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Based on observation, review of facility documents, and staff interviews, it was determined that the hospital failed to protect and promote the rights of each patient.

Findings include:

The facility failed to ensure that staff communicated changes in patient condition to consulting providers to ensure the provision of necessary treatments. (Cross refer, Tag A-144)

Based on medical record review, staff interview, and facility policy review, it was determined that the facility failed to ensure that staff communicated changes in patient condition to the consulting providers to ensure the provision of necessary treatments for 1 of 1 patient (P1) receiving continuous renal replacement therapy (CRRT). Failure to notify consulting providers of complications related to their ordered treatment prevents the opportunity for the provider to make changes to prescribed interventions.

Findings include:

Review of P1's medical record revealed a physician's order for continuous hemodialysis, dated 11/25/22 at 12:57 PM by the nephrologist (S10). CRRT, a type of blood purification therapy used with patients experiencing acute kidney injury, was initiated on 11/25/22 at 3:45 PM (15:45) after a dialysis catheter was inserted.

Review of the "Prismaflex System Continuous Renal Replacement Therapy (CRRT) 24 Hour Flowsheet" included a note that stated, "stopped @ 8pm restarted @ 925 - Dr [nephrologist (S10)] aware." An additional note stated, "stopped @ 0125 access issues. PA [physician assistant] [name (S14)] aware."

Review of the Nursing assessment documentation in the electronic medical record (EMR) indicated that the right internal jugular vein central venous catheter (CVC) was assessed every four hours, during the night shift, as follows: 7:00 PM and 11:00 PM on 11/25/22, and 3:00 AM on 11/26/22. The CVC site condition was documented as having "No complications" and both of the CVC blue and red ports were documented as having "Brisk blood return." The medical record lacked evidence of any interventions performed by the nurse or practitioners. The medical record lacked documentation of any provider orders obtained. Additionally, the medical record lacked evidence that the nephrologist was notified that the CRRT was discontinued at 1:25 AM (0125).

A physician's progress note, dated 11/26/22 at 5:07 AM, stated, "... PA EVENT NOTE ... I was called by nursed [sic] because pt [patient] desatted [oxygen levels dropping] to 80s ... ASSESSMENT & PLAN ... - HD [hemodialysis] - Dr. [name] pulmonologist made aware - cardiologist Dr. [name] made aware." The medical record lacked evidence that the nephrologist was made aware.

Documented evidence in the medical record revealed that a Code Blue was called on 11/26/22 at 5:47 AM, and that Patient #1 was pronounced by Staff #17 at 6:08 AM.

During an interview with the nephrologist, Staff #10 (S10), on 1/4/23 at 3:27 PM, S10 stated that he does not remember receiving any calls about P1 having issues with the hemodialysis access on the night of 11/25/22-11/26/22. S10 stated that if he had spoken with the nurse nothing as serious as the access not working was communicated. S10 stated that he had received a text message from P1's pulmonologist on 11/26/22 at 4:46 AM letting him know about the patient's hemodialysis access issues. S10 stated that after receiving the text message, he contacted P1's nurse "right away" and told the nurse to have the central venous catheter (CVC) line replaced by the intensivist who placed the line, or by whomever was the covering practitioner on-call. S10 stated that dialysis related issues should be reported to the nephrologist. A review of the medical record lacked evidence of an order to replace the central line or documentation that the central line was replaced on 11/26/22.

On 1/5/23 at approximately 8:00 AM, an interview was conducted with S11, the nurse providing care to P1 on the night shift on 11/25/22-11/26/22. S11 stated that he had difficulties with the patient's hemodialysis access and that the dialysis lines were clotting a lot. S11 stated that he was changing the dialysis tubing frequently and at one point he disconnected the lines and there was a rather large blood clot. S11 stated that he was troubleshooting the dialysis machine and the access by following the prompts on the machine and by having other nurses assist him. S11 stated that he did speak to the nephrologist (S10) once, but confirmed that he did not call the nephrologist at 1:25 AM when the CRRT was stopped due to "access issues." S11 did not recall the details of the call with S10 in the morning of 11/26/22, but stated that he did not remember receiving orders to have the CVC line changed and believed S10 stated that it was something to be done on day shift. S11 stated that issues with the dialysis access should be reported to the nephrologist. S5, who was present for the interview, clarified that although the nephrologist would be notified, the intensivist would be the primary decision maker for the patient's care.

On 1/5/23 at 9:29 AM, S14, the physician assistant (PA) in the intensive care unit (ICU) who treated P1 on the night of 11/25/22-11/26/22 was interviewed. S14 stated that she did not call the nephrologist after being notified that the CRRT was stopped by S11. S14 stated that the nurse's would be responsible for calling the renal doctor.

During an interview on 1/5/23 at 9:53 AM, S5 was asked about the process for notifying providers of hemodialysis related issues and concerns. S5 stated that the nurse should communicate with both the nephrologist and the intensivist.

During a phone interview with, S17, the attending hospitalist physician, on 1/10/23 at 2:00 PM, S17 stated that all consulting practitioners were aware of P1's declining health status on 11/25/22-11/26/22, including renal. S17 stated that there was nothing the nephrologist could have done because the patient was "medically futile" and that the dialysis machine could not create enough volume to pull blood from the patient. S17 was asked if she spoke to the nephrologist herself and S17 stated that she did not speak to the nephrologist, but she believed her NP (nurse practitioner) did. Staff #2 clarified that the NP was was actually the PA, S14.

Review of the facility policy titled, "Assessment/Reassessment And Documentation," revised 11/2020, stated, "... POLICY: 1. A systemic collection and analysis of patient specific data is performed to identify the patient's relevant behavioral, cognitive, communication, developmental, educational, emotional, physical, psychosocial, and spiritual needs. This assessment also identified facilitating factors and possible barriers to reaching care/treatment goals. The scope and intensity of any further assessment is based on: a) The patient's diagnosis, presenting conditions, or symptoms; ... d) The patient's response to care; ..."

Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to maintain a complete and accurate medical record for all patients treated at the hospital.

Findings include:

1. The facility failed to ensure that all entries into the medical record are authenticated by the individual making the entry for a patient receiving continuous renal replacement therapy (CRRT). (Cross refer Tag A-438)

2. The facility failed to ensure that all information pertinent to the patient condition was documented in the medical record for a patient receiving continuous renal replacement therapy (CRRT). (Cross refer Tag A-467)

Based on medical record review (MR1) and staff interview, it was determined that the facility failed to ensure that all entries into the medical record are fully authenticated by the individual making the entry, for a patient receiving continuous renal replacement therapy (CRRT). Failure to fully complete a medical record entry can impact the course and provision of patient care as an incomplete entry does not provide a complete and accurate accounting of information necessary to inform care.

Findings include:

Review of MR1 revealed an order for continuous hemodialysis dated 11/25/22. A "Prismaflex System Continuous Renal Replacement Therapy (CRRT) 24 Hour Flowsheet" used by nursing staff lacked the date, time, and/or signature of the individual making the medical record entry, as follows:

- The date the flowsheet was in use was left blank.
- The initials of the person completing the 22:00 (10:00 PM) hourly monitoring entry and the time they completed the entry.
- A comment under the "NOTES" section stated, "stopped @ 8pm restarted @925 - Dr [nephrologist] aware." An additional comment stated, "Stopped @ 0125 access issues. PA [name] aware." Neither comment was dated, timed, or signed by the individual making the notation.

During an interview on 1/4/23 at 2:38 PM, the above findings were reviewed with Staff #2 and Staff #5, who confirmed that the above medical record entries were not fully authenticated by the staff member(s) completing the documentation.

Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure that all information pertinent to the patient's condition was documented in the medical record for a patient (P1) receiving continuous renal replacement therapy (CRRT). Failure to document in the medical record has the potential to seriously impact the course and provision of patient care.

Findings include:

1. A review of P1's medical record revealed that CRRT, a type of blood purification therapy used with patients experiencing acute kidney injury, was initiated on 11/25/22 at 3:45 PM (15:45). Hourly assessments were documented on a form titled, "Prismaflex System Continuous Renal Replacement Therapy (CRRT) 24 Hour Flowsheet" from initiation of treatment until 19:00 (7:00 PM). After the 19:00 (7:00 PM) entry, the next documented hourly check was at 22:00 (10:00 PM). The 19:00 check lacked evidence of: the target hourly net fluid removal rate, actual fluid removal, current hourly fluid balance, on-going fluid balance, access ... return, filter ... effluent, TMP (transmembrane pressure) ... pressure drop, BW Temp ... hourly chamber check ... the RN's initials, and the time the check was performed. Hourly checks were not documented at 8:00 PM, 11:00 PM, 12:00 AM, and 1:00 AM.

A note on the "Prismaflex System Continuous Renal Replacement Therapy (CRRT) 24 Hour Flowsheet" stated, "stopped @ 8pm restarted @ 925 - Dr [nephrologist] aware." The flowsheet lacked evidence of the reason the CRRT was stopped at 8:00 PM, any interventions that were performed, and if any practitioner orders were obtained. An additional note stated, "stopped @ 0125 access issues. PA [physician assistant] [name] aware." The flowsheet lacked evidence of what the access issues were, any interventions that were performed, and if any practitioner orders were received. The medical record lacked evidence that the nephrologist was made aware that CRRT was stopped at 01:25 AM.

A nursing note on 11/25/22 at 22:00 (10:00 PM), indicated that S11, the nurse, placed a call to the nephrologist and was awaiting a return phone call. A note from S11 at 22:44 (10:44 PM) indicated that he had spoken with the nephrologist. The "Reason for Call to Provider" stated, "Other: CRRT," but did not include any additional information about what was communicated and discussed during the phone call with the nephrologist.

The medical record lacked any additional evidence of access issues, barriers to the CRRT treatment, interventions performed on the dialysis access, interventions performed to enable the CRRT treatment to be performed, information communicated to practitioners related to the CRRT, and any practitioner orders related to the CRRT.

Nursing assessment documentation in the electronic medical record (EMR) indicated that the right internal jugular vein central venous catheter (CVC) was assessed every four hours, during the night shift, as follows: 7:00 PM and 11:00 PM on 11/25/22, and 3:00 AM on 11/26/22. The CVC site condition was documented as having "No complications" and both of the CVC blue and red ports were documented as having "Brisk blood return."

During an interview on 1/4/23 at 2:38 AM, the above medical record findings were reviewed and confirmed with S2 and S5. S2 confirmed that the medical record lacked documentation of complications related to P1's CRRT treatment and that the CRRT flowsheet was not completed hourly in accordance with facility policy. During a follow up phone interview on 1/6/23 at approximately 4:15 PM, S2 stated that the access site should be documented every 4 hours and that the CRRT policy stating that documentation should be every 2 hours was not clear.

Review of the facility policy titled, "Continuous Renal Replacement Therapy CRRT," effective date 9/20/2022, stated, "... DOCUMENTATION: ... 2. Document access site for location and signs/symptoms of complications and if access in femoral vein document distal pulse check every 2 hours. ... Use the CRRT flowsheet to document hourly intake and output and blood pump functioning:
a. Blood Flowrate - rate of the blood pump. b. Arterial Pressure Monitor- average amount of pressure needed to pull blood into the system. ... c. Venous Pressure Monitor - average amount of pressure needed to push blood out of the system. ... d. Ordered net loss/gain ... e. IV Fluids - all IV fluids that the patient is receiving should be labeled and accounted for in this section. f. Flush ... g. PO Intake ... h. Dialysate - the amount of dialysate infusing into the hemofilter per hour. i. Total Hourly Intake ... j. Ultrafiltrate ... k. Urine Output ... l. NG Output ... m. Other Output ... n. Total Hourly Output ... o. Ultrafiltrate Volume to be removed ... p. Net Volume gained (+)/lost (-) ... q. Add the rows of the total hourly intake to determine a 12-hour cumulative intake and a 24 hour cumulative intake. r. Add the rows of the total hourly output to determine a 12-hour cumulative output. s. Add the rows of fluid balance to determine a 12-hour cumulative fluid balance and a 24-hour cumulative fluid balance. ..."

2. During an interview with the nephrologist, S10, on 1/4/23 at 3:27 PM, S10 stated that he had received a text message from P1's pulmonologist on 11/26/22 at 4:46 AM letting him know about the patient's hemodialysis access issues. S10 stated that after receiving the text message, he contacted P1's nurse "right away" and told the nurse to have the central venous catheter (CVC) line replaced by the intensivist who placed the line or by whoever was the covering practitioner on call. The medical record lacked evidence that an order was received to replace the central line. The medical record lacked evidence that S11, the nurse, and S10, the nephrologist, had communicated the morning of 11/26/22.

On 1/5/23 at approximately 8:00 AM, an interview was conducted with S11, the nurse providing care to P1 on the night shift 11/25/22 into 11/26/22. S11 stated that he had difficulties with the patient's hemodialysis access and that the dialysis lines were clotting a lot. S11 stated that he was changing the dialysis tubing frequently and, at one point, he disconnected the lines and there was a rather large blood clot. S11 stated that he was troubleshooting the dialysis machine and the access by following the prompts on the machine and by having other nurses assist him. S11 stated that he did speak to S10, the nephrologist, once. S11 stated that he spoke to "practically all" of the doctors involved with P1's care during his shift. S11 confirmed that he did not document the communication with the various providers and stated that he typically would document when he spoke with a practitioner and the time the conversation occurred. S11 stated that he should have documented every hour that P1 received CRRT. S11 did not recall the details of the call with S10 in the morning of 11/26/22, but stated that he did not remember receiving orders to have the CVC line changed and believed S10 stated that it was something to be done on day shift.

During an interview with S14, the physician assistant (PA) in the intensive care unit (ICU) who treated P1 on the night of 11/25/22-11/26/22, was asked if she documented in the medical record after being notified by the nurse (S11) that the patient could not continue to receive the CRRT. S14 stated that she would not consider that "an event" and would not document that the CRRT had been discontinued.

Facility policy titled, "Assessment/Reassessment And Documentation," revised 11/2020, stated, "... POLICY: ... 12. Assessment of continuum care needs is initiated on initial contact with the patient and reassessed as care needs change or evolve. ... 17. Reassessment of each patient is based on: ... b) The evaluation of response to care, treatment, and services provided; c) In response to a significant change in status, condition, or diagnosis; ..."

Medical Staff of Community Medical Center Rules and Regulations, last amended 2/11/20, stated, "... 3. All orders for treatment shall be in writing or placed in the computer. ... 4. A physician, advanced practice provider, registered nurse, registered/certified respiratory therapist/technician, licensed physical therapist, speech pathologist, or registered dietician may accept telephone or verbal physician orders for evaluation and/or treatment relative to their respective discipline and enter orders via appropriate method, i.e. in writing or placed in the computer. ... 7. The treating provider be held responsible for the accurate, timely and legible completion of a medical record for each patient. ..."