HospitalInspections.org

Based on review of medical records, review of facility policy and procedures and staff interview, it was determined the facility failed to ensure the RN (Registered Nurse) provided care for each patient in accordance with facility policy for one (#1) of four patients sampled.

Findings include:

Review of the medical record for Patient #1 revealed the patient was admitted on 7/15/2021. Review of the physician orders revealed on 7/16/2021 an order for Continuous Renal Replacement Therapy (CRRT) was entered. The CRRT was initiated on 7/17/2021 at 2:55 am by the contracted staff that provided dialysis therapy for the facility.

Review of the facility policy, "Continuous Renal Replacement Therapy (CRRT), NxStage," effective 7/2020, stated the responsibilities of the contracted dialysis staff included changing out the CRRT cartridge every 72 hours. Review of the facility nurses documentation, dated 7/20/2021 at 10:45 pm, revealed the CRRT was stopped and the CRRT filter was changed and CRRT was restarted at 11:50 pm.

Review of nursing documentation, dated 7/22/2021 at 4:10 am, revealed the CRRT NxStage machine stopped due to power surge and a new tubing setup and filter was completed by the facility bedside nurse. The CRRT therapy was resumed at 4:52 am by the facility nurse.

Review of the facility policy, "Continuous Renal Replacement Therapy (CRRT), NxStage," effective 7/2020, states the facility bedside nurse will contact the contracted service for troubleshooting. The policy states the contracted dialysis staff be on-call continuously during CRRT therapy.

On 8/30/2021 at 9:30 am an interview was conducted with the Chief Nursing Officer (CNO) and Risk Manager (RM). The CNO and RM confirmed the bedside nurse did not follow facility policy.