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Based on observation, interviews, and policy review, the hospital failed to ensure that dialysis services were provided in a manner that ensured the safety of those patients.

The findings include:

Cross reference: A 0049: To ensure medical staff provided quality of care necessary for patient treatment for one of seven peritoneal dialysis patients (Patient #3), thoroughly assessed for possible causes of volume overload, persistent negative UF (ultrafiltration) volume leading to retained fluid, insufficient communication with other healthcare providers about concerns with fluid volume, administration of intravenous fluids and total parenteral nutrition, initiation of orders for fluid restriction and unattended Plan of Care meetings by dialysis or internal medicine staff to address the goals for fluid volume and dialysis management.

Cross reference: A 0083: To ensure clear delineation of responsibilities for the care of patients receiving peritoneal dialysis (PD) treatments.

Cross reference: A 0084: To ensure contracted radiology services provided a stat chest x-ray in a timely manner for the correct patient, the hospital policy outlined procedures to be used by contracted services for patient identification and specific time frames are identified for stat versus routine orders for radiology technicians providing care at the facility for 1 of 1 dialysis patient. (Patient #3)

Cross reference: A 0144: To ensure peritoneal and hemodialysis patients received care in a safe setting.

Based on record review, interview and review of the hospital's Quality Assessment Performance Improvement (QAPI) Program, the hospital's governing body (GB) failed to ensure the program included the effectiveness and quality of care by contracted dialysis services when weighing of dialysis patients was not monitored, measured, tracked or analyzed.

Findings:

Cross reference: A 273: To monitor the effectiveness and quality of dialysis care regarding weights for dialysis patients before and/or after dialysis care by measuring, tracking and/or analyzing.

Cross reference: A 392: To provide appropriate care and services for 8 of 20 patients reviewed undergoing peritoneal dialysis or hemodialysis in the hospital from 11/10/23 to 7/24/24. (Patients #3, #5, #6, #8, #9, #12, #13, and #15)

Based on record reviews, interviews, and review of facility policies and procedures, the hospital failed to ensure contracted dialysis nursing staff and hospital nursing staff provided appropriate care and services for 3 of 13 patients (Patients #6, #12, #13) undergoing hemodialysis and 5 of 7 (Patients #3, #5, #8, #9, and #15) patients undergoing peritoneal dialysis at the hospital.

The findings include:

Cross reference: A 392: To provide appropriate care and services for 8 of 20 patients reviewed undergoing peritoneal dialysis or hemodialysis in the hospital from 11/10/23 to 7/24/24. (Patients #3, #5, #6, #8, #9, #12, #13, and #15)

Cross reference: A 398: To ensure nursing staff caring for dialysis patients were provided adequate training to ensure care in a safe setting and no oversight was provided of the contracted dialysis services utilized by the hospital.

Based on record review, interviews, and review of facility policy, the hospital failed to ensure medical staff provided quality of care necessary for patient treatment for one of seven peritoneal dialysis patients (Patient #3), thoroughly assessed for possible causes of volume overload, persistent negative UF (ultrafiltration) volume leading to retained fluid, insufficient communication with other healthcare providers about concerns with fluid volume, administration of intravenous fluids and total parenteral nutrition, initiation of orders for fluid restriction and Interdisciplinary Plan of Care meetings were addressed for patient goals for fluid volume and dialysis management.

The findings include:

1. Record review on 9/24/24 at 8:39 AM revealed Patient #3 was admitted to the rehabilitation hospital on 11/10/23 with a diagnosis of stroke and fractured Humerus. Further review of the chart revealed active medical issues and treatment included, but was not limited to: End Stage Renal Disease on PD (peritoneal dialysis) 6 days a week, fall with left Humerus fracture, and history of Congestive Heart Failure.

Review on 9/25/24 at 9:22 AM of Patient #3's peritoneal dialysis treatment from 11/12/23 to 11/23/23 revealed persistent negative ultrafiltration volumes and dwell times less than the 2 hours ordered. Nephrology progress notes document worsening edema and increase the dialysate concentration to get more ultrafiltration volume. There was no indication from the nephrology progress notes that Nephrologist #1 and/or #2 reviewed Patient #3's dialysis treatment sheets and identified the problem of the persistent negative UF. A nephrology progress note dated 11/17/23 at 12:41 PM by Nephrologist #2 revealed Patient #3 did well with PD last night but has some edema. The assessment and plan states; continue CCPD (Continuous Cyclic Peritoneal Dialysis) 4 x (times) 2500 ml (milliters) over 9 hours with 2.5 % (percent) now given her/his edema. BP (blood pressure) stable. Would dc (discontinue) IVF's (intravenous fluids). During an interview on 10/01/24 at 12:40 PM, Rehab Medical Director #1 was informed that (Nephrologist #2) had recommended to discontinue IVF in a progress note. When asked if the Internal Medicine Providers who had ordered the fluids would have read that note to know the recommendation; Rehab Medical Director #1 stated if there is a physician to physician concern, there should be a phone call or face to face. Physicians are expected to reach out.

Record review on 10/01/24 at 2:01 PM with the Director of Quality and CNO revealed there was no physician's order to discontinue all IVF's. It was unknown if the Internal Medicine Providers who had ordered the IVF had read the Nephrologist's progress note or if a face to face/phone communication had occurred. The Internal Medicine Providers were no longer working for the hospital and attempts to interview them were unsuccessful. A progress note dated 11/20/23 at 5:02 PM by Nephrologist #1 documented that Patient #3 was on room air, with 1-2 plus tibial edema. The note documented to continue usual PD with 2.5% dialysate for moderate UF. Depending on UF, may need to increase to 4.25% dialysate.

Review of physician's orders on 9/24/24 at 9:47 AM revealed no fluid restriction was ordered for Patient #3.
An interview conducted on 9/26/24 at 11:00 AM with Registered Dietitian (RD) #1 revealed RD #1 completed an initial assessment on 11/13/23 at 12:25 PM. She/he verified the fluid requirements for Patient #3 was calculated between 1926 and 2247 milliliters a day. She/he stated PD patients aren't usually put on a fluid restriction. A second assessment completed by RD #1 on 11/20/23 noted the fluid requirements were the same based on Patient #3's weight as documented by the admission nurse.

A phone interview on 9/26/24 at 12:35 PM was conducted with Nephrologist #1. She/he recalled Patient #3 because she/he was the patient's Nephrologist prior to coming to the hospital. When asked if she/he reviewed the dialysis treatment sheets for PD patients at the hospital, the Nephrologist stated she/he did not have a PD patient at the hospital currently. Nephrologist #1 was informed of the concerns related to Patient #3's persistent negative UF volume and that she/he was receiving intravenous fluids. The Nephrologist stated that sometimes the issue with a negative UF is that the machine is working properly, but it is a catheter problem. She/he stated that they also make adjustments in the dialysate concentrate to get more fluid off, with 4.25 % being the highest concentrate to get more fluid removed. The Nephrologist stated that Patient #3 had comorbidities including poor heart function with a low ejection fraction and a history of coronary stents. She/he recalled there had been a conversation about converting the patient to hemodialysis. When asked about the concern related to how much IV fluids Patient #3 was receiving, she/he stated that pretty much the hospitalists care for the patient (would order fluids at their discretion). Nephrologist #1 stated that as a Nephrologist, she/he would supervise the dialysis care. When informed of the concern about interruptions in treatment with the cycler machine alarming, she/he stated that Patient #3 did have Heparin added to his/her dialysate while doing his/her treatments at home. When informed of the concern with Patient #3 having a negative UF, receiving IV fluids, and the lack of documentation of weights; Nephrologist #1 stated there is a problem with getting weights, and that at times they are unreliable. She/he stated in a perfect world it would be really great if they were carefully done. When asked how it is determined whether a PD patient should be on a fluid restriction, she/he stated that with PD it is not as strict as hemodialysis. She/he stated you want to make sure they don't go overboard. There should be a little restriction, you don't want the PD patient taking in 3-4 liters a day. She/he stated that 1500 milliliters is a good amount. Better to be modest with the restriction. When asked how often a PD patient should be weighed, she/he stated that if they are weighed daily it would be okay. PD patients get edema for a week. There are ups and downs. You would look for other signs of fluid retention like edema. She/he stated that Patient #3's course was complicated by chronic cardiac disease. Nephrologist #1 stated they probably should have watched him/her closer, didn't know the UF was as low. The Nephrologist stated they look at blood pressure, labs, complaints, and volume status. If the dialysis nurses see fibrin, they know to add it to the dialysate; with some patients getting Heparin one time a week. When informed that the capability of the cycler to monitor treatment and alarms was not in place to bring potential problems to the dialysis staff's attention; Nephrologist #1 stated that in the past, the cyclers did not have the capabilities they have now. Getting on line and being able to review the treatments can help troubleshoot things quicker.

During an interview on 10/1/24 at 12:40 PM, Rehab Medical Director #1 was informed that Nephrologist #2 recommended to discontinue IVF(intravenous fluids) in a progress note. When asked if the Internal Medicine Providers who ordered the fluids would have read that note to know the recommendation; Rehab Medical Director #1 stated if there is a physician to physician concern, there should be a phone call or face to face. Physicians are expected to reach out.

Review of facility policy, entitled "Fluid Restriction" revealed information that it is the responsibility of the physician to place fluid restriction orders as medically necessary".

2. Review on 9/24/24 at 4:15 PM of Patient #3's Plan of Care documentation revealed an entry for dialysis, with goals to maintain adequate fluid volume and to be able to tolerate the therapy schedule without shortness of breath or undue fatigue. Nephrology and IM (Internal Medicine) Providers were noted not in attendance for the meeting. During an interview conducted on 9/25/24 at 3:18 PM with the Director of Quality revealed that in rehab, team conferences are geared toward a discussion of impediments to the patient returning home. She/he stated that dialysis care would not be discussed as it was not an impediment to going home. Nephrology, Internal Medicine, nor the patient attend the IPOC (Interdisciplinary Plan of Care) meetings. In the meetings Rehab staff talk about barriers to discharge, impediments to therapy progress. Attendees include nursing, case management, PT (Physical Therapy), OT (Occupational Therapy), speech, dietary, the Rehab Medical Director, and Respiratory.

During an interview on 10/01/24 at 12:30 PM, Rehab Medical Director #1 stated that Patient #3's shortness of breath, anasarca, or the need for oxygen could be addressed if impeding progress with therapy. She/he stated that issues with dialysis could also be addressed. When asked to comment on these medical issues that had been documented for the patient by other physicians, the Rehab Medical Director stated that each physician is responsible for his/her own documentation.

During a phone interview on 10/01/24 at 12:55 PM, the Acute Dialysis Medical Director stated she/he has been the Medical Director over acutes since September 2023. She/he attends QAPI (Quality Assessment Performance Improvement) quarterly to discuss systems related to deliver the best care. There have been issues with documentation. If private physicians have concerns related to dialysis care they discuss it. The Acute Dialysis Medical Director stated that for PD patients, they put in the orders for the machine. What we put in and what is delivered may be different. What we can control, the machine delivers. When asked about the negative UF for Patient #3, she/he stated that if the machine alarms, it does not mean the machine is malfunctioning, but there could be a problem with draining fluid, the PD catheter, or problems with the omentum. She/he stated the acute dialysis nursing staff would not investigate these type of issues, that it would be the Nephrologist's responsibility. The UF can be influenced by the concentrate used, dwell times not meeting, and drainage issues. The Nephrologist would need to look into what is happening. You do a physical assessment of the patient and look at what the PD UF is. You look at weights. Weights are hard to get in the hospital. They need to document the weight. Find out if there is something going on with the machine and drainage. Make a decision. Is dialysis failing because the patient is hypervolemic? Is the PD procedure failing? There needs to be a discussion why PD is not doing what it needs to do and discuss transitioning to HD (hemodialysis) if PD ineffectual. Try to troubleshoot. It could be an intraperitoneal problem, the omentum not doing its job. The catheter can get kinked. They may need to add Heparin to the dialysate due to fibrin. When asked about weights for dialysis patients, including PD patients, the Acute Dialysis Medical Director stated that the nursing staff need to clearly document the weight pre and post treatment. If limited in positioning due to the patient not being able to get up, this needs to be documented. Weights can also be inaccurate. The Nephrologist should be looking at the UF and looking at the patient. If they did not drain all the fluid and PD not achieving its goal, they need to make a decision on the individual patient and see why they are not achieving their goal. It is really up to the primary Nephrologist. The Medical Director did not think it was the responsibility of the acute dialysis nursing staff to notify the Nephrologist that the patient had a persistent negative UF. If the machine keeps alarming, we should be made aware of it. It needs to be documented. As a practicing physician, we are concerned with outcomes. This is the UF, clearance, labs- BUN (blood urea nitrogen), creatinine, and potassium. If these are not what they should be, I will add an exchange. I don't see (the alarms) as a machine issue, it is the outcome of dialysis, UF-labs; that is the objective. Many factors play a role in the UF. It could be middle of night machine issues (alarms). It could be vital signs, or that their sugar is high. These all influence the amount of UF. This is where the Nephrologist comes in. If I am pulling a lot (of fluid), and the UF is poor and I see the patient is gaining fluid, then their dialysis (prescription) needs to be adjusted. We need to look at their electrolytes, their bicarbonate, potassium, BUN, and creatinine.

Based on interview, review of hospital contracts, and review of facility policy, the governing body failed to ensure clear delineation of responsibilities for the care of patients receiving peritoneal dialysis (PD) treatments.

Finding include:

Record review of contracted Dialysis #1's policy and hospital policy on 9/23/24 a 11:00 AM revealed no clear delineation of responsibility for the patient care and safety when a patient is receiving peritoneal dialysis treatment by the contracted dialysis staff versus the hospital staff. During an interview on 9/23/24 at 1:00 PM, contracted Registered Nurse (RN) #1 stated that in emergencies the patient is competent to disconnect from the cycler since they are doing treatments in their homes on a routine basis. During an interview on 9/25/24 at 11:00 AM, the Chief Nursing Officer (CNO) stated that floor supervisors would be capable of disconnection of PD patients if there was an emergency, floor staff does not interfere with the dialysis cyclers but would answer call lights, assist patients to the bathroom and provide basic care.

During an interview on 10/01/24 at 11:00 AM, the Director of Quality and Risk Management stated floor staff do not receive specific training for caring for dialysis patients.

Review of facility service agreement on 9/24/24 at 9:15 AM, entitled "HOSPITAL DIALYSIS MASTER SERVICES AGREEMENT" dated August 21, 2023, showed operating hours for contracted dialysis staff "...from 7:00 a.m. to 5:00 p.m., Monday, Wednesday and Friday for Hemodialysis; and 7:00 a.m. to 7:00 p.m. for Peritoneal Dialysis (CCPD-Continuous Cycling Peritoneal Dialysis)...No on call coverage will be provided".

Facility policy, entitled "Dialysis/Renal Services" dated 05/09/2023, showed "The CNO (Chief Nursing Officer) is responsible for providing a safe dialysis service regardless of location ...Peritoneal Dialysis...".

Based on record review, interviews, review of the hospital contract and radiology service provider, and review of hospital policy, entitled "Radiology", the hospital governing body failed to ensure contracted radiology services provided a stat chest x-ray in a timely manner for the correct patient, the hospital policy outlined procedures to be used by contracted services for patient identification and specific time frames are identified for stat versus routine orders for radiology technicians providing care at the facility for 1 of 1 dialysis patient. (Patient #3)

The findings include:

Review on 9/26/24 at 12:00 PM of Patient #3's chest x-ray report dated 11/15/23 revealed the heart and mediastinum are normal, with no congestive heart failure, pneumonia or effusion. No adenopathy is seen. No acute bony abnormality is visible. The conclusion was there were no acute findings in the chest. A chest x-ray report for Patient #3 dated 11/24/23 revealed the heart and mediastinum were normal, without adenopathy. "There are moderate bilateral lower lobe infiltrates. The osseous structures are unremarkable. There is a large right pleural effusion. There is a pacemaker in position. Conclusion: Bilateral moderate infiltrates and large right pleural effusion. Findings new from 11/15/2023".

During a phone interview on 9/26/24 at 12:04 PM, Radiologist #1 was asked if she/he could compare the two chest x-rays completed for Patient #3, one completed on 11/15/23 and the other on 11/24/23; to determine if both x-rays had been completed on the same patient. According to Radiologist #1, the chest x-ray on 11/15/23 showed no fracture, and no pacemaker present; whereas the chest x-ray from 11/24/23 showed a pacemaker, fracture, and degenerative changes to the shoulder. She/he stated there is evidence that the two chest x-rays had been completed on different people. During an interview on 9/26/24 at 12:15 PM, the Director of Quality was asked how that could happen and did not know. She/he was not able to provide a policy on patient identification for radiology or procedures used when radiology comes to perform x-rays on patients.

Record review on 10/01/24 at 2:01 PM with the Director of Quality and the CNO (Chief Nursing Officer) revealed a stat chest x-ray had been ordered on 11/14/23 at 9:18 PM for Patient #3. It resulted on 11/15/23 at 3:30 PM. When asked how fast stat procedures such as x-rays should be completed, the CNO was not aware of anything written that said how soon it should be done.

During an interview on 10/02/24 at 9:29 AM, Night Nursing Supervisor #1 verified having worked the night of 11/14/23, and ordered a stat chest x-ray for Patient #3 at 9:18 PM for respiratory failure with hypoxia. When asked why the stat chest x-ray had not been completed until the next day; the nursing supervisor stated that the x-ray technician wouldn't have been expected to come until the next day. Night Nursing Supervisor #1 stated that if ordered routine, they have up to 2 days to get it (done). If ordered stat, it should be done the next morning. When asked if there was a policy that specified those time frames, she/he was not aware of a policy. Night Nursing Supervisor #1 stated that if Patient #3's condition was "that bad" and the patient couldn't wait (for the x-ray), they would send the patient out to an acute care hospital.

Review on 10/02/24 at 10:00 AM of facility policy, entitled "Radiology", revealed information that all radiology requests need to be addressed within 4 hours of order. Under "PROCEDURE", was "See contracted services agreement". During an interview on 10/02/24 at 10:02 AM, the Director of Quality stated there is no policy on how soon stat or routine orders should be completed (by the technician). She/he stated the contract with the radiology provider specified turn around times for after the x-Ray was taken and when the report would be expected.

During a phone interview on 10/02/24 at 2:45 PM, the Mobilex Director of Operations verified a stat chest x-ray was ordered on 11/14/23 at 9:20 PM, with the stat chest x-ray read and reported the next day on 11/15/23 at 3:30 PM. She/he stated at the time it was ordered, the Mobilex technician was not able to come do the x-ray. She/he stated when that happens, they (the Mobilex technician) typically notify the physician they are not able to do it and reschedule the procedure. When asked how they notify the hospital that they were not able to do the x-ray, she/he stated that typically they make a phone call, but did not see that a call had been documented in the system. When asked about how the technician would verify they were performing the x-ray on the correct patient, the Director of Operations stated there was a 3 way match to verify the order. The technician arrives, verifies the service order, the patient name, and date of birth. They look at the order prescription documented in their system to match. They go to the bedside, and have the patient state their name and date of birth. An alternate method would be to check the patient's wrist band. The third method would be to have a hospital staff member verify this is the correct patient. The Mobilex Director of Operations stated the hospital's electronic medical record interfaces with them at a nearby hospital. She/he stated that someone from the nearby hospital would have called the hospital Patient #3 was at to reschedule the chest x-ray. She/he could see it had been rescheduled on 11/14/23 at 11:26 PM. When asked how soon the technician was expected to come for a "stat" x-Ray, the Mobilex Director of Operations stated they should come within 4-6 hours from the time ordered to perform the exam. She/he stated there was no note from the technologist as to why that didn't happen. The Director of Operations stated that the radiologist reads stat exams and these are reported back in 30 minutes to 1 hour.

During an interview on 10/02/24 at 4:30 PM, the Chief Nursing Officer (CNO) verified the hospital's "Radiology" policy stated that all radiology requests need to be addressed within four hours of orders. The CNO stated this meant that if the x-ray service called back with the x-ray report results by 8:00 AM, you would have 4 hours to ensure it is addressed by the physician. A review of the contracted service agreement between Mobilex and the hospital on 10/02/24 at 4:35 PM revealed under "Technical Services", that stat x-rays will be typed and interpreted within two (2) hours after the technical services are provided. There was no information as to how soon technical services would need to come to provide the x-ray service for stat orders.

Based on record reviews, interviews, and review of contracted dialysis services and hospital policies, the hospital failed to ensure peritoneal and hemodialysis patients received care in a safe setting.

The findings include:

Cross reference: A 49: To ensure medical staff provided quality of care necessary for patient treatment for one of seven peritoneal dialysis patients (Patient #3), thoroughly assessed for possible causes of volume overload, persistent negative UF (ultrafiltration) volume leading to retained fluid, insufficient communication with other healthcare providers about concerns with fluid volume, administration of intravenous fluids and total parenteral nutrition, initiation of orders for fluid restriction and unattended Plan of Care meetings by dialysis or internal medicine staff to address the goals for fluid volume and dialysis management.

Cross reference: A 84: To ensure contracted radiology services provided a stat chest x-ray in a timely manner for the correct patient, the hospital policy outlined procedures to be used by contracted services for patient identification and specific time frames are identified for stat versus routine orders for radiology technicians providing care at the facility for 1 of 1 dialysis patient. (Patient #3)

Cross reference: A 392: To provide appropriate care and services for 8 of 20 patients reviewed undergoing peritoneal dialysis or hemodialysis in the hospital from 11/10/23 to 7/24/24. (Patients #3, #5, #6, #8, #9, #12, #13, and #15)

Cross reference: A 398: To ensure nursing staff caring for dialysis patients were provided adequate training to ensure care in a safe setting and no oversight was provided of the contracted dialysis services utilized by the hospital.

Based on record review, interview and review of the hospital's Quality Assessment Performance Improvement (QAPI) Program documentation, the hospital failed to monitor the effectiveness and quality of dialysis care regarding weights for dialysis patients before and/or after dialysis care by measuring, tracking and/or analyzing.

Findings include:

Review of the hospital's QAPI Program documentation for 4th Quarter 2023, 1st Quarter 2024 and 2nd Quarter 2024 was conducted on 9/23/24 at 2:08 PM. Review of the Quality Council Meeting Minutes on 5/07/24 for 1st Quarter 2024 data revealed, "...reported on dialysis patient trends around weight orders per policy...". In an interview with the DQ on 10/02/24 at 3:40 PM, she/he stated this was specific to dialysis patient weight orders. The DQ stated the hospital Electronic Medical Record (EMR) does not have an option for weights to be done pre/post dialysis. The DQ confirmed she/he was aware of weights not always being done pre/post dialysis, but she/he was "not aware of the severity". The DQ confirmed the QAPI Program did not measure, analyze and track quality indicators for dialysis patient weights and effectiveness and quality of dialysis care and stated there was "no action plan".

In an interview with contracted Dialysis Registered Nurse (RN) #1 on 9/25/24 at 11:25 AM, she/he stated patients are supposed to be weighed before and after dialysis (both hemodialysis and peritoneal dialysis).

In an interview with Nephrology Medical Director (NMD) on 10/01/24 at 1:03 PM, she/he stated "...Pre and post (dialysis) weights are expected...".

In an interview with the Dialysis Program Manager (DPM) and the Director of Quality (DQ) on 10/01/24 at 1:24 PM, she/he stated, "we (hospital) just have daily weights; before and after is just not something we've looked at". The DQ stated the contracted Dialysis provider has a policy for weights before and after dialysis but the hospital does not. The DQ stated the hospital policy is for daily weights for dialysis patients. The DPM stated the Nurses and Nursing Technicians were responsible for getting weights on dialysis patients and they "need to be weighed daily" for both hemodialysis and peritoneal dialysis patients. The DPM stated "I don't look at any of their (contracted dialysis provider) stuff". The DPM stated she/he does not review the content of the "Run sheets" (dialysis record/treatment sheets), she/he just checks to see if they are there.

Based on record reviews, interviews, and review of facility policies "(Contracted Dialysis) Hospital Services Policy & (and) Procedure" policies #1412, #1401, #304 and #250, and "Hospital Services Flowsheet Documentation", the hospital's nursing and contracted dialysis nursing staff failed to provide appropriate care and services for 8 of 20 patients reviewed undergoing peritoneal dialysis or hemodialysis in the hospital from 11/10/23 to 7/24/24. (Patients #3, #5, #6, #8, #9, #12, #13, and #15)

The findings include:

The contracted dialysis nursing staff failed to identify and notify the Nephrologist of shortened dialysis dwell times and persistent negative UF (ultrafiltration) volumes that affected Patient #3's volume status. Patient #3 was later diagnosed with volume overload. Hospital nursing staff failed to report and document peritoneal dialysis cycler alarms/interruptions in treatment, actions taken to resolve the issue causing the alarms, or an assessment of Patient #3 during the interruption in treatments to ensure that nursing/medical intervention was not warranted. The peritoneal dialysis cycler used by the hospital had the capability to monitor the whole dialysis treatment to include monitoring of alarms for Patient #3; but had not been enabled to do so. The hospital nursing staff failed to document nursing assessments of Patient #3 during times when the physician had to be called and medical/nursing interventions provided. Though indicated by a nephrology progress note and pharmacy information, peritoneal dialysate with the medication Heparin added had not been documented as administered to Patient #3. Weights were not documented pre and post dialysis treatment and/or there were discrepancies in weights for Patients #3, #5, #6, #8, #12, #13, and #15. Dialysate concentrate had not been administered as ordered for Patients #3, #8, and #9. There were missing vital signs documented pre and/or post treatment for Patient #3. A pre dialysis treatment nursing assessment had not been documented for Patient #15, along with treatment start times and the names of dialysis nursing staff initiating the treatment. The amount of dialysate (fill volume) was not administered as ordered for Patient #15. Intake and Output had been ordered, but not all the Intravenous Fluids (IVF) had been documented for Patient #3's intake. There was no documentation for Patient #3 that nursing staff notified the Provider of a stat Chest -X-ray report that had been resulted with an "Alert".

Record review on 9/24/24 at 8:39 AM revealed Patient #3 was admitted to the Rehabilitation hospital on 11/10/23 after being discharged from an acute care hospital. Patient #3 had been brought to the acute care hospital's Emergency Department with confusion and hallucinations, and had been admitted on 10/30/23 with Metabolic Encephalopathy (that had resolved) (a chemical imbalance in the blood that affects brain function), and an acute stroke of the left cerebellar area. Patient #3 suffered a left Humerus Fracture on 9/30/23. Review of the Rehab hospital's Pre-Admission information revealed the patient's primary diagnosis was Stroke. Active medical issues and treatment included, but was not limited to; acute stroke, End Stage Renal Disease on PD (peritoneal dialysis) 6 days a week, fall with left Humerus fracture, and history of Congestive Heart Failure. A Pre-Admission Update/Addendum dated 11/08/23 at 3:38 PM revealed information that while at the acute care hospital, Patient #3 was "continuing to have issues with PD (Peritoneal Dialysis) machine...". Further review of the acute care hospital's documentation in Patient #3's Rehab medical record revealed an entry dated 11/07/23 which documented "...She/he was having frequent alarms with PD today. She/he was having frequent alarms over the last 12 hours with PD. She/he had not had these issues as outpatient. I have asked the PD RN (Registered Nurse) in-house to help trouble shoot...11/08/23- PD yest(erday) but machine is malfunctioning again... 11/09/23- Continues on PD...continue to have issues with PD machine, Nursing working on it". The acute care hospital's "Discharge Summary" information included the patient's weight was 59 kg, 130 pounds.

Record review on 9/24/24 and 9/25/24 revealed the following physician orders, dialysis treatment sheets, and progress notes for Patient #3:
Orders dated 11/10/23 revealed Patient #3 was to receive daily peritoneal dialysis with a 1.5% (percent)concentrate, 4 exchanges of 2.5 liters each, to be administered over 9 hours using a Baxter Claria cycler, and a 2 hour dwell time.

Dialysis treatment sheet dated 11/12/23 listed a dry weight (weight of patient without any fluid on) of 64.2 (kg)(kilogram) (141.24 lb) (pounds). Patient #3's pre-treatment weight was documented as "Bed was not zeroed". The post treatment weight was documented as 173.4 (lbs). No edema was noted. The dialysis nurse did not document (circle) whether the effluent was clear or cloudy on initiation of treatment. The initial drain was documented as 9 (milliliters/ml), with the total ultrafiltration documented as -832 (ml). The average dwell time was 2 hours. A note documented by the dialysis nurse indicated a termination of dialysis treatment at 2:44 AM, "machine was turned off before my arrival. Initial drain and total UF lost. 3 exchanges complete. Nephrologist #2 notified". Under comments was documented "Start 6:40 pm, stop 02:44 (AM)". Per (hospital) staff turned off machine d/t (due/to) alarming. Nephrologist #2 said same orders, same # of exchanges for tonight". Further review of the chart revealed no documentation on the treatment sheet or in the hospital nursing notes to indicate what may have caused the alarm and/or interventions attempted to resolve it. During an interview on 9/26/24 at 9:59 AM, Night Nurse Supervisor #1 verified she/he was working the night of 11/12/23. After review of the 11/12/23 treatment sheet and the medical record for Patient #3, she/he verified there was no documentation by the hospital nursing staff of what had occurred, any interventions attempted, and/or a call to the acute dialysis nurse or Baxter (PD cycler manufacturer) representative to troubleshoot. Night Nurse Supervisor #1 stated there was documented nursing assessments of Patient #3 on 11/12/23 at 8:50 PM, and then again on 11/13/23 at 10:56 PM; but nothing documented for the time frame in which the PD dialysis treatment had stopped. Night Nursing Supervisor #1 stated the floor nurse should have notified her/him.

A Nephrology consult dated 11/13/23 at 2:54 PM revealed Patient #3's lungs were clear, with no edema bilaterally in the lower extremities. Under "Assessment" was documented to continue CCPD (Continuous Cycling Peritoneal Dialysis, a type of dialysis that uses a machine to automatically exchange dialysate in the abdomen while the patient sleeps) for 9 hours, 2500 ml (milliter) x (times) 4 using Heparin in bags for fibrin. Nephrologist #2 documented, "Had some drain issues last night apparently...". Review of physician orders revealed no orders inputted into the electronic medical record to add the medication Heparin (medication that prevents fibrin development) to the dialysate bags. Review of dialysis treatment sheets from 11/12/23 to 11/23/23 revealed no documentation of the administration of dialysate with Heparin added. During an interview on 9/26/24 at 9:36 AM, Pharmacist #1 stated the acute dialysis unit staff provide the dialysate, and they send the dialysate along with an order to add the Heparin to the compounding pharmacy they use. The dialysate bags are then brought back for patient use. Pharmacist #1 could not find a physician's order for the addition of Heparin to Patient #3's dialysate. Pharmacist #1 did provide faxed information from the compounding pharmacy that Heparin was added to 2 bags of peritoneal dialysate for Patient #3, and that the 2 bags had been delivered back to the hospital. The pharmacist was unsure how the compounding pharmacy provided the Heparinized dialysate without an order. During an interview on 10/01/24 at 2:52 PM, the Acute Dialysis Nurse Manager reviewed the dialysis treatment sheets for Patient #3 for the entire hospitalization and verified they revealed nothing documented that would indicate that Heparinized dialysate was administered to the patient.

Dialysis treatment sheet dated 11/13/23 under "Patient Information" was documented, dry weight 130 (lbs) per patient. Under pre-treatment assessment, Patient #3's respiratory rate was not documented. Under pre-treatment and post-treatment weights was documented (scale) "Broken". There was 2+ bilateral lower extremity edema noted pre-treatment and +1 bilateral lower extremity edema noted post treatment. The clarity of the initial drain of effluent was not documented. The initial drain was 24 (ml), with the total ultrafiltration documented as -645 ml, and the average dwell time was 28 minutes, not the prescribed order for 2 hours. Further review of the chart revealed no documentation to indicate why the dwell time did not meet the 2 hours as ordered, and/or consideration for why the patient was retaining fluid instead of eliminating it through dialysis. There was no documentation of an alarm and/or interruption in treatment. Under comments was documented "Primary nurse reports good run".

Dialysis treatment sheet dated 11/14/23 revealed Patient #3's dry weight was listed as 130 lb. The contracted dialysis nurse failed to document who she/he gave the post treatment hand off to and when. The pre-treatment/post treatment nursing assessment did not include the patient's respiratory rate; and the pre and post-treatment weight the nurse documented "scale broken" and "bed scale broken". The post treatment assessment indicated the patient's oxygen saturation was 95% on oxygen, with lungs clear and no edema. The effluent color or clarity was not documented for the initiation of treatment. The initial drain was documented as 11 milliliters, with the total ultrafiltration documented as -440 ml, with an average dwell time of 1:43, not the prescribed 2 hours as ordered. A nursing note documented (11/14/24 at 9:30 PM), an emergency call with physician orders to discontinue peritoneal dialysis and drain. Further review revealed no documentation on the treatment sheet and/or in the hospital nursing notes as to what may have occurred with the patient to warrant the emergency call to the physician with discontinuation of treatment and/or a nursing assessment to indicate why the patient was placed on oxygen. A physician progress note documented by Physician #1 and Nurse Practitioner #2 dated 11/15/23 at 10:53 AM revealed that overnight coverage called last night for shortness of breath with some desaturation. No fever or leukocytosis. BP (blood pressure) stable, EKG (electrocardiograph) paced rhythm. No chest pain or palpitations. Continued problems with nausea, remains constipated. PD dwell likely contributing as well. Did not sleep well because of above. Off PD, sats 99% on nasal oxygen. During an interview on 9/26/24 at 9:59 AM, Night Nursing Supervisor #1 verified she/he was working the night of 11/14/23. She/he verified there was no documentation in the record by the night supervisor, the floor nurse taking care of the patient, or the acute dialysis nurse that came to discontinue the treatment as to what occurred and/or nursing assessment documented for Patient #3. She/he verified the dialysis treatment sheet documented the dialysis treatment started on 11/14/23 around 6:27 PM. A nursing assessment completed by a floor nurse on 11/14/23 at 6:52 PM, that indicated no problems. The next nursing assessment by the hospital floor nurse was not documented until 11/15/23 at 1:58 PM. When asked if she/he would have documented a nursing note for the occurrence, Night Nursing Supervisor #1 stated she/he would have. She/he was not sure if the floor nurse called her/him for assistance with the patient. When informed it appeared the acute dialysis nurse came in that night to discontinue the treatment, the Night Nurse Supervisor #1 stated it would have been the night supervisor that called the acute dialysis nurse to come in. Night Nurse Supervisor #1 verified there was no documentation of hospital nursing staff calling the acute dialysis nurse to come in for any problems with the patient's treatment. During an interview on 10/02/24 at 9:29 AM, Night Nursing Supervisor #1 verified she/he ordered a stat chest x-ray for Patient #3 on 11/14/23 at 9:18 PM for "respiratory failure with hypoxia". Review of the medical record with the nursing supervisor revealed no documentation of vital signs or oxygen saturation for the time frame when the chest x-ray was ordered. Night Nursing Supervisor #1 stated that normally the floor nurse working with the patient would complete the nursing assessment.

Dialysis treatment sheet dated 11/15/23 revealed under pre-treatment assessment, the pulse and respiratory rate was not documented, with the weight documented as 124 (pounds). The lungs were clear, with +3 pitting edema noted to" bilateral low and upper". The patient's blood pressure pre-treatment was documented as 88/50 and level of consciousness "Sleepy/Lethargic". The post-treatment weight was documented as 136 (pounds), which was 12 pounds greater than the pre-treatment weight with no documentation to explain the discrepancy in weight gain. Patient #3's post treatment respiratory rate was 14, with the pulse and blood pressure not documented. The initial drain was 16 ml, the "Final" ultrafiltration volume was documented as 1187 ml, and the average dwell time was documented as 1:36, not the 2 hours as prescribed with no documentation to indicate why the dwell time did not meet the 2 hours as ordered, or anything to indicate an alarm and/or interruption in treatment. During an interview on 10/02/24 at 9:29 AM, Night Nursing Supervisor #1 verified she/he had worked the night of 11/15/23. She/he could not recall any alarms or getting called by the nurses to check the PD cycler. She/he stated that in November 2023, the floor nurses were allowed to silence the PD cycler alarm and restart the cycler if they felt comfortable doing so. If the alarm didn't resolve and they needed to call Baxter (the manufacturer of the cycler) to troubleshoot the problem, the nursing supervisor would be called to get in touch with the manufacturer.

Dialysis treatment sheet dated 11/16/23 revealed under pre-treatment weight, was documented "not accurate, with 12_" (pounds). The last number of the weight was not able to be determined. The patient's post weight was documented as 122 pounds. No edema was noted. The initial effluent color and clarity was not documented. The initial drain was 17 ml, with the total ultrafiltration documented as -1124 ml, with an average dwell time of 1:36. There was no documentation to why the patient did not meet the ordered dwell time of 2 hours, and/or notation for the patient retaining fluid instead of eliminating it with the dialysis treatment.

Orders dated 11/17/23 at 12:43 PM revealed Patient #3's dialysate concentrate was changed to 2.5%. A nephrology progress note dated 11/17/23 at 12:41 PM by Nephrologist #2 revealed information that Patient #3 did well with PD last night but has some edema. Assessment and plan, continue CCPD 4 x 2500 ml over 9 hours with 2.5 % now given her/his edema. BP (blood pressure) stable. Would dc (discontinue) IVF's (intravenous fluids).

Dialysis treatment sheet dated 11/17/23 revealed Patient #3's pre-treatment weight was documented as 136 lbs, and the post treatment weight was 135.5 lbs. Trace edema was noted pre-treatment, and +1 BLE (bilateral lower extremity) edema was noted post treatment. The initial effluent color and clarity was not documented. Comments included the patient complained of nausea with the nurse notified believed to be non-treatment related. The initial drain was documented as 73 ml, with a total ultrafiltration of 142 ml, and an average dwell time of 1:23, not the 2 hours as prescribed with a lost dwell of 1:04 with no documentation why.

Dialysis treatment sheet dated 11/18/23 revealed the nurse did not document the percentage of dialysate concentrate used for the patient's treatment. Under pre-treatment weight was documented, "Scale Off". The post treatment weight had an entry that was crossed out for "Scale Off", with 134 (lbs) documented over the entry. The nurse documented +2 BLE (edema) for the pre and post treatment assessment. The machine number, effluent color and clarity on initiation was not documented. The initial drain was 151 ml, the total ultrafiltration -727 ml, and the average dwell time was 1:09, not the 2 hours as prescribed was documented. There was no documentation specific as to consideration of the negative ultrafiltration (fluid retained) and/or for the dwell time that did not meet the ordered 2 hours. The dialysis nurse documented, "nauseated, no meds, not eating, IV Fluids".

During a phone interview on 10/02/24 at 4:40 PM, Night Nursing Supervisor #2 stated she/he could not recall any problems with the cycler alarming when she/he was working on the nights of 11/16/23, 11/17/23, and 11/18/23. The CNO who was present for the interview reviewed the record and verified there was no documentation of a cycler alarm/interruption in treatment for those nights nor nursing documentation to indicate troubleshooting for any problems.

A progress note dated 11/20/23 at 5:02 PM by Nephrologist #1 documented that the patient was on room air, with 1-2 plus tibial edema. The note documented to continue usual PD with 2.5% dialysate for moderate UF. Depending on UF, may need to increase to 4.25% dialysate.

Dialysis treatment sheet dated 11/20/23 revealed the nurse did not document to whom and at what time the post treatment hand off occurred. The pre treatment weight was documented as 72 (kg), which would be 158.4 lbs. The post treatment weight was documented as 74 (kg), which would be 162.8 lbs. This would indicate the patient gained 4 pounds during the treatment and weighed much more than previous treatments documented. The initial drain was documented as none. The total ultrafiltration was -767, with an average dwell time of 1:43. The dialysis nurse documented there was no complaints, found to be within normal limits. Nothing outstanding from the assessment. The nurse did not document anything related to consideration of the differences between the pre and post weight, any indication as to why the ordered dwell time of 2 hours was not met, and/or an indication to why the patient retained fluid instead of eliminating it. During an interview on 10/02/24 at 9:29 AM, Night Nursing Supervisor #1 verified she/he worked on 11/20/23. She/he did not recall any cycler alarms or getting called by the floor nurses to check the cycler.

Dialysis treatment sheet dated 11/21/23 revealed the pre-treatment weight was not documented, with the nurse documenting +3 BLE edema. The post weight was documented as 74 (kg), which is 162.8 lbs, and post treatment edema documented as trace. The initial effluent color and clarity was not documented. The pre-treatment note documented "Pt (Patient) refusing BP (blood pressure) meds/not eating, on Clinimix IV (Total Parenteral Nutrition). The initial drain was documented as 140 ml, the total ultrafiltration 275 ml, and an average dwell time of 1:39. The post treatment nursing note documented that there was no complaints, vital signs within normal limits, resting well, upon entering room no issues noted or been reported. During an interview on 10/02/24 at 9:29 AM, Night Nursing Supervisor #1 verified she/he worked on 11/21/23. She/he did not recall any cycler alarms or getting called by the floor nurses to check the cycler.

Nephrology progress note dated 11/22/23 at 5:07 PM by Nephrologist #1 revealed Patient #3 developed worsening bilateral tibial edema on 2.5 % dialysate. The Assessment and Plan included information that the patient had multivessel coronary artery disease, inoperable, with an ejection fraction of 35-40%; that the patient was deconditioned, had volume overload with 2+ edema, and hypokalemic. The plan was "Due to the 2+ tibial edema, will adjust dialysate to 4.25% and 2.5%. Agree with KCL (Potassium Chloride) supplementation ...". Review of physician orders revealed no orders inputted into the medical record to change the dialysate to alternate 4.25% and 2.5% concentrations. During a phone interview on 9/26/24 at 12:35 PM, Nephrologist #1 was asked about her/his progress note dated 11/22/23 in which she/he documented a change in dialysate concentration from 2.5% to 4.25% and 2.5% due to edema. Nephrologist #1 was informed no order was inputted into the medical record for the change. Nephrolologist #1 could not recall what happened. She/he stated that dialysis nurses put in the orders and she/he usually communicated any changes with them verbally.

Dialysis treatment sheet dated 11/22/23 under orders for dialysate, revealed Patient #3 was administered a dialysate concentrate of 2.5 %. It did not include that the dialysis nurse should have or had alternated the 2.5% with a 4.25% concentrate as per the Nephrologist's 11/22/23 progress note. The pretreatment handoff was documented on 11/22/23 at 8:30 PM. The pre and post treatment weight section was blank. Lungs were documented as clear and diminished, with facial and abdominal edema noted on the pre-treatment assessment. The dialysis nurse documented Patient #3 was on oxygen. Under progress notes was documented (on 11/23/23) at 6:30 AM, "Tx (treatment) did not administer due to kinks in line found this AM at 0630 hours ...". The patient complained of not sleeping last night. Vital signs stable. Oxygen saturation 100% on 2 Liters oxygen via nasal cannula. (Nephrology Physician Practice) called. The initial drain was documented as 0. Final ultrafiltration volume was 0. Average dwell time 0. The note documented the patient's vital signs were within normal limits. The oxygen saturation was 100% on 3 liters of humidified oxygen via nasal cannula. (Nephrology Physician Practice) on call. Called several times, documented call back to inform Nephrologist treatment not received on 11/22/23 due to equipment malfunction/kinked line, with no treatment administered. On 11/23/23 at 8:30 AM, Nephrologist #1 responded, but what was written in the note by the nurse was not able to be deciphered. The dialysis treatment sheet documentation revealed the dialysis nurse came in on 11/23/23 at 6:30 AM and identified the problem that the treatment did not administer due to kinks found in the line that morning. During an interview on 9/26/24 at 12:26 PM, the Chief Nursing Officer (CNO) reviewed the record and verified there was no nursing notes documented for 11/22/23 through 11/23/23 by the hospital nursing staff of any events that occurred with Patient #3's dialysis machine alarming and/or of interventions attempted to resolve an interruption in dialysis treatment. Review on 9/24/24 at 11:34 AM of a progress note by Nurse Practitioner #3 dated 11/23/23 at 9:50 AM stated there were technical difficulties with PD last night, did not run all night. Renal aware, no additional run, to resume this evening.

Dialysis treatment sheet dated 11/23/23 under orders for dialysate concentrate, the 2.5% concentrate was checked. There was no indication from the treatment sheet documentation that the 2.5 % concentrate was alternated with a 4.25% concentrate as per the 11/22/23 nephrology note. Patient #3's weight was documented pre treatment as 136 lbs and post treatment 137 pounds. Lung sounds were documented as "Wet/Rales" (indicating fluid presence) with generalized edema in the abdomen. Oxygen was not documented in use. The initial drain was documented as 887 ml, final ultrafiltration -99 ml, and the average dwell time was documented as 1:14. The dialysis nurse documented the patient "tolerated the treatment well, no problems noted or reported. Resting quietly. Denied any c/o (complaints)". During a phone interview on 10/02/24 at 4:40 PM, Night Nursing Supervisor #2 verified she/he worked that night. She/he could not recall any alarms for the cycler and/or problems with the patient's treatment for that night. She/he stated that if the dialysis machine alarmed, she/he would have the patient change position and adjust the catheter/line so it could drain, and then reset the machine. When asked if she/he would document this information, she/he stated she/he would make a note only if she/he had to reach out to a dialysis nurse or Baxter representative. When asked if she/he had to call Baxter in the past to get a cycler alarm resolved, she/he stated maybe once in the past. Night Nursing Supervisor #2 stated the only way she/he knew if a patient's cycler had alarmed was if the floor nurse or patient made her/him aware. She/he stated the cyclers did not alarm loudly. As nursing supervisors, they did the troubleshooting to fix the cycler alarm. Typically the floor nurse assigned to the patient would document any nursing assessments of the patient. Review of the medical record with the CNO during the interview revealed nothing was documented to indicate the machine alarmed and/or treatment was interrupted for Patient #3's dialysis treatment on 11/23/23.

Nephrology progress note dated 11/24/23 at 1:15 PM documented by Nephrologist #2 stated that the patient had 2+ edema, volume overload. To continue CCPD for now with 4.25% for volume overload with the same order.

Review of Physician orders on 9/24/24 at 10:45 AM revealed orders for Intake and Output dated 11/10/23 at 3:11 PM.

Record review on 9/25/24 at 2:17 PM revealed Patient #3 had received IV fluids, 1 liter each on 11/17/23, 11/18/23, and 11/22/23; 1 liter each of Clinimix Total Parenteral Nutrition (TPN) on 11/19/23 at 3:03 PM, on 11/20/23 at 4:12 AM, on 11/20/23 at 7:26 PM, and on 11/21/23 at 11:13 AM. Review of intake and output nursing documentation revealed these IV fluids was not been included as intake volume. The findings was verified by the CNO during an interview on 9/25/24 at 2:30 PM. The CNO stated she/he would include the IV fluids and TPN as intake.


During an interview on 9/24/24 at 11:11 AM, Acute Dialysis Registered Nurse (RN) #1 stated they use the Baxter Claria PD cycler in the hospital. Staff sets up the cycler in the evening, connects the patient, and comes back in the morning to disconnect the patient after their dialysis treatment. If anything happens at night, the hospital nursing staff can call technical support at a 1-800 number for Baxter (the manufacturer). The hospital nursing staff had been told to call Baxter or the contracted dialysis nursing staff. Acute Dialysis RN #1 stated since the Claria cycler is not wi-fi connected like patients doing peritoneal dialysis at home, they may not see if the patient had an alarm or interruption in treatment. She/he stated that they ask the patient if there was anything that gave them problems, and for the most part the patient says no. Acute Dialysis RN #1 stated that she/he had contacted Baxter and they stated if the cycler was in a particular mode, you could trace back and look at the last 5 treatments. But they have the cycler on standard mode so they can't track PD treatments.

During an interview on 9/25/24 at 12:21 PM, the Acute Dialysis Nurse Manager reviewed the treatment sheets for Patient #3 and verified the findings related to weights not documented, the dwell time not as ordered, vital signs and handoff documentation missing. According to the Acute Dialysis Nurse Manager, the dwell times was affected by cycler alarms. Whether it was an interruption in drain or fill time, the dwell is going to be less. When asked how the dialysis nurses knew if someone silenced an alarm or restarted a patient treatment due to an alarm; the Acute Dialysis Nurse Manager stated they would receive that information in hand off, and that information would be documented on the bottom of the treatment sheet.

Record review on 9/25/24 at 12:38 PM revealed Patient #3 with physician orders on admission dated 11/10/23 at 3:11 PM to be weighed every 7 days. Review of weights documented by the floor nurses revealed weights for Patient #3 dated 11/10/23 of 141.5 lbs and on 11/24/23 a weight of 142.5 lbs only. Further review revealed a physical therapist documented a weight of 141. 5 lbs on 11/22/23. The entries were verified by the Director of Quality during the time of the review.

During a phone interview on 9/25/24 at 12:52 PM, the Acute Dialysis Nurse Manager stated that the dialysis nurses don't monitor if there is an interruption in treatment. The dialysis nurse looks at the UF to show if everything went well or not. A positive UF would mean the patient is removing more fluid than what had been instilled into the abdomen during dialysis. A negative UF means the patient is retaining fluid, that not all the fluid instilled is being removed. If the Dialysis Nurse Manager saw that the patient had a negative UF, that the patient did not meet the ordered dwell time, and if it were a recurring issue; she/he would refer the concern to the Nephrologist. When it happened the first time, she/he might think the patient needed to turn or reposition themselves, or that something was happening with the PD catheter tube placement. The patient could be constipated or some other variable that would inhibit the flow. It could be that the patient does not have a good enough peritoneum to absorb. But if it was recurrent, like if it happened 5, 6, or 7 times with the patient not meeting the dwell time; that is a red flag that the peritoneal dialysis is not working properly. Possibly a catheter problem. After reviewing Patient #3's treatment sheets, the Acute Dialysis Nurse Manager verified the negative UF and shortened dwell times and stated she/he assumed this was due to interruption in treatment, that the peritoneal dialysis was not working properly.

During an interview on 9/26/24 at 6:08 AM, Night Nurse Supervisor #3 stated she/he works as a floor nurse and relief supervisor. She/he stated that the floor nurse may call the nurse supervisor if they have a concern with a dialysis patient. Maybe they see something that is not baseline. She/he stated the floor nurses are not to touch the PD machine. The nurse supervisor would need to call Baxter (manufacturer of the cycler) if there was a problem. The nurse supervisor can also call the acute care dialysis nurse. The nurse supervisor stated she/he had not received training on Peritoneal dialysis prior to July 2024; but as of July 2024 had received training with connecting or disconnecting patients from the cycler or troubleshooting problems with machine alarms; though hasn't put this training into use. Prior to July 2024, they had been instructed to reach out to Baxter for any problems. If the problem was not resolved after reaching out to Baxter, they would call the acute dialysis nurse. If a machine alarmed, they would call Baxter. They would put a nursing progress note in the medical record if the issue was not resolved after talking to Baxter. If the issue is resolved after talking with Baxter, they would just pass that information on to the acute dialysis nurse during handoff. When asked if she/he had documented a PD machine alarm, she/he stated she hadn't; but thought she/he had passed the information on in report. Night Nurse Supervisor #3 stated they don't document because it is a machine issue. But if the patient were symptomatic with complaints of shortness of breath or other complaints, she/he would document this in a nursing note. Night Nursing Supervisor #3 stated that Baxter tells them over the phone to silence the alarm. Night Supervisor #3 stated that night nurse supervisors do hourly rounding on patients. If they have a PD patient, they will check to make sure the cycler is working normally and draining. They do not document what they find on their rounds.

During an interview on 9/26/24 at 12:26 PM, the CNO reviewed the record and verified there was no nursing notes documented for 11/12/23 through 11/23/23 by hospital nursing staff of any events that occurred with Patient #3's dialysis machine alarming or interruptions in dialysis treatment.

During a phone interview on 9/26/24 at 12:35 PM, Nephrologist #1 stated she/he had been Patient #3's primary Nephrologist prior to the patient coming into the hospital. Ne

Based on interview, personnel record review and review of facility policy, the hospital failed to ensure nursing staff caring for dialysis patients were provided adequate training to ensure care in a safe setting and no oversight was provided of the contracted dialysis services utilized by the hospital.

Findings include:

Facility policy, entitled "Policy #250" revealed information that "The need for dialysis should not be a deterrent to receiving inpatient rehabilitation. Maintaining a safe environment, competent staff, and regulatory compliant service is expected whether the service is contract or provided in house. The CNO (Chief Nursing Officer) is responsible for providing a safe dialysis service regardless of location ... Dialysis services may include hemodialysis, ultrafiltration and peritoneal dialysis (PD). ... The following applies to any form of dialysis:...3. Staff performing the services must be shown to be competent with documentation available from Human Resources or the contracted company".

Record review of personnel files on 9/25/24 at 3:15 PM revealed 2 of 6 current nursing supervisors has documented training for working with dialysis patients and their equipment, disconnecting a patient from a cycler. Further review revealed that 10 of 10 personnel files requested contained no documentation of licensed staff with training specific to care of dialysis patients during peritoneal and/or hemodialysis treatment. During an interview on 10/01/24 at 11:00 AM, the Director of Quality and Risk Management stated that the hospital was unable to find documentation for dialysis training for 7 other licensed hospital nurses.



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During an interview on 9/24/24 at 11:11 AM, Acute Dialysis Registered Nurse #1 stated they use the Baxter Claria PD cycler in the hospital. Staff sets up the cycler in the evening, connects the patient, and comes back in the morning to disconnect the patient after their dialysis treatment. If anything happens at night, the hospital nursing staff can call technical support at a 1-800 number for Baxter (the manufacturer).

During an interview on 9/26/24 at 6:08 AM, Night Nurse Supervisor #3 stated she/he works as a floor nurse and relief supervisor. She/he stated that the floor nurse may call the nurse supervisor if they have a concern with a dialysis patient. Maybe they see something that is not baseline. She/he stated the floor nurses are not to touch the PD machine. The nurse supervisor would need to call Baxter (manufacturer of the cycler) if there was a problem. The nurse supervisor can also call the acute care dialysis nurse. The nurse supervisor stated she/he had received training on Peritoneal dialysis in July 2024; with connecting or disconnecting patients from the cycler or troubleshooting problems with machine alarms. She/he stated that she/he and the nursing staff were not performing any of these newly trained procedures with patients as of yet. They were still calling Baxter for troubleshooting. Prior to July 2024 they had not received training and had been instructed to reach out to Baxter for any problems. If the problem was not resolved after reaching out to Baxter, they would call the acute dialysis nurse. If a machine alarmed, they would call Baxter. She/he stated that Baxter tells them over the phone to silence the alarm. Night Supervisor #3 stated that night nurse supervisors do hourly rounding on patients. If they have a PD patient, they will check to make sure the cycler is working normally and draining. They do not document what they find on rounds.

During an interview on 9/26/24 at 9:59 AM, Night Nurse Supervisor #1 stated they had not had training on caring for peritoneal dialysis patients (back in November 2023). If there was an issue with the machine, they would call Baxter for help. Nursing staff are able to push the button to silence the alarm and restart the PD treatment. She/he was not aware of any troubleshooting measures. She/he would call Baxter and they would take her/him through the troubleshooting process.

Based on interview, record review and review of facility policy, the hospital failed to provide documentation of consent for dialysis treatment for 1 of 20 patient charts reviewed for dialysis treatment. (Patient #15).

Finding include:

Record review on 9/24/24 at 1:30 PM of Patient #15's chart revealed Patient #15 was admitted to the hospital on 12/11/23 for rehab services post Cerebral Vascular Accident (CVA). Review of physician orders revealed peritoneal dialysis daily "1.5% fluid, 200 L dwell volumes, with the following Settings 8 total hours dwell time, 4 cycles/exchanges 2000 volume (ML) with each exchange". Patient #15's first PD treatment was noted on 12/12/23. Further review of the chart revealed no documentation for a consent for peritoneal dialysis treatments. During an interview on 10/01/24 at 11:00 AM the Director of Quality and Risk Management stated that the hospital was unable to find a copy of the consent in the hospitals' medical records. During an interview on 10/02/24 at 3:50 PM, the Acute Dialysis Nurse Manager stated that she/he could not find a copy (of the consent for treatment).

Facility policy, entitled "Dialysis/Renal Services" dated 05/09/2023, showed "The CNO (Chief Nursing Officer) is responsible for providing a safe dialysis service regardless of location ...Peritoneal Dialysis. 2. A Renal Services Consent must be completed".