HospitalInspections.org

Based on observation, staff interview, and review of facility documents, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the facility.

Findings include:

1. The facility governing body failed to implement its medical staff bylaws for a patient requiring emergent dialysis. (Cross Refer Tag 048, part A)

2. The facility governing body failed to ensure that medical staff document all necessary information in progress notes where a rapid response team (RRT) was initiated. (Cross Refer Tag 048, part B)

3. The facility governing body failed to ensure that medical staff obtain informed consent prior to performing hemodialysis. (Cross Refer Tag 048, part C)

4. The facility governing body failed to ensure that a root cause analysis (RCA) was conducted for adverse events associated with a contracted provider. (Cross Refer Tag 083, part A)

5. The facility governing body failed to ensure that the contracted renal services provided dialysis treatments in accordance with the physician order. (Cross Refer Tag 083, part B)

6. The facility governing body failed to ensure that the contracted renal services follow facility policy to initiate and acknowledge physician orders. (Cross Refer Tag 083, part C)

7. The facility governing body failed to ensure that emergent hemodialysis is provided by the contracted hemodialysis provider to ensure patient safety. (Cross Refer Tag 084, part A)

8. The facility governing body failed to develop and implement policies and procedures with the contracted hemodialysis provider for the provision of emergent hemodialysis. (Cross Refer Tag 084, part B)

A. Based on medical record review, review of facility medical staff bylaws, and staff interview, it was determined that the facility governing body failed to implement its medical staff bylaws for the entering of physician orders for one (1) of one (1) emergent hemodialysis patient reviewed (Medical Record #1).

Findings include:

Reference #1: Facility document titled, "Medical-Dental Staff Bylaws, Revised February 2020," states, "... Section 3 - General Conduct of Care ... D) The practitioner's orders must be written clearly, legibly and completely. Orders that are illegible or improperly written will not be carried out until rewritten or understood by the nurse. ..."

Reference #2: Facility contract with hemodialysis provider titled, "Hospital Acute Dialysis Services and Support Agreement," states, "... EXHIBIT B-1 ... 3. Response Time. Company agrees to demonstrate commercially reasonable efforts in providing Services within four (4) hours following the receipt of an Order from the respective Hospital for treatment, or within a later specified time frame as by a patient's Physician. Company agrees to demonstrate commercially reasonable efforts in responding on-site at the respective Hospital within two (2) hours of receipt of an Order that requires emergency or urgent provision of Services (a "STAT Order"). ..."

1. A review of Medical Record #1 revealed that Patient #1 was admitted to the hospital Critical Care Unit (CCU) on 2/1/22 with acute renal failure, acute hyperkalemia, abdominal pain, and atrial fibrillation. Per Staff #2, the following addenda to a nephrologist's (Staff #26) progress note was entered at 12:44 PM, "... patient is critically ill ... will need urgent/emergency dialysis ... dialysis orders entered and discussed with dialysis team ..." An order for hemodialysis was entered by the physician at 12:43 PM. The order does not specify that the physician ordered the treatment as emergent, urgent, or STAT.

a. A nursing progress note at 17:48 [5:48 PM], stated, "This RN spoke with [name] from Dialysis to inform her that patient was supposed to have 2 hour emergent HD [hemodialysis] treatment Coded [sic] for second time since 1600 [4:00 PM]. Per [name] in Dialysis room, RN [name] is on her way to this hospital now. Per [name] Dialysis Room was supposedly not 'aware that pt was an emergent HD treatment.'"

b. Patient #1 did not receive hemodialysis and documented evidence indicated that the patient expired of cardiac arrest on 2/1/22 at 19:05 [7:05 PM] after experiencing four (4) codes at 1611 [4:11 PM], 1715 [5:15 PM], 1749 [5:49] PM, and 1844 [6:44 PM]. The patient expired more than six (6) hours after Staff #26 entered an order for hemodialysis and per his/her progress note, notified hemodialysis staff that the patient was to receive hemodialysis emergently.

c. During an interview on 3/18/22, Staff #2 provided a visual representation of the physician order set used in the electronic medical record to order hemodialysis. The order did not contain a pre-set drop down box to order a treatment as "STAT" or "Emergent" but did include a space for the physician to enter "Special Instruction". Staff #2 confirmed that the physician could enter that the treatment was needed emergently within the "Special Instruction" space.

2. During an interview on 3/17/22 at 1:56 PM with Staff #17 from the contracted hemodialysis provider, staff stated that the process for ordering emergent dialysis was that the nephrologist would call the Charge Nurse at a separate hospital location and communicate the need for emergent dialysis. Staff #17 stated that the Charge Nurse at the other hospital location could see any orders for hemodialysis entered at this facility.

3. During an interview on 3/17/22 at 4:43 PM, Staff #2 confirmed that although the nephrologist (Staff #26) documented that he/she verbally informed hemodialysis staff that the order was "STAT", the actual entered order lacked evidence of any indication that the hemodialysis treatment was to be provided "STAT".



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B. Based on staff interview, medical record review, and review of facility documents, it was determined that the facility governing body failed to ensure that medical staff document all necessary information in progress notes for one (1) of one (1) medical record reviewed (Medical Record #4) where a rapid response team (RRT) was initiated.

Findings include:

Reference #1: Facility document titled, "Medical-Dental Staff Bylaws, Revised February 2020," states, "... Article XVI - RULES/REGULATIONS ... These shall relate to the proper conduct of Medical Staff organizational activities as well as embody the level of practice that is to be required of each practitioner in the Hospital ... Section 2 - Medical Records ... D) Pertinent progress notes shall be recorded at the time of observation sufficient to permit continuity of care and transferability. Whenever, possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatments ..."

Reference #2: Facility policy titled, "Rapid Response Team," states, "... The Rapid Response Team will include (in addition to the primary care nurse): A. Hospitalist ... IV. Role of the Rapid Response Team Members: ... B. Hospitalist -Perform advanced assessment ... -Document the RRT [rapid response team] call in the physician progress notes ... -Call the attending physician of the RRT and inform them of the details of the RRT call and disposition of the patient. ... V. Documentation The RRT documentation is to be completed by the appropriate qualified team members at the time of each call. ... -Hospitalist- Document RRT Interventions and details ...".

1. A review of Medical Record #4 revealed a nursing progress note dated 2/26/22 at 19:51 (7:51 PM), which stated that a (RRT) was called at 7:45 PM.

a. The hospitalist's RRT note at 19:04 (7:04 PM) stated, "... A/P [Assessment/Plan]: # Chest Pain Likely musculoskeletal -IV [intravenous] tylenol 1 gm [gram] -EKG [electrocardiogram] -Inform cardiology -Notify primary physician Resuscitation Status Not Documented ..." The Hospitalist RRT Note lacked evidence of the following:

(i) The name of the primary physician that was notified.

(ii) The time that the primary physician was notified by the Hospitalist.

(iii) The name of the cardiologist that was notified.

(iv) The time that the cardiologist was notified by the Hospitalist.

(v) The details of the results of the interventions provided.

(vi) A patient disposition.

2. Upon request to Staff #1 on 3/18/22 at 10:27 AM, the facility was unable to provide evidence that the cardiologist and primary physician were notified and aware of the RRT. Staff #1 confirmed that the physician's progress note for the RRT did not contain all the elements as required by facility policy. Staff #1 stated that it remained unclear if the Hospitalist notified the patient's primary physician and cardiologist of the RRT.

C. Based on staff interview, medical record review, and review of facility documents, it was determined that the facility governing body failed to ensure that medical staff obtain informed consent prior to performing hemodialysis in one (1) out of six (6) medical records reviewed (Medical Record #6).

Findings include:

Reference #1: Facility document titled, "Medical-Dental Staff Bylaws, revised February 2020" states, "... Article XVI - Rules/Regulations ... These shall relate to the proper conduct of Medical Staff organizational activities as well as embody the level of practice that is to be required of each practitioner in the hospital ... Section 3 - General Conduct of Care ... B) Except in emergency situations, a general consent form, signed by or on behalf of the patient admitted to the hospital must be obtained. In addition, a specific consent that informs the patient of the nature and risks inherent in any special treatment or surgical procedure, and indicates other therapeutic options or alternate methods of treatment must be obtained from the patient by the attending physician or the physician performing the procedure. This process of informing the patient shall be documented in the medical record. ..."

Reference #2: Facility policy titled, "Informed Consent," states, "... Informed Consent is the process of disclosure and decision making ... 1. Prior to any procedure, the Physician must obtain informed consent from the patient or Surrogate Decision Maker. For a consent to be valid, it must be the result of an informed decision making process ... Informed Consent: ... 2. It is preferred that the consent form be signed by the patient or the Surrogate Decision Maker at the time the Procedure is explained by the Physician. It must be signed before the Procedure is provided to the patient, except in an emergency ... 4. A properly executed informed consent must contain at least the following: a) Name of the patient ... c) Name of Procedure for which consent is being given; d) Name of responsible practitioner(s) performing the Procedure(s) ... g) Signature of the patient or Surrogate Decision Maker (with relationship); h) Date and Time the consent is obtained from patient or Surrogate Decision Maker; and i) Date, time, and signature of the professional person witnessing the consent ..."

1. A review of Medical Record #6 revealed a form titled, "Hemodialysis Consent Chronic Renal Failure". The informed consent for hemodialysis lacked evidence of the following:

a. The area to enter the name of the patient was left blank.

b. The area to enter the treatment physician(s) name(s) was left blank.

c. The form lacked a signature from the patient or the Surrogate Decision Maker.

d. The form lacked a signature from the witness to the consent.

e. The time after the physician signature was partially covered by the patient label and did not indicate AM or PM.

2. Patient #6 received his/her first hemodialysis treatment at the facility on 2/9/22 without the consent being signed by the patient or Surrogate Decision Maker of the patient. Upon request to Staff #1 on 3/17/22 at 2:02 PM, the facility was unable to provide a consent for hemodialysis that had been completed.

3. During an interview on 3/17/22 at 2:07 PM, Staff #1 confirmed the above findings.

A. Based on medical record review, facility document review, and staff interview, it was determined that the facility governing body failed to ensure that a root cause analysis (RCA) was conducted for one (1) of one (1) adverse events associated with a contracted provider.

Findings include:

Reference #1: Facility policy titled, "Contracts for Care, Treatment, and Services Provided to Hospital Patients," states, "... B. Contract Performance Monitoring Process ... 3. Monitoring efforts may include, but are not limited to, the following action items or other monitoring activities as appropriate: ... (f) Collecting and reviewing data that addresses the efficiency of the services provided. ... (j) Reviewing the results of the Hospital risk management activities. ..."

Reference #2: Facility policy titled, "Patient Safety Event Reporting and Management: Serious Sentinel Event," states, "... POLICY: It is the policy of this organization to utilize the Root Cause Analysis process as outlined below to investigate all serious patient safety events and sentinel events that occur within the organization. ... Event Management and Root Cause Analysis (RCA) Process ... Preliminary Serious Event Management (5 Days Total) ... Root Cause Analysis Process Meeting #1 (5 Days Total) ... Root Cause Analysis Process Meeting #2 (10 Days Total) ... Improvement Process (15 Days Total) ... Action Plan Implementation ..."

Reference #3: Facility contract with hemodialysis provider titled, "Hospital Acute Dialysis Services and Support Agreement," states, "... EXHIBIT B-1 ... 3. Response Time. ... Company agrees to demonstrate commercially reasonable efforts in responding on-site at the respective Hospital within two (2) hours of receipt of an Order that requires emergency or urgent provision of Services (a "STAT Order"). ..."

1. A review of Medical Record #1 revealed that the patient was admitted to the hospital Critical Care Unit (CCU) on 2/1/22 with acute renal failure, acute hyperkalemia, abdominal pain, and atrial fibrillation. An order for hemodialysis was entered by the physician at 12:43 PM. A corresponding nephrology progress note states, "... patient is critically ill ... will need urgent/emergency dialysis ... dialysis orders entered and discussed with dialysis team ..." An order for hemodialysis was entered by the physician at 12:43 PM.

a. The patient did not receive hemodialysis treatment and documented evidence indicated that the patient expired of cardiac arrest on 2/1/22 at 19:05 [7:05 PM] after experiencing four (4) codes at 1611 [4:11 PM], 1715 [5:15 PM], 1749 [5:49] PM, and 1844 [6:44 PM].

2. During an interview on 3/17/22 at 12:32 PM, Staff #1 and Staff #2 were asked if a Root Cause Analysis (RCA) of this event had been conducted. Staff #2 stated that an RCA had been initiated but was still in progress.

3. During an interview on 3/17/22 9:52 AM, Staff #2 stated that the RCA was still in the "Meeting 2" phase and that there had been multiple "Meeting 2's". It was confirmed with Staff #2 that this was not consistent with the RCA policy timeline as referenced above which indicated that the "Meeting 2" phase was to last 10 days for a total of 20 days from the initiation of the RCA process. It had been 45 days from the event as of 3/17/22.




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B. Based on staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure that the contracted renal services provided dialysis treatments in accordance with the physician order in one (1) of six (6) medical records reviewed (Medical Record #2).

Findings include:

Reference: Facility contract with hemodialysis provider titled, "Hospital Acute Dialysis Services and Support Agreement," states, "... 3. Provision of the Services 3.1 Performance of the Services. (a) Company will perform the Services in accordance with (i) the direction of the physician prescribing the treatment ... Exhibit B-1 ... Services 1. ... Company Staff shall perform, monitor, report, and document the services ... in conformity with Physician's orders and patient condition ... "

1. A review of Medical Record #2 revealed a Nephrologist order written on 2/21/22 at 14:11 (2:11 PM), for a hemodialysis treatment for the patient to occur on 2/22/22 at 15:41 (3:41 PM). The medical record lacked evidence of a hemodialysis treatment flowsheet for this treatment. Upon request to Staff #1 on 3/17/22 at 3:56 PM, the facility was unable to provide evidence that Patient #2 had received a dialysis treatment that corresponded with the 2/21/22 physician's order.

2. The above findings were confirmed with Staff #1 at the time of discovery on 3/17/22.

C. Based on staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure that the contracted renal services follow facility policy to initiate and acknowledge physician orders for three (3) out of the six (6) patients (MR #2, MR #3, and MR #4).

Findings include:

Reference: Facility contract with hemodialysis provider titled, "Hospital Acute Dialysis Services and Support Agreement," states, "... Exhibit B-1 ... Services ... 6. Treatment Services. General Duties of Company's Staff include: ... (b) Company Staff will be responsible for provision of the ordered Services, including, as applicable and/or except as otherwise specified in the Agreement: ...(ii) initiating treatment, monitoring of treatment, and termination of treatment; (iii) documentation of treatment on Hospital-approved forms and electronic medical records systems ...".

1. An interview with Staff #1 and Staff #2 on 3/17/22 at 3:45 PM outlined the following process for physician planned orders:

a. Physicians will enter dialysis orders into Cerner, the facility's electronic medical record program (EMR), in a planned state.

b. The dialysis RN would then view the orders in a planned state to verify and check the order, then would initiate the orders in the EMR to acknowledge the order prior to the start of dialysis.

2. The following medical records had orders that remained in the "planned state" after treatments were provided, as follows:

a. Medical Record #2: 2/25/22 and 2/28/22

b. Medical Record #3: 2/18/22 and 2/28/22

c. Medical Record #4: 2/26/22

3. During the interview with Staff #1 and Staff #2 confirmed all orders not initiated would be left in a planned state and would fall out of the EMR after thirty (30) days. Staff #1 and Staff #2 also confirmed that if an RN failed to initiate an order, the medical record would be incomplete and inaccurate and there would not be a confirmation from the dialysis RN if the planned physician order had been seen and acknowledged.

4. Upon request to Staff #1 and Staff #2 on 3/18/22 at 10:45 AM, the facility was unable to provide evidence of the Cerner education and training for all the contracted dialysis nurses that provide services at the facility.

A. Based on a review of one (1) of one (1) medical record of a patient requiring emergent hemodialysis (Medical Record #1), review of facility documents, and staff interview, it was determined that the facility governing body failed to ensure that emergent hemodialysis is provided by the contracted hemodialysis provider to ensure patient safety.

Findings include:

Reference #1: Facility contract with hemodialysis provider titled, Hospital Acute Dialysis Services and Support Agreement, states, "... EXHIBIT B-1 ... 3. Response Time. ... Company agrees to demonstrate commercially reasonable efforts in responding on-site at the respective Hospital within two (2) hours of receipt of an Order that requires emergency or urgent provision of Services (a "STAT Order"). However, factors such as weather conditions, traffic conditions, available Company Staff's proximity to such Hospital at the time the STAT Order is received, the day and hour of the request, and other facts and circumstances beyond Company's control may make such response time impractical or impossible in a given instance. ..."

Reference #2: Contracted hemodialysis provider's guidelines titled, [Name of Large Dialysis Organization] Hospital Services: Dialysis & Apheresis [sic] Triage Guidelines, states, "... Purpose: ... 5. Guidelines are NOT policies or protocols. They are not "set in stone" but rather used to to gauge patient acuity during critical time periods when triaging becomes necessary to manage the entire population of dialysis patients. Stat: Dialysis typically indicated within approximately 2-3 hours (or as soon as possible) ... Urgent: Dialysis typically indicated within approximately 6 hours ..."

1. A review of Medical Record #1 revealed that the patient presented to the Emergency Department (ED) via ambulance on 2/1/22 at 3:02 AM. The ED physician documented that the patient presented with acute renal failure, acute hyperkalemia, abdominal pain, and atrial fibrillation. The patient was admitted to the hospital and a nephrology consult was ordered on 2/1/22 at 8:16 AM. The nephrologist, Staff #26, initially saw the patient at 9:06 AM.

a. The patient was transferred to the Critical Care Unit (CCU) at approximately 11:30 AM after a Rapid Response Team was called to the ED while the patient was awaiting a bed. Per Staff #2, the following addenda to the nephrologist's (Staff #26) progress note was entered at 12:44 PM, "... patient is critically ill ... will need urgent/emergency dialysis ... will have temp [temporary] dialysis cath [catheter] placed by critical care ... dialysis orders entered and discussed with dialysis team ..." An order for hemodialysis was entered by the physician at 12:43 PM.

b. A central line was inserted at 12:36 PM. A nursing progress note at 13:30 [1:30 PM] states, "Dialysis cath[eter] placed at bedside ... Spoke with dialysis nurse- made aware line was in place and xray was being preformed [sic] at this time to confirm placement. Informed of [Nephrologist's] orders for 2.5 hours of dialysis today and tomorrow. Dialysis nurse verbally confirmed orders and line status."

c. A nursing progress note at 15:20 [3:20 PM], states, "CCU Director [name] notified that HD RN has still not arrived to perform emergent 2 hour HD treatment on Critical pt [patient]." An addendum to this note at 18:18 [6:18 PM] states, "[Nephrologist, Staff #26] also made aware of situation".

d. A nursing progress note at 17:48 [5:48 PM], states, "This RN spoke with [name] from Dialysis to inform her that patient was supposed to have 2 hour emergent HD [hemodialysis] treatment Coded [sic] for second time since 1600 [4:00 PM]. Per [name] in Dialysis room, RN [name] is on her way to this hospital now. Per [name] Dialysis Room was supposedly not 'aware that pt was an emergent HD treatment.'"

e. The patient did not receive hemodialysis and documented evidence indicated that the patient expired on 2/1/22 at 19:05 [7:05 PM] after experiencing four (4) codes at 1611 [4:11 PM], 1715 [5:15 PM], 1749 [5:49] PM, and 1844 [6:44 PM].

2. A review of email correspondence between the CCU Director and members of the hospital leadership dated 2/1/22 at 5:57 PM, states, "... [Nephrologist] called the dialysis RN and made her aware of the emergent treatment and a 2 hour window for her arrival was given. The dialysis nurse called back to CCU at 1pm to confirm the line was in and spoke with the primary RN caring for the patient who told her the line was in. At 3:20pm when the dialysis RN was still not on the unit the staff escalated to myself. I called the dialysis unit and was told she was doing a treatment at [different hospital] and would be another 2 hours. I made them aware this was an emergent treatment ordered at 12:44pm today to which they said she will be here within the hour then. I made [nephrologist] aware of the delay as well as the [contracted dialysis provider] leadership and [name of hospital leadership staff member]. The patient has since coded twice and is now too critical for conventional HD [hemodialysis]."

3. On 3/17/22, Staff #2 provided a "DIALYSIS PROCESS FOR COMMUNICATING STAT TREATMENTS WITH [hospital]" that was put into effect "a few days" after the above incident with Patient #1. Upon request, the facility could not provide evidence that physicians, staff, and contracted staff were educated on this process.

4. On 3/17/22 at 4:01 PM, Staff #2 stated that there was not a written alternative plan or process for providing care to patients requiring emergent hemodialysis if the contracted provider could not meet the two (2) hour timeframe for the provision of emergent dialysis as specified in the above referenced contract (Reference #1).

5. During an interview with contracted provider Staff #17 and Staff #19 on 3/18/22 2:32 PM, staff were asked about the difference in the timelines for provision of hemodialysis between the "[Name of Dialysis Organization] Hospital Services: Dialysis & Apheresis Triage Guidelines" (Reference #2) and the contracted timelines in Reference #1. Staff #19 stated that the form (Reference #2) is a national guideline and is not specific for this facility. Staff #17 stated that staff are informed of the contractually required timeframe's during the hiring process. Upon request, the contracted hemodialysis provider could not provide evidence that its staff were aware of the contractually required timeframe's for the provision of emergent hemodialysis.

The above findings resulted in an Immediate Jeopardy (IJ) on 3/17/22. The IJ template was provided to Staff #2 at 5:05 PM, and a removal plan was requested. An IJ removal plan was provided by the facility on 3/18/22 at 3:57 PM and was accepted.

On 3/21/22, it was determined that the facility took the following steps to remove the immediacy of the IJ: the hospital established an improved communication process that included the nephrologist notifying the dialysis Charge RN, or the on-call dialysis RN if after hours, of the need for emergent dialysis after determining the patient's need; the primary hospital RN for the patient will then be in contact with the dialysis RN to determine arrival details and document the information on a log; the primary RN will notify the nephrologist and the Unit Director and/or the Nursing Supervisor; if the arrival time is anticipated to be greater than two (2) hours; at 90 minutes from the initial call from the nephrologist the RN will contact the dialysis RN if he/she has not arrived and the primary RN will notify the Unit Director and/or Nursing Supervisor; if the 2 hour arrival time cannot be confirmed the primary nurse will contact the nephrologist; the name and arrival time of the dialysis RN will be documented on the hemodialysis log; if at the 2 hour mark the hemodialysis RN has not arrived the nephrologist will be contacted to re-evaluate the patient's plan of care. The facility provided proof of education, a tour, and staff interviews were conducted. It was determined that the IJ removal plan was successfully implemented and the IJ was removed on 3/21/22.

B. Based on one (1) of one (1) medical record reviewed (Medical Record #1), review of facility documents, and staff interview, it was determined that the facility governing body failed to develop and implement policies and procedures with the contracted hemodialysis provider for the provision of emergent hemodialysis.

Findings include:

Reference: Facility contract with hemodialysis provider titled, "Hospital Acute Dialysis Services and Support Agreement," states, "... Provision of the Services ... 3.2 Policies and Procedures. ... (b) Upon execution of this Agreement, Health System and Company agree to use good faith and commercially reasonable efforts to jointly establish medical care policies and procedures governing the provision of the Services hereunder. Such policies and procedures include, but are not limited to, clinical procedures, administration of medication, medical record documentation, and responsibilities for patient care in emergency situations. ..."

1. A review of Medical Record #1 revealed that the patient was admitted to the hospital Critical Care Unit (CCU) on 2/1/22 with acute renal failure, acute hyperkalemia, abdominal pain, and atrial fibrillation. A nephrology progress note states, "... patient is critically ill ... will need urgent/emergency dialysis ... will have temp [temporary] dialysis cath [catheter] placed by critical care ... dialysis orders entered and discussed with dialysis team ..." An order for hemodialysis was entered by the physician at 12:43 PM.

a. The patient did not receive emergent hemodialysis and documented evidence indicated that the patient expired of cardiac arrest on 2/1/22 at 19:05 [7:05 PM] after experiencing four (4) codes at 1611 [4:11 PM], 1715 [5:15 PM], 1749 [5:49] PM, and 1844 [6:44 PM].

2. During an interview with the Nephrologist, Staff #26, on 3/21/22 at 9:57 AM, staff was asked about Patient #1 and the events of 2/1/22. Staff #26 stated that he/she received a phone call sometime between 5:00 PM and 6:00 PM, informing him/her that Patient #1 had not received hemodialysis. Staff #26 was asked if he/she was present in the hospital at the time of the phone call and Staff #26 stated that he/she was not in the hospital at the time and had left for the day. When asked if a nephrologist is usually present during the initiation of emergency dialysis, Staff #26 stated that he/she would be present if in the hospital at the time but would not be present at the bedside if he/she was not in the hospital.

3. Upon request on 3/21/22, the facility was unable to provide a hospital policy or a contracted hemodialysis provider policy related to staff responsibilities for patient care during emergency situations. At 2:38 PM, Staff #2 stated that neither the contracted hemodialysis provider or the hospital could provide a policy for the provision of the first emergent hemodialysis treatment.