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Based on record review and interview the facility failed to establish competency for nurses assigned to perform peritoneal dialysis (PD) resulting in increased risk of unmet patient care goals for all patients. Findings include:

On 5/20/2015 between 0800 and 1200 during medical record review of three peritoneal dialysis (PD) [manual dialysis used to filter the patient's blood of waste products] patient records (#1, #6, #14) the names of the nurses providing the dialysis exchanges were identified.

On 5/20/2015 at 1300 during interview with staff A, Chief Nursing Officer (CNO) who was asked to provide verification of the training and competency of the nurses that provided the PD exchanges. Staff A stated, "we do not have any way to identify who is competent to provide PD when the nurses are assigned, we do have on line training with a quiz after, but I do not know who has not completed it, and we do not have a preceptor qualified to do verification of skills (competency)."

Based on document review and interview, the facility failed to ensure that it staffed nurses who were trained in performing dialysis when peritoneal dialysis (PD) patients (patient's #1, #6, #14, #16) were admitted to the facility and required manual PD exchanges resulting in the potential for peritonitis infection and poor patient outcomes for all patients admitted that require PD treatments. Findings include:

On 05/20/2015 between 0900-1100, during review of medical records for patients #6 and #14 revealed that both patients received PD during inpatient hospitalizations and that several facility staff had performed the treatments. On 05/20/2015 at 1500 a request was made to staff A for documentation of staff education and competencies for performing PD dialysis. The documentation of staff education and competencies for Registered Nurses (RN) was compared to patient treatment records for patient #6 and patient #14 and revealed that on several occasions RN's that had provided the PD did not have training or competencies documented/completed by the facility.

On 05/20/2015 at 0900, during review of the document titled "Peritoneal Dialysis Flowsheet" for patient #6 revealed that on 08/08/2014 at 0830 the morning PD drain was performed, at 0850 fluid was administered into the peritoneal cavity for the next 4 hour dwell, at 1315 the fluid was drained off and at 1330 the dialysate was again administered into the peritoneal cavity. Then at 1715 the fluid was again removed from the peritoneal cavity and more fluid was again administered for the next 4 hour dwell time. All of the above PD treatments were performed by staff K. Staff K's education file lacked documentation showing that she had been trained or was competent at performing PD. On 08/09/2014 both staff L and M had performed PD treatments for patient #6. The employee files for both staff lacked evidence of education and competencies for performing the treatments. On 08/10/2014 and 08/11/2014, the dialysis flowsheet revealed documentation of four RN's ( Staff L, M, N, O) that had performed PD treatments for the patient. The facility was unable to provide evidence of training for the staff prior to providing PD. Flowsheet documentation also supported that between 08/14/2014 and 09/03/2014 (08/14, 08/15, 08/16, 08/17, 08/18, 08/24, 08/25, 08/26, 08/27, 08/28, 08/29, 08/30, 08/31, 09/01, 09/03/2014 PD was provided by staff that the facility was unable to provide evidence of education or competencies for performing the treatments.

On 05/20/2015 at 1100 during review of the medical record for patient #14 revealed that he was hospitalized at the facility from
09/05/2014 thru 09/15/2014. Patient #16 was started on PD treatments upon admission. Review of flowsheet documentation for 09/09, 09/10, 09/11, 09/12, 09/14 and 09/15/2014 all contained signatures of staff whom the facility was unable to provide evidence/documentation of training or competencies for performing the PD treatments.

In an interview with staff A on 05/20/2015 at 1330, when queried if he had any documentation showing that staff K, L, M, R, Q, and P had education or competencies for performing peritoneal dialysis treatments he stated, "I do have it for (staff K) but it was after she had already performed treatments for (patient #6). I cannot locate it (documented competencies) for any of the other staff."


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On 5/20/2015 between 0800 and 1200 during medical record review of patient #1 it was found that Staff H, a RN was documented giving PD exchange to PD patient #1 on 11/4/2014 the completion of the "Just in time-PD 101: The Short Story" is documented completed on 12/10/2014.
Staff N, a RN is documented giving PD exchange to PD patient #1 on 11/30/2014 and no documentation could be found for PD training.
Staff O, a RN is documented giving PD exchange to PD patient #1 on 11/30/2014 and no documentation could be found for PD training.

Based on observation, interview and document review, the facility failed to ensure that the Chief Nursing Officer (CNO-Staff A) and assigned Charge Nurses monitored and evaluated nursing care for patients #4, 6, 8, 9, 11, 12, 13, and 14, resulting in the risk of infection(s) and poor patient outcomes. A total universe of 14 records were reviewed. Findings include:

On 05/19/2015 during tour between 1000 and 1330 with staff A, revealed that in room 540 (patient#4) the graduated container (measuring container) and syringe used for the patient's tube feeding was stored on the counter under the paper towel dispenser. When staff A was queried about the graduated container stored on the counter under the paper towels so that after staff washed their hands water would drip into the container, he stated, "It should not be there. It should be on the other side of this (indicating the splash guard) that is why we put them up." The graduated container and syringe lacked a date as to when they were initiated into care. When staff A was queried as to if the items should contain a date, he stated, "Yes, they should be dated everyday when they are put out." The room also contained a tube feeding bottle that lacked a date and time as to when it was hung and a flush (water) bag that also lacked a date when hung. When staff A was queried about the lack of dates and time, he stated, "They should both be dated and timed as to when they are hung."

Further review of rooms 530 (patient #11), 542 (patient #12), 546 (patient #9), 548 (patient #13) and 549 (patient #8), all revealed that the graduated measuring containers and syringes all used for the patients' tube feedings were stored on the sink side of the splash guard where they could be splash contaminated during hand hygiene. None of the graduated containers or syringes contained dates as to when they were initiated.

In an interview with staff A on 05/19/2015 at 1430, he confirmed the findings and stated, "That is why we put up the splash guards so they would have an area identified as clean and that supplies should not be set on the sink side." When queried as to the lack of staff not dating the items when they are put out, he stated, "They are supposed to be putting a date on them. We will start looking at that to see that it is done."

On 05/19/2015 at 1600, a review of the facility's policy titled, "Guidelines and Protocols, #S05-G, Revised Date: 01/01/2015, Policy: To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality. Nutrition and Fluids-Gastric feedings / PEG tube bags / tubing, graduates and syringes changed-every 24 hours if closed bottle system."

In an interview with staff A on 05/19/2015 at 1700, when queried if it was the expectation of the facility that the graduates and syringes are dated when put into use, he stated, Yes, they are supposed to put the date on them."

On 05/20/2015 at 0900, during review of the medical record documentation of delivery of peritoneal dialysis (PD) for patients #6 revealed the following:
Patient #6 had a PD order written on 09/05/2014 at 1530 for 3 liters (3000 ml) 2.5% intraperitoneal-dwell for two hours to start in the morning (09/06/2014) at 0900 and 2 liters (2000 ml) at 2100 every night, dwell overnight and drain in the morning at 0900.
Then on 09/05/2014 at 1830, an order was written to change the PD exchanges to 2.5 liters (2500 ml) of 2.5% every 2 hours while awake.
The PD Flowsheet for 09/06/2014 showed that the patient's overnight dwell was drained at 0910.
On 09/06/2014 at 1445 the PD Flowsheet revealed documentation that the patient received 3000 ml's Dianeal.
On 09/06/2014 at 1500 a PD order was written for four exchanges every 4 hours during the day (7 am-11 pm and 1 exchange 4.25% Dianeal a 11 pm-7am. The order does not contain a volume.
At 2140, 2000 ml's was administered and at 0115 2600 was administered.
Then on 09/07/2014 the patient was administered 2800 ml's of 4.25% at 1230.
On 09/07/2014 at 1510 a new order was written to change 4.25% Dianeal to 2.5 %, keep time schedule the same. Again the order lacked a fill volume.
On 09/07/2014 at 1700, the patient was then administered 2500 ml and at 2100 the fill volume was 2900 ml's. Then on 09/08/2014 at 0210 the fill volume was again documented as 2900 ml's.
On 09/08/2014 the fill volumes and times were documented as 0830-2700 ml's, 1230-2700 ml's, 1630-2600 ml's, 2140-3100 ml's.
On 09/09/2014 at 0200-2850 ml's.

On 05/20/2015 at 1100 during review of the medical record for patient #14, the same inconsistencies with following the PD prescription fill volumes was noted in patient #14's record.

In an interview with staff A on 05/20/2105 at 1445, he confirmed that the PD treatment orders for both patients #6 and #14 were not followed as ordered by the physicians. When staff A was queried as to the inconsistencies and what staff should be doing for a 2500 ml order, he stated, "If they are ordered 2500 ml's, we weight the bag on this scale and if it weights more than the 2500 ml's then they should be draining off the excess prior to starting the treatment and if it is not 2500 ml's then they need to add another bag up to the ordered dose." During the interview, a review was conducted of the small hand held scale used to weigh a bag of solution. Staff A demonstrated the use of the scale and the solution bag weight 2500 ml's. However, a review of the scale showed that it was not calibrated to zero, making the bag actually weigh more than the 2500 ml's.

In an interview with staff A on 05/20/2015 at 1330, when queried if he had any documentation showing that staff were educated in performing PD treatments, he stated, "Yes." Staff A was only able to provide documentation of some staff education for PD. When queried if he could provide education or competencies for staff K, L, M, R, Q, and P, he stated, "I do have it for (staff K) but it was after she had already performed treatments for (patient #6). I cannot locate it for any of the other staff that you asked for."

Based on record review and interview the registered nurse (RN) failed to ensure competence of caregivers before assigning nursing care for two peritoneal dialysis (PD) patients (#1, #6), resulting in failure to follow physician orders and the potential for poor patient outcomes for all patients requiring PD. Findings include:

On 5/20/2015 between 0800 and 1200 during medical record review of three peritoneal dialysis (PD) patient records (#1, #6, and #14) 9 of 9 nurses did not provide PD exchanges as ordered by the physician, including fill volumes and dwell times.

Patient #1:
On 11/2/2014 PD orders"...fill volume 2500 ml for three exchanges and fill volume 2200 ml for 2 exchanges 1100 am and 500pm, dwell time 2.5 hours.
On 11/2/2015 the inflow amounts documented were: 0830-2700 mls instead of 2500 mls, at 1145- 2250 mls inflow instead of 2200, at 1420- 2600 mls instead of 2500, at 1800- 2100 mls instead of 2200, and at 2210- 2700 mls inflow instead of 2500. Staff D.
On 11/3/2014 the inflow amounts documented were: 0900- 2300 mls instead of 2500, 1200-2100 mls instead of 2200, 1540- 2600 mls instead of 2500, 1800-2100 mls instead of 2200, and at 2220-2700 mls instead of 2500. Staff D.
On 11/4/2015 the inflow amounts documented were: 0920-2700 mls instead of 2500, 1830- 1900mls instead of 2200. Staff H .
On 11/28/2014 at 1640 PD orders read, "Resume PD- q 4hours 2 liter exchanges..."
On 11/30/2014 the inflow amounts documented were: 0810 1750 mls instead of 2000, 1100-1900 mls, 1400-2500 mls, 1700-2900 mls, 2100-2400 mls.
On 12/1/2014 the inflow amounts documented were: 0800-2400 mls, 1125-2200 mls, 1425- 2400 mls.
No other Peritoneal Dialysis Flowsheets were found in the medical record for review.

On 5/20/2015 at 1300 during interview with staff A, Chief Nursing Officer (CNO) was asked to provide verification of the training and competency of the nurses that provided the PD exchanges, he stated, "we do not have any way to identify who is competent to provide PD when the Nurses are assigned to care for patients......" "I can see that the Inflow amounts and the dwell times were not what the Physicians ordered."


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On 05/20/2015 review of the medical record for patient #6 at 0900 revealed that peritoneal dialysis (PD) treatments were performed on the patient between 08/07/2014 - 09/03/2014 by staff K, L, M, P, Q, R, and S (Registered Nurses).

Further review of patient#14's medical record on 05/20/2015 at 1100, also revealed that facility staff K, L, M, Q, R and S performed PD treatments for the patient between 09/05/2015 - 09/15/2015.

In an interview with staff A on 05/20/2015 at 1330, when queried if he had any documentation showing that staff K, L, M, R, Q, and P had education or competencies for performing peritoneal dialysis treatments he stated, "I do have it for (staff K) but it was after she had already performed treatments for (patient #6). I cannot locate it for any of the other staff."