HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to ensure a physician's order for a peritoneal catheter flush and a physician's order for peritoneal dialysis were performed for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's policy, "PERITONEAL CATHETER IRRIGATION" revealed, "...A RN [Registered Nurse] may irrigate a peritoneal catheter for inflow/outflow problems or to maintain the patency of a capped off catheter. Physician order is required...PROCEDURE...Document procedure..."

Review of the facility's policy, "MULTI-BAG (MB) CAPD [continuous ambulatory peritoneal dialysis] EXCHANGES" revealed, "...PURPOSE: To provide steps for performing a multiple bag, continuous ambulatory peritoneal dialysis system (MB-CAPD) exchange...Documentation...Document the procedure, patient tolerance, specimens sent, and exit site appearance...Document patient teaching and how patient tolerated the procedure...Document exchanges using PD [peritoneal dialysis] flowsheet/EMR [electronic medical record] ..."

2. Medical record review for Patient #1 revealed an admission date of 9/1/2020 with diagnoses which included End-Stage Renal Disease, Diabetes Mellitus, Hypertension, Hyperlipidemia, Morbid Obesity and History of Ischemic Stroke in June 2020.

A physician's order dated 9/15/2020 revealed, "...Flush PD catheter with 500 ml [milliliters] 1.5% [percent] PD solution every week..."

There was no documentation the PD catheter was flushed from 9/15/2020 through 10/1/2020.

During an interview in the conference room on 11/16/2020 at 12:00 PM, the Corporate Interim Chief Nursing Officer confirmed there was no documentation the PD catheter was flushed from 9/15/2020 through 10/1/2020.

A physician's order dated 11/6/2020 revealed, "...All 1.5% solution. 1000 ml exchanges. Perform CAPD with 4 exchanges each day..."

A physician's order dated 11/9/2020 revealed, "...All 1.5% solution. 1500 ml exchanges. Perform CAPD with 4 exchanges each day..."

A physician's order dated 11/10/2020 revealed, "...All 1.5% solution. 2000 ml exchanges. Perform CAPD with 4 exchanges each day..."

The Peritoneal Dialysis spreadsheet dated 11/7/2020 revealed Exchange 1 was 1000 ml of 1.5% solution instilled from 1:00 PM to 1:10 PM and was drained from 6:50 PM to 7:00 PM with 1000 ml of drainage. Exchange 2 was 1000 ml of 1.5 % solution instilled from 7:00 PM to 7:05 PM. There was no documentation of this exchange being drained.

The Peritoneal Dialysis spreadsheet dated 11/8/2020 revealed CAPD was drained from 8:00 AM to 8:34 AM with 500 ml of drainage. CAPD was instilled from 8:34 AM to 8:45 AM with 1000 ml of 1.5% solution. There was no documentation of this exchange being drained.

A dialysis note dated 11/8/2020 revealed CAPD drained from 8:40 PM to 8:50 PM with 1100 ml of drainage. CAPD was instilled with 1000 ml of dialysate completed at 9:05 PM. There was no documentation of the dialysate used, or the duration of the instillation.

A dialysis note date 11/9/2020 revealed CAPD drained from 2:30 AM to 2:40 AM with 700 ml of drainage. CAPD was instilled with 1000 ml of dialysate completed at 3:10 AM. There was no documentation of the dialysate used, the duration of the instillation, or this exchange being drained.

There was no other documentation for any other exchanges being performed. A total of 5 exchanges were documented from 11/6/2020 (when physician order was written) through 11/13/2020 (when Patient #1 passed away), but the physician's orders were for 4 exchanges each day.

During an interview in the conference room on 11/16/2020 at 12:15 PM, the Nurse Manager confirmed these 5 exchanges were the only exchanges documented in the medical record.