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Based on record reviews, observations, and interviews, the hospital failed to ensure ongoing nursing assessment, supervision and oversight to meet patient care and services and prevent complications for 3 (#5, 6, and 15) of 15 patients. Failed to monitor and assess patients receiving hemodialysis treatments. Facility census was 62 and 15 of 62 was the sample.

Findings Include:

Patient #6 was admitted to the Kindred Hospital Kansas City facility on August 4, 2009. According to the record the patient was admitted for ventilation weaning, respiratory failure, renal failure on hemodialysis, recent right side CVA (stroke) with left side hemiparesis (paralysis) of the body. The admission history and physical indicated the patient had chronic atrial fibrillation and coronary artery disease with post arterial bypass graft and stents. The history indicated the patient had recurrent C difficile colitis, gastrointestinal (GI) bleed and transient ischemic attacks. The record indicated the patient was transferred to Kindred Hospital in Kansas City for continuation of medical care, weaning from mechanical ventilator, hemodialysis treatments, recent hypotension, and for rehabilitation services.

Admission physical Orders dated August 4, 2009 included Benadryl p.r.n. (as needed) for agitation, sliding scale of insulin, peg tube feeding with Nepro supplement feeding, vancomycin (antibiotic) 250 milligram two times a day, hemodialysis treatments three times a week and rehabilitation services for range of motion, cognition assessment and bed mobility.

Record review showed that the physical therapist evaluation dated 8/6/09 documented that the patient had significant decreased with blood pressure while the patient was in a supine lying position. The therapist recommended and received a verbal physician order on 8/10/09 for the patient to use bilateral thigh high ACE bandages wrapping of lower extremities prior to getting up and transferring from bed to chair to prevent orthostatic hypotension. On 8/17/09, the patient developed redness above the left knee to lower leg and pressure ulcer to lateral site of left leg and the ACE bandages were discontinued. The physical therapist progress notes dated 8/17/09 indicated that a mechanical lift was being used to transfer the patient without ACE bandages and without TED hose. The physical therapist progress notes did not document swelling, pressure ulcer or blue colored toes. Review of physician orders dated 8/10/09 at 11:45am the rehabilitation physician wrote for bilateral thigh high ACE wrapping of lower extremities prior to getting the patient out of bed to bed side chair. There was no physician order for TED Hose noted in the patient record.

On August 11, 2009, the rehabilitation physician documented in the Patient Care Summary notes that the patient had no focal calf swelling of his legs with the ACE wrapped nor that the patient had become hypotensive with getting up into the Geri-chair.

On August 13, 2009 at 12:44am the rehabilitation physician documented in the Patient Care Summary notes that the patient is currently sitting up in the bedside chair with bilateral lower extremities ACE wrapped. The physician indicated the patient had no problems and did not become hypotensive with getting up in the Geri-chair.

On August 17, 2009 at 11:53pm a physician of internal medicine documented in the Patient Care Summary notes that the patient extremities " Showed no edema. There is a skin discoloration. It is a pressure ulcer they grow in round circles on the left lower extremity. It seems to me that it is from previous ACE wrap. I did remove (his/her) ACE wrap last Friday. "

On August 17, 2009 at 9:09am the physician wrote an order to " do not apply ACE wraps " . At 9:30am the physician order was acknowledged by a licensed practical nurse (LPN).

On August 17, 2009 at 1:18pm the rehabilitation physician wrote an order to cancel the use of bilateral thigh high Ted Hose and requested that the patient be monitored for orthostatic blood pressure closely when the mechanical lift transfers are being done with the Ted Hose.

Direct observation of the patient on the Afternoon of 1/5/10 and 1/12/10 at 11:45am showed that the patient had three (3) dry sores with scabs on the middle supine bone of the left leg below the knee. On the lateral left lower leg the surveyor observed the patient had a circular ulcer resembling a large prune shape. The ulcer was open, redden and clean, and the edges showed signs of granulating tissue. The patient left heel was dry, soft and without open sores. The patient right heel and leg was observed to be dry but without any open sores or ulceration.

Record review showed that on 1/5/10 at 11:34pm a wound care physician documented on Patient Care Summary notes that he/she examined the patient and determined that the ulceration of the patient left lower leg has improved and pressure ulcers of the heels were now resolved. The physician recommendation indicated that he/she wanted to continue treatment with topical silver alginate (ointment) to the left lateral lower leg ulcer and to continue with boots for pressure prophylaxis.

The record lacked evidence to show the patient was evaluated and assessed for pressure ulcer development of left leg while wearing ACE bandages wrap on legs. The record did not document that the patient had sores on left leg on admission but developed sores on left leg 13 days later after admission.

The record showed that the patient developed complications during hemodialysis treatments without evidence of assessment, evaluation and physician notification of the patient problems. The record lacked evidence to show the patient was evaluated and assessed during dialysis treatments. The record lacked documentation of communication, verification of physician orders and recommendations.

For detailed evidence, refer to A0267 citation.

Patient #5 (closed record) was admitted to the facility on 4/17/09 for ventilator weaning and hemodialysis treatments. The record showed the patient had multiple comorbid conditions that included respiratory failure, off the vent, respiration infection, malnutrition and history of a stroke. A physician progress note dated 10/8/09 stated that the patient was off the vent, alert and interactive.

Review of hemodialysis flow sheet dated 10/9/09 showed that the patient pre assessment blood pressure was 105/44 at 6:27am. The flow sheet recorded that the patient was alert and responded by nodding that he/she had no pain. Dialysis treatment was initiated at 6:27am and blood pressure was recorded at 105/42. At 7:51am the patient blood pressure dropped to 97/86 and fluid removal was documented as 0.89 kilogram (1.95 pounds). At 8:13am the nurse recorded that fluid bolus given due to unable to obtain blood pressure, pulse, and the patient had agonal respiration. Nurse recorded a Code Blue (resuscitation team) was called and Code Blue was initiated. The Code Blue record dated 10/9/09 showed the patient was resuscitated and was admitted to the intensive care unit. The record did not show that the attending nephrologists was notified of the patient condition, change during the dialysis treatment.

Review of preventative maintenance reports, did not show that the facility followed their policy to check the dialysis machine for malfunction failure. There was no evidence that the dialysis staff checked and tested the dialysate solution used in the dialysis treatment for chemical concentration, bacteria and electrolyte verification. As required by the facility policy, the dialysis machine was not sequestered for bio medical investigation.

Patient #15 (closed record) was admitted to Kindred Hospital-KC on 8/7/09 for mechanical ventilator weaning, wound care for sacral pressure ulcer and maintenance dialysis treatment. Review of the patient ' s record showed multiple comorbid conditions that included severe metabolic acidosis, cardio-respiratory failure, severe hypotension, diabetes, renal failure, malnutrition and pneumonia.

Record review showed that the patient had hemodialysis treatments on 8/10/09 and 8/12/09 without documented complications to treatment. Review showed that on 8/14/09 at 7:35am the patient hemodialysis treatment was initiated using a right tunnel catheter access, and the nurse documented that the flow was good, the patient skin was warm and the patient was alert but non-verbal. The record showed the patient blood pressure was recorded at 80/29 (normal is 100/60) and heart rate was 84 beats per minute. Review showed the patient treatment was initiated at 7:35am with 80/29 blood pressure. At 8:15am, the hemodialysis flow sheet indicated that the patient had no blood pressure and a Code Blue (resuscitation team) was called. The dialysis treatment was ended and the patient blood was returned. The hemodialysis flow sheet did not document that the physician was notified of the patient low blood pressure before the treatment started. Review showed the renal physician signed the dialysis protocol orders at 7:30am but did not document a patient evaluation and assessment of the patient low blood pressure.

Interview with Chief Clinical Officer on 1/6/10 at 5:45pm stated that he/she did not know that patient (#6) coded and bagged on 1/2/10 and 1/4/10, during dialysis treatment. Chief Nursing Officer stated that there were supervisors on duty when the patient coded, but this was not reported in the flash report given to all disciplines. Chief Nursing Officer stated that the patient coded in dialysis in October was not addressed in the November QA report, but will look into it.

Interview with Vascular Surgeon on 1/8/10 at 3:50pm, stated that the patient (#6) catheter was not advanced 7 cm as requested by the radiologist because he did not think it was clinically appropriate. Vascular Surgeon stated that he reviewed the patient x-ray downstairs and felt the patient dialysis catheter was appropriately placed so he verbally communicated to the nurse the catheter was ready for treatment.

Telephone interview with the Nephrologists on 1/8/10 at 4:15pm stated that he did not see the patient until the second episode of events Nephrologists stated that he/she did not know the patient catheter was infected, but will have to review the patient record to know what happened to the patient.

Interview on 1/12/10 at 5:15pm the Chief Nursing Officer stated that the contracted dialysis services supervisor findings are not documented and evaluated to determine improvement. Chief Nursing Officer stated we know that documentation must be improved so that opportunities for improvement can occur.

Based on record reviews and interview the facility failed to initiate care plans for two patients (#12, and #3) out of 15 records reviewed. Facility census was 62.

Findings included:

1) Review of policy: Assessment / Reassessment - Multidisciplinary Patient H-PC 04-009 dated 11/09 on 1/08/10 stated in part: Nursing Department:
1. An assessment is performed by a Registered Nurse and is recorded in the patient medical record, within 12 hours of admission. This assessment is based upon actual observation, patient/family interview, and records accompanying the patient from the referral facility.
2. The initial assessment shall determine the need for an assessment and possible referral to appropriate disciplines of the patient's nutritional and functional status, as well as discharge planning needs, when appropriate. The initial assessment of the patient's nursing care needs will include:
Biophysical, Psychosocial, Cognitive Environmental, Self-Care Needs Assessment, Wound Risk Assessment, Pain, Fall Risk Assessment, Educational Needs Assessment, Communication, Age and Development, Social and Cultural and Spiritual and Discharge Planning. This assessment allows an RN to determine and prioritize the patient's nursing care needs.
A Patient Care Treatment Plan is then prepared in accordance with the patient's needs and identified problems.

2) Review of Patient's #12's open medical record on 01/08/10 at 10:40 a.m. showed admission to the facility on 12/14/09 for end stage renal disease - dialysis, lethargy, History of Methicillin resistant staph Aureus (MRSA- an organism resistant to penicillin), History of deep vein thrombosis (blood clot) - on Heparin (medication to thin the blood), Diabetes Mellitus, hypertension (elevated blood pressure) etc.

The care plan failed to address Isolation precautions for the MRSA.

During an interview at the time of the record review Staff C, registered nurse (RN) manager verified the absence of a care plan for MRSA.

3) Review of Patient's #3's open medical record on 01/08/10 at 09:00 a.m. showed admission to the facility on 01/05/10 for treatment of a right heel wound and record also documented status post right buttocks abscess (a collection of pus) with MRSA.

The care plan failed to address the need for infection control for the history of the abscess and MRSA diagnosis.

During an interview at the time of the record review Staff C, registered nurse (RN) manager verified the absence of a care plan for MRSA.

Based on observation, interview and policy review the facility failed to ensure staff followed infection control policies for: hand hygiene policy for two Patients (#12, #4), failed to follow the policy for urinary catheter (a tube inserted into the bladder to drain urine) care for one Patient (#3), and failed to follow the policy for personal protective equipment (PPE) for two observed care incidents for Patients (#3 and #16). The facility census was 62 and the sample size was 15.

1) Review of the facility policy titled HAND HYGIENE dated 01/2007 stated in part the following:

PURPOSE:
To remove transient microorganisms from hands. Handwashing with soap and water to remove soil and gross debris on hands, but does not offer continued antimicrobial action. Antimicrobial hand gel is used as an adjunct to handwashing. The product is available in patient rooms and at the nurses' station. This product has a one hour extended kill time and a four hour bacteriostatic action. Adherence to recommend hand hygiene practices could help reduce rates of healthcare acquired infections.

POLICY:
HAND HYGIENE WILL BE PERFORMED AS FOLLOWS:
A. Before beginning a work shift
B. After finishing a work shift.
C. Before performing invasive procedures
D. Before and after patient contacts
E. Between patients.
F. After situations during which microbial contamination of the hands is likely to occur (i.e. contact with potentially contaminated environmental surfaces)
G. Before and after eating
H. After covering a cough or sneeze
I. After removal of gloves, including between tasks on the same patient.

The United States Center for Disease Control Hand Hygiene Guidelines Fact Sheet states in part the following:

5. The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70 percent to 80 percent, prevent cross-contamination and protect patients and health care personnel from infection. Hand rubs should be used before and after each patient just as gloves should be changed before and after each patient.

2) Record review of Patient #12's medical record on 01/06/10 revealed the patient admitted on 12/30/09 with bilateral gangrene (the decay and death of tissue when the blood supply of a living person is interfered with by injury, infection etc) of the feet, paraplegia (loss of ability to move lower limbs) etc.

Observation on 01/06/10 at 02:25 p.m. revealed Staff H, Licensed Practical Nurse (LPN), clean the left foot wound of Patient #12 with a wound cleaner. Staff H did not change gloves after cleaning wounds on left foot. Staff H then applied a wound dressing to the left foot wound.

Staff H then cleaned the wounds on Patient #12's right foot. Staff H removed gloves and then put on another pair of gloves without hand hygiene.

During interview with Staff H after wound care observation, Staff H said "I should have changed my gloves after wound care on the left foot before applying the dressing. I also should wash my hands each time I change my gloves."

3) Observation of dialysis care on 01/08/10 at 09:00 a.m. showed Staff U, a physician put on gown and gloves to visit dialysis Patient #12. Patient #12 is on contact precautions for Methicillin Resistant Staph Aureus (MRSA,an organism resistant to penicillin). Staff U touched patient #12's bedding and person during the patient contact.

Staff U left patient #12's bedside, removed gloves and reapplied gloves. Staff U did not perform hand hygiene, before contact with the next dialysis patient.

Staff C, registered nurse (RN) manager verified Staff U should have washed hands after glove removal and before reapplying gloves.

4) Lippincott Manual for Nursing Care, reference source provided by facility for nursing to follow for management of the Patient with an indwelling catheter reveals in part the following staff direction:
2. Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or other securement device.

Properly securing the catheter prevents catheter movement and traction on the urethra (tube through which urine is discharged from the bladder - tube urinary catheter is inserted into).

Observation on 01/06/10 09:10 a.m. showed Patient #3 with a urinary catheter. Patient #3's urinary catheter had no securement. Patient #3's urinary catheter tubing was tight and pulling with each movement by the patient.

Staff C, RN manager confirmed the lack of urinary securement device.

5) Review of facility policy for PPE application reveals in part the following CDC guidelines:
1. Gown
*Fasten in back of neck and waist

6) Observation on facility unit tour on 01/05/10 at 02:50 p.m. showed Staff I, LPN going into Patient #16's room. Staff I had on an Isolation PPE gown. Staff I did not have the gown tied at the waist.

Sign on Patient #16's door revealed patient on isolation requiring gown and glove PPE application.

During an interview on 01/05/10 at 03:30p.m., Staff I said I didn't tie my gown in the room, I should have done that to protect all of my clothing.

7) Observation on 01/06/10 at 09:10 a.m. revealed Staff J, RN wound care nurse, performing wound care for Patient #3. Patient #3 is on Isolation precautions for MRSA. Staff J wore a PPE gown but did not tie the gown at the waist during wound care. Staff J came into contact with Patient #3's bedding during the wound care.

During an interview with Staff J, after wound care, Staff J said "I should have tied my gown, to protect my clothing."

Based on record review and interviews, the hospital failed to ensure the contracted dialysis services is monitored and evaluated for services provided to patient receiving hemodialysis treatments, failed to develop oversight procedures to ensure effective communication among hospital staff and the contracted dialysis services. Failed to have a system in place for reporting and overseeing patients that develop complications and life threatening adverse events during hemodialysis treatment and failed to monitor, evaluate and implement corrective improvement plan for contracted dialysis services. Facility census was 62 with nine of 62 were chronic dialysis patients, who were at risk for potential and actual negative outcomes during dialysis treatment. (Patients # 5, 6, and 15).

Findings Include:

Patient #6 was admitted to the Kindred Hospital Kansas City facility on August 4, 2009. According to the record the patient was admitted for ventilation weaning, respiratory failure, renal failure on hemodialysis, recent right side CVA (stroke) with left side hemiparesis (paralysis) of the body. The admission history and physical indicated the patient had chronic atrial fibrillation and coronary artery disease with post arterial bypass graft and stents. The history indicated the patient had recurrent C difficile colitis, gastrointestinal (GI) bleed and transient ischemic attacks. The record indicated the patient was transferred to Kindred Hospital in Kansas City for continuation of medical care, weaning from mechanical ventilator, hemodialysis treatments, recent hypotension, and for rehabilitation services.

Admission physical Orders dated August 4, 2009 included Benadryl p.r.n. (as needed) for agitation, sliding scale of insulin, peg tube feeding with Nepro supplement feeding, vancomycin (antibiotic) 250 milligram two times a day, hemodialysis treatments three times a week and rehabilitation services for range of motion, cognition assessment and bed mobility.

Record review showed that on 8/5/09 at 11:52am a nephrologist physician wrote a consultation report for maintenance of hemodialysis. The nephrologist assessment plan documented that the patient had congestive heart failure, coronary artery disease, end stage renal disease and a stroke. The physician indicated that the patient will be followed for fluid electrolyte imbalance management, but the record did not show evidence the physician wrote specific hemodialysis prescription orders at the time of consultation based on the patient assessment.

On 8/5/09 at 2:16pm, the patient first hemodialysis treatment was initiated at Kindred Hospital using a physician signed protocol. The protocol indicated the patient was to have 3.5 hours of dialysis treatment using a D170 dialyzer, a blood flow rate of 500 and a dialysate bicarbonate bath. Dialysate flow rate was 600 milliter (ml) per minute and ultrafiltration to reduce weight was not to exceed 3 kilogram or as blood pressure tolerates. The physician did not document a target weight or estimated dry weight for this patient to determine evaluation and assessment of the patient volume status each treatment. This initial protocol order was not signed by the physician until 8/29/09, 24 days later after the patient first treatment.

Review of hemodialysis flow sheets dated 8/12/09, showed that the patient hemodialysis order included Albumin 25%, 25 grams intravenously 200 ml of normal saline to keep systolic blood pressure above 90 mm Hg. The dialysis blood flow rate used was written 400 - 500 ml/min and the ultrafiltration to reduce weight was not to exceed 1.2 kg or as blood pressure tolerates. The physician signed the order on 8/12/09 at 7:00am. The flow sheets showed that the hemodialysis treatment was initiated at 7:06am and blood pressure was recorded at 114/58 (normal ranges is between 100/60 to 140/90). At 8:03am the patient blood pressure dropped to 99/55 and continued to drop throughout the dialysis treatment. At 10:36am the patient blood pressure was recorded at 89/42. At 10:40am the dialysis treatment ended and the patient blood was returned. The dialysis flow sheet did not record that the staff administered normal saline 200 milliters intravenous (IV) and did not show the patient was administered the Albumin 25%, 25 milligrams (mg) IV as ordered to keep the systolic blood pressure above 90 mm Hg as ordered by the physician. The flow sheet showed the dialysis nurse removed 1.5 kilograms (3.3 pounds) of fluid, and then wrote a note stating the patient tolerated the fluid removal, lungs were still course and the patient had no edema. The flow sheet did not document that the physician was notified of the patient low blood pressure during the treatment to determine re-evaluation of the patient dialysis prescription. The patient did not have an estimated dry weight (EDW) ordered and the patient weight removal was based on the patient ' s fluctuating pre-weight. The record did not show reassessment and evaluation of the patient dialysis needs and adverse effect of low blood pressure during the treatment.

Review of hemodialysis flow sheet dated 10/21/09 showed that the patient received 3.5 hours of hemodialysis treatment and 3.0 kilogram (kg) (6.6) of fluid was removed. The treatment started at 7:01am and ended at 10:31am. The patient ' s blood pressure was recorded at 10:31am to be 89/40. The record did not show the patient was evaluated and reassessed to determine prescription changed and dialysis treatment needs. The record did not show evidence the physician was notified of the low blood pressure.

Record review showed that on 10/22/09 the patient was found by a Certified Nurse ' s Assistance (CNA) to be unresponsive. Review showed a Code Blue (resuscitation team) was called and CPR (cardio pulmonary resuscitation) procedure was initiated. The record indicated the patient was transferred to the intensive care unit (ICU) for further care, monitoring and mechanical ventilation. On 10/23/09 at 8:13pm a physician progress notes summary report documented that the patient had a low blood pressure and never lost pulse rate. The record indicated that patient received intravenous (IV) fluids and blood pressure normalized.

Review of handwritten Renal Physician progress notes dated 12/21/09 at 7:35am stated: " ESRD infected cath - to be changed today. Dialysis today or in AM. "

On 12/21/09 at 3:00pm the vascular surgeon progress notes documented that the patient had catheter Sepsis and the dialysis tunnel catheter was removed using local anesthesia. Review showed that on 12/23/09 at 3:00pm the surgeon progress notes documented that the procedure of a temporary hemodialysis catheter was placed in the right femoral vein, and a central line was placed in the left " I.J. " (Internal jugular) under local anesthesia.

Review of internal medicine physician progress notes summary dated 12/22/09 documented that the 12/16/09 culture report showed the patient dialysis catheter was infected with pseudomonas bacteremia. Review showed that the physician indicated the patient missed dialysis treatments for a few days because of the infected dialysis catheter and the physician wrote that: " I think this also might be responsible for the worsening chest x-ray and the fluid retention " .

On 12/23/09 the hemodialysis flow sheet recorded that the patient received treatment through the new right femoral vein access located in the right groin. Review showed that the patient ultrafiltration weight removal was recorded as 1.5 kg and the patient tolerated the fluid removal.

On 12/24/09 at 5:58pm, the record showed that the patient bleed from the site of the removal of the infected dialysis catheter. Review showed that pressure dressing was applied, and the surgeon who removed the infected dialysis catheter on 12/21/09 was notified. On 12/25/09 a physician progress note summary indicated that the patient hemoglobin dropped to 7.4. The record showed the last hemoglobin level was recorded on 12/22/09 was 8.2 g/dl (normal range is 11.7 - 15.5).

On 12/30/09 at 11:30am the nursing notes recorded that the patient returned from surgery after a scheduled permanent dialysis catheter placement. The notes indicated that the dialysis catheter was confirmed okay for use by the surgery department. The name of the person giving confirmation to use the dialysis catheter was not identified in the notes. Review of invasive operative procedures report dated 12/30/09 at 10:32am dictated by a surgeon confirmed that placement of tunneled hemodialysis catheter was performed in the left subclavian vein. The surgeon indicated in the report that post procedure a chest film was obtained and the patient tolerated the procedure well.

Review of Diagnostic Radiology Report dated 12/30/09 at 10:54am showed that a portable chest x-ray was performed and the radiology physician dictated the findings as follows: " There is a left subclavian dialysis catheter in place. The catheter is at the junction of the brachiocephalic and superior vena cava. This is more proximal than typically noted for dialysis catheters. If possible the catheter should be advanced approximately 7 cm ... to the cavoatrial junction " . Review showed that the radiology physician ' s findings were not addressed in the medical records. There was no information that the facility staff clarified the radiology physician impression and findings to advance the patient ' s dialysis catheter 7 cm to the cavoatrial junction. The record did not show evidence that the nursing staff clarified the use of the left subclavian dialysis catheter placement with the surgeon after the radiology physician documented the catheter placement needed to be advanced 7 cm to the cavoatrial junction.

Review of hemodialysis orders dated 1/2/10 showed that the dialysis nurse used a protocol to initiate the dialysis treatment. The protocol did not address the radiology findings and there was no evidence the dialysis nurse questioned or clarified the use of the newly placed dialysis catheter use for hemodialysis treatment.

Review of hemodialysis flow sheet dated 1/2/10 showed that dialysis treatment was initiated at 8:45am using a right subclavian catheter access for treatment. Pre treatment blood pressure was recorded at 110/50 at 845pm. At the time of the initiation of the treatment the patient ' s blood pressure dropped to 99/46. The dialysis nurse recorded on the flow sheet that the patient right subclavian catheter was inspected and it was WNL (within normal limits) but there was poor blood flow related to the catheter. Review showed that at 8:49am the dialysis nurse called a Code Blue (resuscitation team) and documented the following: " Tx initiated Code Blue called. O2 SAT 80%, pt color dusky, pulse weak. Blood not returned d/t high venous pressure. Tx terminated. Report given to charge nurse (name) " . (See Code Blue Report). The nurse recorded that he/she used a right subclavian catheter for dialysis, when it should have been the left subclavian catheter access. The hemodialysis flow sheet did not document that the dialysis nurse confirm or clarify the correct subclavian catheter before he/she initiated the patient treatment. A radiology report of a portable chest x-ray done on 1/2/10 at 12:23pm reported that the patient chest examination revealed multiple lines and tubes. It was unknown what line the nurse used for the initiation of hemodialysis treatment. The record did not show a nephrologist physician signed the protocol for dialysis treatment nor did it show evaluation that the patient ' s dialysis catheter was safe to use.

Review of physician progress note summary dated 1/3/10 documented that the patient did have a code blue yesterday (1/2/10) but was not sure exactly what happened to the patient. The note indicated the patient probably had aspirated.

Review of hemodialysis flow sheet dated 1/4/10 showed the dialysis nurse use a protocol as physician orders to initiate dialysis treatment. Review showed the nurse filled in the blanks in the protocol for physician orders, but the physician did not sign the protocol, before or after the patient had treatment and the nurse did not document if the physician was consulted before the treatment was initiated.

The hemodialysis flow sheet dated 1/4/10 did not clearly identify what dialysis access the nurse used to initiate the dialysis treatment at 6:39am. The initial assessment showed the nurse used a left shoulder access then a right femoral access for dialysis treatment. Review showed that at 6:39am dialysis treatment was initiated by a dialysis nurse and the patient had pain reflection to the flush. At 6:40am the dialysis nurse wrote the following: " At 0640 unable to return pt ' s blood, had to restring machine. Orders received not to use permanent access in L shoulder " . The hemodialysis flow lacked documentation of what happened to the patient and what action the nurse took to clarify the physician orders before initiation of the dialysis treatment.

Review of physician progress notes summary dated 1/4/10 at 8:47am documented that dialysis was started 10 minutes earlier and the patient looked dusky and somewhat agonal. The physician documented that the patient did not lose his/her blood pressure but was bagged. The physician progress notes is as follows: " The patient, I was called to see him on emergency basis this morning. The dialysis was started 10 minutes earlier and he looked dusky and somewhat agonal. He did not lose his blood pressure or his rhythm. I discussed with the dialysis nurse. Apparently, the new dialysis catheter in the right subclavian was tried to be accessed and the patient has some discomfort and agitation when it was flushed and given small fluid bolus. So, he has to access the groin dialysis catheter the old one. We bagged him. He was okay, put him back on the vent, and we did an ABG on him this morning. His PO2 of 543, PCO2 of 34, pH 7.38, serum bicarbonate of 20. I gave him 1 amp of sodium bicarbonate. " The physician documented plan indicated that the patient received 1 unit of packed cells and told the dialysis nurse and the RN not to use the new dialysis catheter unless it was cleaned by the nephrologist and vascular surgeons.

Review of handwritten nephrologist progress notes dated 1/4/10 at 10:00am documented the following: " Pt seen on dialysis, using femoral line. Discussed with HD nurse. Pt earlier had (his/her) IJ line used and within a few minutes, pt had desaturation " respiratory event " and (he/she) was taken off HD and nurse changed to other line which is working fine. In retrospect, (he/she) had similar episode Saturday 1/2/10 when (he/she) was started on HD with IJ line. Discussed with nurse who will let Dr. (name) know and Dr. (name) will correct line problem if exists. I advised dialysis nurse NOT to use IJ line until situation rectified. " Note: (The nephrologist typed and signed the above note from his handwritten note for surveyor review on 1/8/10, then confirmed the note by telephone interview on 1/8/10 at 4:15pm).

The patient ' s medical record reviewed did not show that the facility investigated the patient ' s negative problems during hemodialysis treatment to determine what went wrong and what actions would be implemented to prevent reoccurrences. The facility had no information to review that indicated investigation and correction plan.

Patient #15 (closed record) was admitted to Kindred Hospital-KC on 8/7/09 for mechanical ventilator weaning, wound care for sacral pressure ulcer and maintenance dialysis treatment. Review of the patient ' s record showed multiple comorbid conditions that included severe metabolic acidosis, cardio-respiratory failure, severe hypotension, diabetes, renal failure, malnutrition and pneumonia.

Record review showed that the patient had hemodialysis treatments on 8/10/09 and 8/12/09 without documented complications to treatment. Review showed that on 8/14/09 at 7:35am the patient hemodialysis treatment was initiated using a right tunnel catheter access, and the nurse documented that the flow was good, the patient skin was warm and the patient was alert but non-verbal. The record showed the patient blood pressure was recorded at 80/29 (normal is 100/60) and heart rate was 84 beats per minute. Review showed the patient treatment was initiated at 7:35am with 80/29 blood pressure. At 8:15am, the hemodialysis flow sheet indicated that the patient had no blood pressure and a Code Blue (resuscitation team) was called. The dialysis treatment was ended and the patient blood was returned. The hemodialysis flow sheet did not document that the physician was notified of the patient low blood pressure before the treatment started. Review showed the renal physician signed the dialysis protocol orders at 7:30am but did not document a patient evaluation and assessment of the patient low blood pressure. Review of the Quality Assessment Performance Improvement minutes did not show evidence the facility investigated what happened to the patient.

Patient #5 (closed record) was admitted to the facility on 4/17/09 for ventilator weaning and hemodialysis treatments. The record showed the patient had multiple comorbid conditions that included respiratory failure, off the vent, respiratory infection, malnutrition and history of a stroke. A physician progress note dated 10/8/09 stated that the patient was off the vent, alert and interactive.

Review of hemodialysis flow sheet dated 10/9/09 showed that the patient pre assessment blood pressure was 105/44 at 6:27am. The flow sheet recorded that the patient was alert and responded by nodding that he/she had no pain. Dialysis treatment was initiated at 6:27am and blood pressure was recorded at 105/42. At 7:51am the patient blood pressure dropped to 97/86 and fluid removal was documented as 0.89 kilogram (1.95 pounds). At 8:13am the nurse recorded that fluid bolus given due to unable to obtain blood pressure, pulse, and the patient had agonal respiration. Nurse recorded a Code Blue (resuscitation team) was called and Code Blue was initiated. The Code Blue record dated 10/9/09 showed the patient was resuscitated and was admitted to the intensive care unit. The record did not show that the attending nephrologist was notified of the patient condition, change during the dialysis treatment and the dialysis nurse did not document how much fluid he/she gave the patient.

Review of preventative maintenance reports, did not show that the facility followed their policy to check the dialysis machine for malfunction failure. There was no evidence that the dialysis staff checked and tested the dialysate solution used in the dialysis treatment for chemical concentration, bacteria and electrolyte verification. As required by the facility policy, the dialysis machine was not sequestered for bio medical investigation. Therefore, it was unknown if dialysis machine malfunction occurred.

Review of the facility Dialysis Services Committee minutes dated June 2009 to November 2009 showed that the facility does not monitor, evaluate or investigate patient ' s incidence, accidents or adverse events while receiving hemodialysis treatment. The meeting minutes dated September 23, 2009 identified communication problems between the nephrologists, pulmonary physician and other physician regarding significant access problems and other issues affecting the patients. At the time of the survey the facility had no plan, intervention or recommendations for communication issues regarding patients access problems.

Review of Contracted Dialysis Services Quality Assurance meeting minutes showed that in July, August and September 2009, there were 60 episodes of patients having complications of hypotension during dialysis treatment but this information is not addressed in the Kindred Hospital-KC Quality Council Committee minutes and therefore, indicating this information is not being reviewed, discussed, or evaluated. There was no information to review that determined if Kindred Hospital was informed of the patient ' s complications during hemodialysis treatments.

Although the hospital reports that a supervisor was responsible for oversight of the Contracted Dialysis Services there was no information recorded of the supervisor ' s oversight findings or tracking quality issues affecting patients receiving hemodialysis.

Review showed the hospital did not have evidence of systems in place to measure, analyze, and track quality indicators and adverse patient ' s events that include the high-risk problem prone dialysis unit.

Interview with Chief Clinical Officer on 1/6/10 at 5:45pm stated that he/she did not know that patient (#6) coded and bagged on 1/2/10 and 1/4/10, during dialysis treatment. Chief Nursing Officer stated that there were supervisors on duty when the patient coded, but this was not reported in the flash report given to all disciplines. Chief Nursing Officer stated that the patient coded in dialysis in October was not addressed in the November QA report, but will look into it.

Interview with Vascular Surgeon on 1/8/10 at 3:50pm, stated that the patient (#6) catheter was not advanced 7 cm as requested by the radiologist report because he did not think it was clinically appropriate. Vascular Surgeon stated that he reviewed the patient x-ray downstairs and felt the patient dialysis catheter was appropriately placed so he verbally communicated to the nurse the catheter was ready for treatment.

Telephone interview with the Nephrologists on 1/8/10 at 4:15pm stated that he did not see the patient until the second episode of events. Nephrologists stated that he/she did not know that the patient catheter was infected, but will have to review the patient record to know what happened to the patient.

Interview with Quality Assurance (QA) Director on 1/12/10 at 9:50am and 6:00pm stated the nursing supervisor assigned to oversee the dialysis unit only works on Wednesdays, Thursdays and Fridays. QA Director stated the contracted dialysis staff does not like the Kindred Hospital supervision due to personality conflict. QA Director stated that communication about the patient ' s dialysis treatment is done through communication hand out sheets. QA Director stated that the contracted Facility Administrator (FA) comes to the QA meeting but he/she does not report incidents, adverse events, resuscitation events or rapid response that have occurred during dialysis treatment. QA Director stated the FA report on clinical indicators and dialysis machines, but does not report on patient ' s events. QA Director stated that he/she knew that patient ' s coded in dialysis but no investigation is done, because physicians answering the code usually attributed it to something else.

Interview on 1/12/10 at 4:45pm the Senior Director of Clinical Operations stated that he/she agreed with the QA findings that information is reported, but not being analyzed and assessed to come up with interventions. Senior Director of Clinical Operations stated that the minutes are silent and do not address the discussion that has taken place. Senior Director of Clinical Operations stated they need to look at their process and improve it.

Interview on 1/12/10 at 5:15pm the Chief Nursing Officer stated that the contracted dialysis services supervisor findings are not documented and evaluated to determine improvement. Chief Nursing Officer stated we know that documentation must be improved so that opportunities for improvement can occur.