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KENDALL REGIONAL MEDICAL CENTER 11750 BIRD RD MIAMI, FL 33175 Nov. 13, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review the facility failed to ensure that the nursing care that required the judgment and specialized skill was immediately available to evaluate the dialysis care of 1 of 3 sampled dialysis patients (#3) of 13 sampled patients .

Findings include:

Review of sampled patient #3 nurse ' s notes dated 03/08/2013 stated that a Trialysis catheter (a Short-Term Triple Lumen Dialysis Catheter) was placed in the patient. On 3/11/2013 at 08:45 am, another note has noted -started on CRRT (continuous renal replacement therapy) at this time as per [name of doctor] orders. On 03/11/2013 at 20:40 pm, received patient with CRRT in progress, patient sedated with propofol, family at bedside. Tubing changed on machine and treatment resumed eventful at this time. On 03/11/2013 at 22:56 pm, has noted that the pt ' s treatment interrupted because the machine developed a problem. Unit leader informed and the HD(dialysis) nurse was called. Patient (pt) remained stable at this time awaiting the HD nurse to restart pt ' s therapy. On 03/11/2013 at 23:34 pm (38 minutes later), has that HD nurse came in and changed offending machine and pt ' s treatment recommenced.

The nurses notes also stated that on 03/12/2013 at 08:00 am , CRRT will continue till 7pm as per [name of doctor]. On 03/12/2013 at 20:00 pm, the nursing notes stated- received off CRRT, this will be restarted tomorrow at 8am. Then on 03/13/2013 at 15:14 pm, another note has that the dialysis machine sudden stopped (high venous). RN dialysis in the room unable to flush dialysis spoke with doctor regarding this matter. Doctor OK cath. flow. Procedure to be restarted in one hr (hour). Review of Medication Discharge Summary revealed that Cathflo Activase 2mg was administered on 03/13/2013 at 15:18 pm and 16:19 pm.
On 03/13/2013 at 15:57 pm, the nursing notes also has noted that the CRRT stopped at 14:40 pm line clotted. Pending cath. flow. To be restarted after 2 hours. On 03/13/2013 at 19:05 pm has that the dialysis RN in the room setting up for CRRT. Then another noted on 03/13/2013 at 19:30 pm, that the pt. with BP- 90/28 with order to start HD (hemodialysis) tx (treatment). Notified doctor of pt. condition. Order to stop HD TX. Family oriented of pt. condition.

In an interview with the Dialysis Coordinator, on 11/13/2013 at 3:45 pm; I had started the CRRT; one to two hours later, I received a call from the ICU nurse that venous pressure was elevating; a cartridge in dialysis machine gave an alarm that a line is clogged; I responded to the hospital to flush the line with normal saline to clear the filter. The filter was checked for fiber or blood and the line is replaced if there are many fibers. In this case we did change the filter. This process takes about 10 minutes. We call MD for an Activase order (medication to break clots) and then we must wait one to two hours before we can continue using the machine. This patient was getting CRRT because they were very unstable and unable to tolerate regular three hour dialysis. CRRT is continuous replacement renal therapy.

In a telephone interview with the Associate Director of Patient Care Service on November 21, 2013 at 10:00 am, the director states that the ICU nurses who monitors the dialysis has completed dialysis competencies. The director also states that the ICU nurse to patient ratio is 1:1 or 1:2 depending on the acuity of the patient. An ICU nurse who has a patient on CRRT can have 2 patients. Also, there is contract Dialysis nurse on duty, on every shift. They are primarily on the first floor where there is an inpatient Dialysis unit.

Review of the policy titled: Continuous Renal Replacement Therapy (CRRT) Protocol revealed that under II. Policy (5) Patients requiring CRRT will be taken care of in a critical care setting. The R.N. (registered nurse) who has had CRRT training and has demonstrated competencies can manage and stop therapy with the help of an easily accessible and immediately available Dialysis Nurse by phone.

There was failure to have available a Dialysis Nurse who is immediately accessible and available.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview and record review the facility failed to keep current a nursing care plan and ongoing assessments with the appropriate nursing interventions in response to the identified nursing care needs of 1 of 10 sampled patients (SP) #1.

Findings include :

Review of records of SP#1 revealed that SP#1 had a procedure for implantation of a permanent pacemaker on 09-23-13 in the cardio-vascular laboratory (CVL) unit of the facility. The patient was transferred to the unit (5 East - Room 536 D) at 11:12 am. Further review of SP#1 medial record revealed that she was admitted to the 5th floor (Med/Surg Telemetry) at approximately 11:12 am. Review of the post procedure physician orders include but not limited to vital signs every shift, and cardiac monitor: telemetry - continuous.
Review of the nursing clinical documentation record revealed that the post procedure physician orders were followed except the continuous telemetry monitoring order. On 09/23/2013 at 4:00 pm, it was documented that the monitor rhythm was sinus rhythm with irregular heart rhythm, telemetry: yes, and monitor rhythm : atrial fibrilation on the nurses notes. The nurse notes dated 09/23/2013 at 23:30 pm also revealed that the nurse spoke to the cardiologist of the patient, and according to the medication administration record, Diltiazem 60mg tablet was given one time at 22:55 pm. On 09-24-13 at 12:00 am, the nursing documentation then showed, Received patient from sampled employee (SE) #2 with no telemetry box and no blood sugar coverage. Patient is S/P (status/post) AICD (Automatic Implantable Cardioverter-Defibrillator) placement 9/23. At this time patient heart rate (HR) slowly stabilizing.

Sampled Patient #1 Rhythm Strip Recording showed a reading on 09/23/2013 at 07:57 am and another at 09:44 am pre/post procedure. The next rhythm strip record is noted on 09/23/2013 at 22:40pm(13 hours later) while patient was stationed on the 5th floor. Further review of the rhythm strip recorded at 22:40 pm has noted that the heart rate is 120 bpm and that the patient type of rhythm as Atrial Flutter.

Interview with sampled employee (SE) #1 via phone conducted on 11-13-13 at 10:30 am she stated that she received SP#1 on 9-23-13 at 7 PM and she applied the telemetry monitor to SP#1. She further stated that the family found SP#1 without monitor but she already knew about it and was ready to apply it. She stated that she called the physician due to increase heart rate and to verify orders for medication reconciliation. That after she gave the medication that there was no problem all throughout the night and the heart rate went down from 120 to 80. That she checked the patient all night and patient was ok and not in any distress.

Interview with SE#2 conducted on 11-13-13 at 11:10 am confirmed above findings that SP#1 would have rhythm strips recorded if the patient was put a telemetry monitor. She further stated, I admit that I possibly made mistake that I thought the monitor was placed but not. That the sinus rhythm she documented was taken from the transport monitor when the patient was transferred to the 5 East unit.

Review of the facility's policy and procedure title: "Communication of Remotely Monitored Patients" conducted on 11-15-13 revealed under II. policy - The initial connection of the telemetry pack must be done by a nurse. The nurse must call the monitor room after initial connection to confirm the patient's name, telemetry monitor number and the initial patient's rhythm. The monitor Tech runs patient strips and records interval measurements on the strip every 4 hours.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review and interview the facility failed to ensure accurate and complete the medication reconciliation, and to administer the medications as ordered by the physician in 1 of 10 sampled patients (SP) (#1).

The findings include:
Review of the medication discharge summary of SP#1 conducted from 11-12-13 to 11-13-13 revealed that SP#1 did not receive any home medications: Amaryl 1 mg tablet ( an antidiabetic drug) and Lisinopril 10mg tablet ( used for treating blood pressure) after the procedure on 9-23-13. Review of records revealed that medications prior to admission were reconciled before the patient ' s procedure was done at the facility on 9-23-13 at 7:21 am. Further review of records revealed that the medication reconciliation was not communicated when the patient was transferred to another setting within the facility per policy and procedure.
Review of the HPF LAB discharge summary report in the medical record also revealed that the point of care (POC) Glucose (blood sugar); on 09/23/2013 at 12:00 pm the results was 139 mg/dl (H) (normal range: 70-110 mg/dl); and at 18:44 pm the results was 240 mg/dl (H). Further review of the nursing notes dated 09/23/2013 at 16:00 pm has noted an accucheck (blood sugar) result of 231 mg/dl. There is no documentation of any nursing intervention.
Review of the nursing clinical documentation conducted on 11-13-13 revealed that on 09-24-13 at 12:00 am, documentation also showed, " Received patient from sample employee (SE) #2 with no telemetry box and no blood sugar coverage. Patient is S/P (status/post) AICD (Automatic Implantable Cardioverter-Defibrillator) placement 9/23. Medication reconciliation not completed. Called attending physician 3 times earlier at 9/23 - 8:00pm, 9:00pm, 10:00pm. Physician didn ' t call back. Thus I informed Charge Nurse of situation. Spoke to covering physician who completed medication reconciliation and ordered appropriate medication based on patient condition. "

Review of the facility policy and procedure regarding medication reconciliation conducted on 11-13-13 revealed that the purpose of the medication reconciliation guidelines is " to outline the processes that ensure accurate and complete medication reconciliation for all patients at the time of admission, transfer, and discharge " . Further review of the Procedure B. 1. Post -procedure / transfer Medication Reconciliation revealed that medication reconciliation must occur anytime orders are rewritten, post procedure and when the patient changes setting, provider or level of care and new medications are written.

Interview with sample employee #2 conducted on 11-13-13 at 11:10am confirmed above findings that she did not call the physician to verify the home medication reconciliation. She further stated that if the medications were ordered that the medications would have been given.