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CHRISTUS GOOD SHEPHERD MEDICAL CENTER
PATIENT RIGHTS
Tag No.: A0115
Based on record review, and staff interviews, the hospital failed to ensure the dialysis department had, at a minimum, 2 trained Registered Nurses readily available to provide direct patient care to patients receiving hemodialysis in 1 (Satellite Hospital- 811 South Washington Ave, Marshall, Texas) of 2 dialysis departments. Also, the hospital failed to have a staffing matrix and plan for 2 (Main Hospital, Satellite Hospital) of 2 dialysis departments.
(Cross Refer to Tag A 0144)
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on record review, and staff interviews, the hospital failed to ensure the dialysis department had, at a minimum, 2 trained Registered Nurses readily available to provide direct patient care to patients receiving hemodialysis in 1 (Satellite Hospital- 811 South Washington Ave, Marshall, Texas) of 2 dialysis departments. Also, the hospital failed to have a staffing matrix and plan for 2 (Main Hospital, Satellite Hospital) of 2 dialysis departments.
This deficient practice had the likelihood of resulting in a delay in hemodialysis patient care and/or an incomplete dialysis treatment. Dialysis patients who do not complete or miss treatment are at an increased risk of electrolyte imbalances which can cause heart arrhythmias, cardiac arrest, and death.
A review of the staffing assignments and on-call list for the hospital's dialysis department was conducted with Staff # 12 on 07/12/2024 at 1:30 PM.
A total of 3 patients (# 6, # 7, and # 8) were treated at the Satellite Hospital from July 01, 2024 to July 07, 2024.
Patient # 6
Patient # 6 underwent hemodialysis treatment on 07/01/2024 at the Satellite Hospital. Staff # 24 was the Registered Nurse who provided care to the patient. Staff # 24 was clocked in on 07/01/2024 from 3:45 PM to 9:25 PM at the Satellite Hospital. There were no other hemodialysis-trained Registered Nurses clocked in and working at the Satellite Hospital on 07/01/2024.
Patient # 7
Patient # 7 underwent hemodialysis treatment on 07/06/2024 at the Satellite Hospital. Staff # 25 was the Registered Nurse who provided care to the patient. Staff # 25 was clocked in on 07/06/2024 from 7:30 AM to 3:42 PM at the Satellite Hospital. There were no other hemodialysis-trained Registered Nurses clocked in and working at the Satellite Hospital on 07/06/2024.
Patient # 8
Patient # 8 underwent hemodialysis treatment on 07/10/2024 at the Satellite Hospital. Staff # 25 was the Registered Nurse who provided care to the patient. Staff # 25 was clocked in on 07/10/2024 from 7:02 AM to 3:01 PM at the Satellite Hospital. There were no other hemodialysis-trained Registered Nurses clocked in and working at the Satellite Hospital on 07/10/2024.
The surveyor requested a staffing plan and matrix for the Dialysis Units and no such documents were provided.
A review of the hospital policy, "Incapacitated Acute Dialysis Nurse" with a revision date of 11/2022 revealed,
"OBJECTIVE/S: To ensure the patient's safety will be immediately attended to in the case the hemodialysis nurse becomes incapacitated during dialysis treatment.
POLICY STATEMENT: ...
This policy provides guidance to the hospital nursing staff in immediate interventions to apply in order to ensure patient safety should the hemodialysis nurse become incapacitated during a dialysis treatment ...
DEFINITIONS: A. Incapacitated: unable to act, respond, or the like, deprived of strength or power; debilitated ...
PROCESS OR PROCEDURES:
A. Intervention:
1. Call for medical assistance to treat the incapacitated nurse. Safely move the dialysis nurse from the immediate area.
2. Temporary disconnection procedure:
a. Immediately turn the power switch to OFF position on the dialysis delivery system.
b. Clamp each blood line ...
c. Do not attempt to return the blood to the patient.
4. Notify the Acute Dialysis Charge Nurse and program Director via the emergency contact phone number provided.
5. Notify the patient's nephrologist and document any verbal orders given in the patient EMR for the dialysis nurse reporting to resume the patient's dialysis care as needed.
6. Complete an incident report for review in the quarterly QAPI meeting."
An interview was conducted with Staff # 12 on 07/10/2024 at 1:30 PM. Staff # 12 reported the hospital had stopped contracting out dialysis services in May of 2021. The hospital has been performing dialysis services and treatment at both the Main and Satellite Hospitals since May 2021. Also, Staff # 12 reported that hemodialysis trained Registered Nurses commute from the Main Hospital to the Satellite Hospital to provide hemodialysis treatment to patients. Staff # 12 reported there was only 1 trained and qualified Registered Nurse available at a time to care for hemodialysis patients at the Satellite Campus. When the surveyor asked who would provide care to the dialysis patients in the event the primary Registered Nurse became incapacitated, Staff # 12 stated, "There are instructions printed on every TABLO (hemodialysis) machine to instruct staff on how to clamp the dialysis blood lines and turn the machine off".
Staff # 12 confirmed the registered nurses at the Satellite campus had not been trained or deemed competent in hemodialysis patient care and treatment. The surveyor asked if there were any additional Registered Nurses staffed 24/7 who were trained in hemodialysis. Staff # 12 reported there were no Registered Nurses at the Satellite Hospital who had been trained and deemed competent in hemodialysis to resume care in the event the primary hemodialysis nurse became incapacitated.