HospitalInspections.org

Based on policy review, medical record review, tour/observation, and staff interviews, the hospital's nursing staff failed to supervise and evaluate patient care by: failing to ensure a patient's peritoneal dialysis (PD) treatments were performed according to hospital policy and procedure for 1 of 5 sampled PD patients (Patient #9) and failing to ensure nursing staff knowledge that patients receiving high risk potassium dialysate in hemodialysis treatments should be cardiac monitored according to the hospital's policy and procedures.

Findings include:

1. Review of the hospital's policy "Peritoneal Dialysis with use of the Baxter Home Choice Cycler System" (Dated 05/2010) revealed "Purpose: To provide direction to staff members in the performance of Peritoneal Dialysis on in-patients at ___(Hospital Name) while insuring the highest level of safety. Trained staff members shall follow the procedure provided when performing the dialysis exchange." The policy further revealed "9. Loading the Disposable Cassette: Place the drain bag shiny side up on the floor or lower level of the cart. As effluent drains into bag, you will be able to note effluent appearance. Document appearance on patient flow sheet. 14...Care of catheter and exit site: After peritoneal dialysis complete, clean around exit using sterile gauze pads, water and antibacterial soap starting at exit site and moving outward. Rinse with water and sterile gauze. Dry with sterile gauze. Document exit site appearance on peritoneal dialysis flow sheet."

Review on 05/31/2012 of the closed medical record for patient #9 revealed that the patient, 70 years old was admitted to hospital on 01/08/2012 through 01/10/2012 with diagnosis of "Bradycardia, Renal Failure and Hyperkalemia." The review revealed that the patient was ordered by the physician to receive peritoneal dialysis (PD) treatments using the hospital's "Baxter Cycler" for the treatments beginning 01/08/2012. Review of the hospital's "Peritoneal Dialysis Flow Sheets" dated 01/08/2012 and 01/09/2012 revealed that the hospital's nursing staff failed to document that the patient's PD treatments were completed according to the hospital's policy and procedures. Review of the flow sheets revealed that the nursing staff failed to document "Effluent Description, Exit Site Appearance, Cycler Set Up times, and times of post PD treatments" for the patient's PD treatment on 01/09/2012 and failed to document a second licensed nurse check (required two licensed nurse checks) and the Cycler Set Up times for the patient's PD treatment on 01/08/2012.

Interview on 05/31/2012 at 1205 with the hospital's nursing administration staff revealed that hospital's nursing staff (Not available for interviews) that provided the PD treatments to the patient 01/08/2012 and 01/09/2012 did not document the required care of the patient's PD treatments according to the policy and procedures of the hospital. The interview confirmed the findings of the missed documentation.

2. Review of the hospital's policy "Use of 0.0 mEq/L (milliequivalent per Liter) and 1.0 mEq/L Potassium Dialysate in FMS (name of contracted agency) Inpatient Services" (Effective 08/25/2008) revealed "Purpose: The purpose of this procedure is to provide guidelines for the use of 0.0 and 1.0 mEq/L potassium dialysate in the inpatient program when the use of low potassium dialysate is deemed medically necessary and there is a written order by the credentialed Physician. Caution: The use of 0.0 mEq/L potassium dialysate and 1.0 mEq/L K+ (Potassium) is considered HIGH RISK due to cardiac arrthymias that may occur due to a decrease in serum potassium. Extreme caution must always be maintained to safely deliver treatment to those patients on 0.0 and 1.0 mEq/L K+ dialysate." The review further revealed "The patient MUST have cardiac monitoring/telemetry when dialyzing utilizing a 0.0 mEq/L or 1.0 mEq/L K+ dialysate."

Tour and observation of the hospital's hemodialysis room on 05/30/2012 at 1405 revealed premixed containers of 1.0 mEq/L K+ dialysate unopened located with the other used K+ dialysates strengths. An interview during the observation at 1410 with the hospital's hemodialysis manager revealed that the facility did not use 0.0 mEq/L dialysates but did use 1.0 K+dialysate if needed.

An interview 05/31/2012 at 1005 with the hospital's hemodialysis manager revealed "I am not sure if patients on 1.0 K+ dialysates are cardiac monitored or not." The interview confirmed that the manager (Registered Nurse) of the hemodialysis unit did not know the hospital's policy for 1.0 mEq/L K+ dialysates required the patients to be cardiac monitored while receiving the dialysate. The interview further revealed "We have had patients on 1.0, although not sure of last of names of the patients. I need to review the policy."


Reference NC00078159.