What Is Quality Safe Patient Care?
Fresenius (FMC) Dialysis - San Bernardino
Fresenius (FMC) San Bernardino Dialysis
The survey was conducted on 4/19/10. The last survey was on 1/20/02. This is 6 years between surveys. There were 114 patients and the sample size was 11. Therefore, again, we ask, how many patients have been affected (nonsampled) by these deficiencies, prior to survey, how long were these deficiencies happening, before the survey and why were these deficiencies not noted by unit-level supervision?
NOTE:
Data from CMS (Dialysis Facility Report)
**2006- Deaths due to infection -40% (total deaths 10)
**2007- Deaths due to infection -36.4% (total deaths 11)
**2008- Deaths due to infection - 37.5% (total deaths 8)
Tag V 111 - 494.30 INFECTION CONTROL - SANITARY ENVIRONMENT
“……. the facility failed to ensure a sanitary environment for an universe of 114 patients by failing to ensure that trash cans were placed at a sufficient distance away from the HD (dialysis) machines and they did not touch clean patient’s blood lines, by failing to disposed of expired medical supplies, and by failing to label medication vials with the date the vials were opened.”
There were medication vials e.g. heparin (medication used to prevent clotting of the blood during dialysis treatments and vials of Epogen (medication used to stimulate the production of red blood cells) were opened, but no documented date when vials were opened. Epogen has perservative and may ‘…be retained for 21 days after opening’. Therefore, the facility could have been administering expired medications. Protocol is to mark on vial date opened. The facility staff did not adhere to their own policies and procedures. The Nurse Manager, according to the survey, was aware of correct procedures.There were needle sets, used for dialysis treatment, which had expiration date of 2006. These needles had the possibility of being contaminated and had been expired for 4 years. Therefore, the question is how many patients had these needles inserted into their fistula and/or acquired an infection? Infection rates as above noted.
There were also lab supplies e.g. culture swabs and vacutainers that were expired.
Tag V 114 - 494.30(a)(1)(i) INFECTION CONTROL - SINKS AVAILABLE
“….the facility failed to ensure that warm water was dispensed from all sinks in the treatment floor to facilitate hand washing for staff, patients, and visitors. This failure had the potential to result in the transmission of infectious organisms between facility staff, patients, and visitors for an universe of 114 patients”.
In the treatment area ‘..all but 2 of the sinks….. Were noted to dispense cold water.” The Nurse Manager acknowledged that there should have been warm water.
Tag V 132 - 494.30 INFECTION CONTROL - TRAINING & EDUCATION
“….the facility failed to provide infection control training for 1 of 28 staff members. This failure had the potential to result in the transmission of infectious organisms from staff to patients in an universe of 114 patients.
Personnel files identified that the Chief Technician was hired in 1999 and the last documented infection control training was in 2008, two years before survey date.
The Nurse Manager acknowledged the staff did not have the mandatory annual infection control training.
Tag V 409 - 494.60 (d)(1) PE - EMERGENCY PREP
“….the facility failed to provide emergency preparedness for all staff members working for the facility. This failure had the potential to result in the implementation of inappropriate procedures if an emergency situation should occur in an universe of 114 patients.”
The Nurse Manager acknowledged that 11 staff (of 28) had not had training in two years. This education/training was mandatory annually.
THIS IS A SERIOUS SITUATION IF THERE IS AN EMERGENCY AND STAFF ARE UNAWARE WHAT TO DO.
Tag V 504 - 494.80(a)(2) PA - ASSESS BLOOD PRESSURE< FLUID MANAGEMENT NEEDS
“….the facility failed to ensure that nursing assessment were performed pre and post patient treatments in a consistent manner for 11 of 11 sampled patients and failed to ensure nursing assessments were provided before and after the administration of acetaminophen when patients complained of pain (1 patient)…” “These failures resulted in the potential for delayed identification and treatment of abnormal signs and symptoms including serious health problems related to hemodialysis treatment.”
Both Registered Nurse and patient confirmed that assessments were not always done.
Pain medication was administered by staff to a patient, however, there was no documentation in the medical record that the patient complained of pain (several times) The staff did not follow the facility’s policy/procedure for pain medication e.g. evaluating to determine effectiveness, symptoms leading to administration of pain medication. Further, the Facility Administrator confirmed that what occurred was not the ‘…nurse’s standard of practice…”
Tag V 506 - 494.80(a)(3) PA IMMUNIZATION/MEDICATION HISTORY
“….the facility failed to ensure that all patients were tested at least once for a baseline tuberculin skin test (TST), failed to ensure that chest x-rays were used for individuals for whom the TST was not an option, and failed to offer pneumococcal vaccines for 11 of 11 sampled patients. This failure had the potential to result in the transmission of infection which could result in the futher decline of the compromised health of these patients.”
The question is, “How many nonsampled patients were affected and for how long did this happen, considering the time span between surveys?
Tag V 541 -494.90 PLAN OF CARE GOALS
“….the facility failed to develop a written, individualized comprehensive plan of care built from the results of the Interdisciplinary Team’s (IDT) Comprehensive Assessment for 1 of 11 sampled patients, failed to revise theplan of care according to changes in the patient’s individual health status for 3 of 11 sampled patients, and failed to reassess and revise the patient’s plan of care when the expected outcome/goal was identified as not met for 11 of 11 sampled patients. This failure to develop and to address current health status changes in the patients, and to monitor and update care plans had the potential of the facility not providing and/or providing untimely and inappropriate interventions which may further compromise the patients health.”
Note: A patient acquired sepsis (infection in the blood) and had been hospitalized. (Staph infection). The Nurse manager acknowledged that the patient’s care plan did not address the infection, but should have been. The patient also had an ‘..erratic and unstable blood pressure…” that was not addressed.
Another patient’s blood culture identified positive for Pseudomonas Aeruginosa infection. This infection in the blood resulted in hosptalization and having to have her dialysis catheter changed.
Another patient had potassium levels above normal range.
Tag V 550 - 494.90(a)(5) PLAN OF CARE - VASCULAR ACCESS MONITORING
“….the facility failed to ensure that Heparin 1000 units/ml (medication used to prevent clotting) was administered as prescribed for 1 of 11 sampled patients and failed to ensure accurate labeling was done for the predrawn maintenance Heparin dosages. These failures had the potential to result in a clotted HD access site for the patient and the administration of incorrect heparine dosage for a universe of 114 patients.”
Medications were not labeled according to facility policy/procedure which can result in a medication administration error. A patient received the wrong dosage.
