HospitalInspections.org

Based on interview, record review and review of facility policies and procedures the facility failed to have inpatient dialysis orders which included blood pressure parameters for patients who experienced a hypotensive (low blood pressure) episode or hypertensive (high blood pressure) episode.

Failure to have specific blood pressure parameters about when to notify the physician for hypotensive and/ or hypertensive episodes puts patients at risk for cardiac and or cerebral vascular events, such as myocardial infarction, cardiovascular collapse or stroke.

References: Federal V tag 543: " The plan of care must address, but not, limited to. The following:
(1) Dose of Dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient ' s volume status. "
Interpretive guidance: " Patients ' blood pressures must be monitored pre, during and post treatment and abnormally high or low values must be addressed. "

Findings include:
1. The hospital " Inpatient Dialysis Orders " , revised 12/18/2012; Read in part under nursing: " Normal saline may be given to treat hypotension during treatment in 100 ml increments up to 500 ml then notify the physician. "

2. Patient #1's record was reviewed. The patient had end stage kidney disease, diabetes mellitus and history of stroke and several other co-morbidities. The patient was admitted on 3/17/2016 to the local hospital for diarrhea, dehydration and sepsis.

a. The dialysis treatment record for 3/18/2016 while the patient was in the hospital revealed the patient blood pressure (BP) at the start of dialysis treatment was 153/56. The patient's had blood pressure readings fluctuated in the 70 ' s and 80 ' s. The patient's blood pressure at 2:18 PM was 74/46.

b. The patient returned to his/her room from the hospital dialysis unit on 3/18/2016 at 3:25 PM with complaints of nausea and vomiting back to his hospital room. A Code Blue was called at 4:18 PM and the patient expired after CPR was performed for over 30 minutes which included intubation.

c. There was no documentation indicating that the dialysis nurse informed the physician regarding the patient's low blood pressure during dialysis.

3. Patient #2 was reviewed. The patient had end-stage kidney disease, coronary artery disease with a history of stroke. The patient was admitted to the hospital on 2/12/2016 for treatment of sepsis due to acute health care associated pneumonia.

a. The dialysis treatment record for 2/13/2016 while the patient was in the hospital, revealed the patient ' s BP at the start of treatment was 94/48. During the treatment the patient ' s systolic BP fluctuated between 70 ' s-80 ' s. The blood pressure at 12:56 PM was 81/39.

b. The dialysis treatment was completed at 1:15 PM. The patient returned to their hospital room after the dialysis treatment. At 4:15 PM on 2/13/2016 while the patient was being assisted to the bathroom the patient lost consciousness. A code blue was called and CPR was started but the patient expired on 2/13/2016. The emergency department physician who performed the intubation for the code made a note on 2/13/2016 that read " I was called to perform an emergent intubation on this patient. They are merely post dialysis, hypotensive, decreased LOC (level of consciousness), and septic. "

c. There was no documentation the dialysis nurse informed the physician regarding the patient's low blood pressure during the dialysis treatment.

5. On 4/7/2016 at 10:30 AM, the nurse from the hospital quality department (staff B) was interviewed. The nurse indicated the two patient deaths involving patient #1 and #2 had been referred to the hospital's death and peer review process and the investigation was on going. The quality nurse went on to say the hospital would be working with the dialysis program manager to revise the blood pressure parameters for the hospital dialysis orders and when to notify the physician.

6. The above findings were verified with Kidney Dialysis Program manager (Staff C) on 4/7/2016 at 11:30 AM.

Based on interview and record review the facility failed to follow the facility policy for the use of Lovenox (medication used for the thinning of blood) for a patient (Patient #3) with end stage renal disease.


Failure to follow the policy put patients at risk for harmful and/ or serious side effects.


Findings include:


1. The facility policy "Enoxaparin (Lovenox) Usuage" (Effective 1/26/2015; Reviewed 3/25/2016) was reviewed. "Under purpose: to ensure safe usage of enoxaparin for inpatients". Under "1. d. Adjust enoxaparin according to patient's renal function. See Pharmacist renal dosing protocol for details".


2. Under the pharmacy renal dosing protocol it stated: "Drug: Enoxaparin" under "Hemodialysis" stated "Not recommended".


3. Patient #3 was admitted to the facility on 2/25/2016. The patient's admitting diagnosis was pulmonary embolism and end stage renal diesease on hemodialysis.


4. Review of the hospital medication administration record (MAR) revealed the patient was on heparin drip but received Lovenox on 2/28,, 2/29, 3/1, 3/2, 3/3 while in the hospital. On 3/9/2016 the patient record documented "on heparin drip bridging over to warfarin" (both heparin and warfarin are blood thinners).

5. On the discharge instructions dated 3/13/2016 it stated "You will be receiving injection of Lovenox daily, this medication thins the blood". The patient was discharged on 3/13/2016 back to his/her skilled nursing facility (SNF). Review of the SNF medication administration record revealed the patient did not receive the Lovenox when the patient was in the SNF.


6. Review of the hospital emergency room records revealed Patient #1 was seen on 3/21/2016. At the time of the emergency room visit the patient was found to have :"Intracranial hemorrhage" and "Enterococcal infection". Review of the emergency room record revealed the patient was on coumadin from the skilled nursing facility. While in the emergency room the patient was given medication to reverse the effects from the blood thinners the patient was receiving. The patient was transferred to a hospital which could provide a higher level of care with regards to the patient's infection.


7. Review of the discharge instructions from the hospital revealed that Patient #3 was treated for enterococcus infection, bacteremia and sepsis.


8. The above information was verified on 4/7/2016 at 10:30 AM with the nurse from the quality department (Staff B). Staff B added that education and teaching was to be scheduled with the pharmacy department for nursing and physican staff around the use of Lovenox with patients with end-stage renal disease who were on dialysis.