #6 showed the patient was awake and alert sitting up in the bed. No chair/bed alarm was on/in the bed or chair. The patient stated that no one had instructed him to call for a nurse when he got out of bed or walked. He stated that he went to the bathroom and walked "all over the hospital" without anyone's help.

During an interview and concurrent record review on 12/14/15 at about 3:50 PM, Staff K, and Staff L, RN assigned to the care of Patient #6, stated that the patient stood up and walked by himself without assistance. He did not have to request assistance and did not have a bed/chair alarm. Staff K stated that the care plan for the patient was not accurate and was not updated since he was admitted.

5. Record review of Patient #16's H&P showed the patient was admitted on 12/12/15 for mental status changes, Urinary Tract Infection, Dementia and open wounds on her face.

Record review of the patients' care plan initiated on 12/13/15 at 1:30 AM showed "Infection" with interventions of monitor signs and symptoms, monitor labs and diagnostic test results and report abnormal finding and use aseptic/sterile technique when handling any invasive lines. No documentation was found for assessment or treatment of the wounds on her face.

During an interview on 12/15/15 at 3:45 PM, Staff K, Clinical Coordinator, stated that the care plan did not include the problem, interventions or goals of the wounds on the patient's face nor was it in the task list (a document which the nurses refer to for care of the patient). She stated that she would expect this active ongoing wound care to be in the care plan.

6. Record review of discharged (12/12/15) Patient #23's H&P showed the patient was admitted to the facility on 12/10/15 for cough and fever. A chest x-ray showed pneumonia (a lung infection). The assessment and plan showed the patient had chronic kidney disease and was on dialysis.

Record review of the patient's care plan initiated on 12/10/15 at 11:29 PM showed no problem, intervention or goals for pneumonia or chronic kidney disease with dialysis.

















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