HospitalInspections.org

Intakes: TN00028910
Based on review of staff competencies, medical record review and interview, it was determined the facility failed to provide properly trained staff to care for 2 of 2 (Patient's #1 and 2) sampled patients receiving peritoneal dialysis.

The findings included:
1. Review of competency files for Nurse #1, #2, #3, #4 and #5 provided by the Director of Quality revealed there was no documentation of training and competence for care of a peritoneal dialysis patient.

2. Medical record review for Patient #1 revealed an admission date of 11/15/11 with diagnoses of Status Post Left Above Knee Amputation, Right Forefoot Amputation, End Stage Renal Disease with Ongoing Peritoneal Dialysis and Diabetes Mellitus. The patient was discharged to a skilled nursing facility on 1/12/12. A physicians order dated 11/17/11 documented, "...also record net UF [ultrafiltration] each AM at the end of cycler run (use P.D. [Peritoneal Dialysis] Flow Sheets." Review of the PD Flowsheets for Patient #1 revealed no documentation of UF on 11/21/11 through 11/24/11, 12/7/11 through 12/20/11 and 12/22/11 through 1/12/12. Care was provided by Nurse #1, #2 and #3.

3. Medical record review for Patient #2 revealed an admission date of 12/29/10 with diagnoses of End Stage Renal Disease with Peritoneal Dialysis, Morbid Obesity and Diabetes Mellitus. A physicians order dated 12/29/10 documented, "CAPD [Continuous Ambulatory Peritoneal Dialysis] 5 exchanges per day of 2000 ml [milliliter], use 2.5% [percent] solution for overnight exchange, use 1.5% solution for all others." On 1/4/11, the physician wrote, "Change to all 1.5% PD solution." Review of the PD Flowsheets for Patient #2 revealed blanks on the Flowsheets for the following dates: 12/30/10 through 12/31/10, 1/1/11 through 1/6/11, 1/10/11 through 1/12/11, 1/15/11 through 1/20/11. Care was provided by Nurse #4 and #5.

4. In an interview in the conference room on 3/12/12 at 2:15 PM, the Director of Quality stated, "They have not been trained to care for PD [peritoneal dialysis] patients."

Based on medical record review and interview, it was determined the facility failed to provide an accurate medical record for 2 of 2 (Patient's 1 and 2) sampled patients receiving peritoneal dialysis.

The findings included:
1. Medical record review for Patient #1 revealed an admission date of 11/15/11. A physicians order dated 11/17/11 documented, "...also record net UF [ultrafiltration] each AM at the end of cycler run (use P.D. [Peritoneal Dialysis] Flow Sheets." Review of the PD Flowsheets for Patient #1 revealed no documentation of UF on 11/21/11 through 11/24/11, 12/7/11 through 12/20/11 and 12/22/11 through 1/12/12.

In an interview in the conference room on 3/12/12 at 2:15 PM, the Director of Quality verified the flow sheets were not complete.

2. Medical record review for Patient #2 revealed an admission date of 12/29/10. A physicians order dated 12/29/10 documented, "CAPD [Continuous Ambulatory Peritoneal Dialysis] 5 exchanges per day of 2000 ml [milliliter], use 2.5% [percent] solution for overnight exchange, use 1.5% solution for all others." On 1/4/11, the physician wrote, "Change to all 1.5% PD solution." Review of the PD Flowsheets for Patient #2 revealed blanks on the Flowsheets for the following dates: 12/30/10 through 12/31/10, 1/1/11 through 1/6/11, 1/10/11 through 1/12/11, 1/15/11 through 1/20/11.

In an interview in the conference room on 3/12/12 at 12:20 PM, the Nursing Supervisor verified there were blanks on the Flowsheets and they were incomplete.