What Is Quality Safe Care?
Fresenius (FMC) Dialysis - Rancho Cucamonga
Fresenius (FMC) Dialysis Services - Rancho Cucamonga
A recertification survey was conducted on 3/26/10. The prior survey was June 2004. This was 6 years between surveys. Question: How long were these deficiencies occurring and how many patients were affected? If the survey had not been conducted, how long would these deficiencies continued? Why did unit-level management not identify these? The following cited deficiencies place patients in situations of potential or actual negative outcomes. (114 patients - sample size 10)
Note: This facility, according to CMS’ Dialysis Facility Compare indicates the quality of care is excellent. However, the survey indicates different.
NOTE:
**2006- Death due to infection - 18.5% (total deaths 27)
**2007- Death due to infection - 7.7% (total deaths 13)
**2008- Death due to infection- 23.8% (total deaths 21)
**2009 - Death due to infection - 36.8% (total deaths 19)
V 111 - 494-30 IC (Infection Control)
“….the facility failed to provide and monitor a sanitary environment to minimize the transmission of infectious agents by failing to dispose of expired, open, and dirty supplies and by failing to maintain clean supply carts in a clean and sanitary manner. These failures resulted in the potential for the transmission of infectious agents to patients receiving dialysis treatments for a universe of 114 patients.
(expired medications, expired 85 Vacutainers)
Tag V 114 - 494.30 (a)(1)(I) Infection Control
“….the facility failed to ensure that warm water was dispensed from all sinks on the treatment floor to facilitate hand washing for staff and patients. This failure had the potential to result in the transmission of infectious organisms between staff and patients…………..”
Tag V 116 - 494.30(a)(1)(i) Infection Control
“….the facility failed to ensure that items taken into the dialysis stations would either be disposed of, dedicated for use only on a single patients, or cleaned and disinfected before being taken to a common clean area or used on another patient. This failure had the potential to result in the transmission of infectious organisms from patient to patient for an universe of 114 patients.”
Tag V 117 - 494.30 (a)(1)(i) Infection Control
“…the facility failed to ensure that clean areas were clearly designated as medication preparation areas at the nursing station. This failure had the potential to result in the contamination and the transmission of infectious agents to all patients in a universe of 114
Tag V 119 - 494.30(a)(1)(i) Infection Control
“…the facility failed to ensure that facility staff did not carry supplies in their pockets to be used on multiple patients. This failure had the potential to result in the transmission of infectious organisms in a universe of 114 patients.”
Tag V 124 - 494.30 (a)(1)(i) Infection Control
“…the facility failed to ensure that all patients were managed appropriately based on their Hepatitis B (Hep B) testing results by failing to administer the Hep B immunization series to non-immune patients in a timely manner for 1 of 11 sampled patients. This failure resulted in the potential to result in the transmission of Hep B infection to the non-immune patients.”
Tag V 403 494.60 (b) Physical Environment
“….the facility failed to ensure that supplies used for water and dialysate cultures were maintained in accordance with the manufacturers recommendation by failing to dispose of expired culture swabs stored in the water treatment storage area.” “The MT (machine technician) confirmed that the culture swabs had expirations dates of 2/20/10 and stated that the culture swabs continued to be used to obtain water culture specimen.”
Tag V 408 - 494.60 (d) Physical Environment (Emergencies)
“…the facility failed to ensure that the contents of the emergency evacuation supply box were periodically checked for expiration dates and completeness which had the potential to result in the inability of staff to manage and provide necessary care to dialysis patients in the event of a disaster in a universe of 114 patients.”
Tag V 409 - 494.60(d)(1) Physical Environment - Emergency
“…the facility failed to provide appropriate training and orientation in emergency preparedness to all staff 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.” “Review of the facility’s personnel files conducted on 3/24/10 revealed that about 40% of staff working for the facility did not have current emergency preparedness training. The last documented emergency preparedness training and education was for the year 2008.”
Tag V 413 - 494.60 (d)(3) Physical Environment - Equipment
“…the facility failed to ensure that emergency equipment be clean, accessible, and ready ot use at all times by failing to have suction tubing immediately available in the crash cart of on the facility’s premises and by failing to replace expired and/or open supplies in a timely manner. These failures resulted in the potential for serious harm to a patient should an emergency crisis would arise for an universe of 114 patients.” It was “……confirmed that no suction tubing was found in the crash cart and was not available anywhere in the facility at the time.”
“AV fistula needle sets were noted to have an expiration date of 8/2006 and 6/2008.………….” Other emergency supplies were not in closed packaging, but open. “2 tri-flo suction catheter with an expiration date of 1/95” “The CNM stated that the expired and open supplies should have been replaced as soon as they became open or expired.”
Tag V 452 - 494.70(a)(1) Patient Rights - Respect & Dignity
“….the facility failed to ensure respect and dignity for 1 of 11 sampled patients……as evidence by the staff’s failure to cover Patient 8’s exposed lower body part during dialysis treatment which had the potential to result in decline of emotional state, self-esteen and self-worth.” “Patient 8’s exposed body part was with in full view as multiple staff passed by including 5 staff who were standing close to Patient 8’s chair side. Staff did not attempt to talk to Patient 8 and to cover her exposed body part until the surveyor intervened.” “….the CNM……………confirmed that Patient 8’s upper thighs were exposed and no attempt were made by staff to talk to patient and to cover the exposed body part.”
Tag V 504 - 494.80 (a)(2) Physical Assessment
“….facility nursing staff failed to perform pre and post treatment assessments in a consistent manner of 10 of 11 sampled patients….. And failed to provide 30 minutes monitoring for 1 of 11 sampled patients……..” “These failures resulted in the potential for delayed identification and treatment of abnormal signs and symptoms including serious health problems related to hemodialysis treatment.”
The dialysis technician “… did not notify the RN regarding Patient 9’s low blood pressure and a post treatment assessment was not performed prior to Patient 9’s discharge home.” The patient, upon discharge had a blood pressure of 90/30. The R.N. acknowledged that the technician should have notified the nurse so an assessment could be done due to low blood pressure and before the patient was discharged home. On several other occasions, the patient “….had been experiencing intradialytic signs and symptoms of hypotension which included complaints of dizziness, cramping and ‘not feeling well’.” No post assessments were conducted prior to discharge home. (several patients experience signs and symptoms which required staff intervention, however, policies and procedures were not followed)
V 506 - 394.80 (a)(3) Physical Assessment Immunization/Medication
“….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 pneumonococcal vaccines and have pneumonococcal immunication histories for 11 of 11 sampled patients. This failure had the potential to result in the transmission of infection which could result in the further decline of the compromised health of these patients.”
Tag V 541 - 494.40 POC-PLAN OF CARE
“…the facility failed to ensure that the patients plan of care consistently included measurable goals/outcomes and estimated timetables and reassessment dates to achieve these goals for 11 of 11 sampled patients.” “This failure resulted in the potential to result in the delayed identification and implementation of appropriate interventions to achieve the goals and the possible decline of the already compromised patient’s health”.
Tag V 542 - 494.90 (a) POC
“….the facility failed to develop a plan of care (POC) for health problems identified by the comprehensive assessment for 2 of 11 sampled patients”
“…the facility failed to develop a care plan for abnormally high potassium level which may have resulted in patient’s continued abnormally high potassium level (hyperkalemia - an abnormally high concentration of potassium in the blood), and had the potential to result in symptoms which would include heart palpitations, weakness, nausea and vomiting, abdominal pain or even sudden death.”
“… the facility failed to develop a care plan for chronic (long standing) pain of the left big toe and right shoulder, frequent hospitalization due to respiratory problems and infections and high risk for fall.”
Tag V 545 - 494.90 (a)(2) POC -
“..the facility failed to provide the necessary care to achieve the appropriate potassium level for 1 of 11 sampled patients by failing to implement a physician’s dialysis treatment order to change the potassium (k+) bath (a solution concentrate containing potassium) which may have resulted in patient’s continued abnormally high potassium level…… and had the potential to result in symptoms which would include heart palpitations, weakness, nausea and vomiting, abdominal pain or even sudden death.” The medical record shoed that the patient “…had been experiencing adverse intradialytic symptoms which included weakness, abdominal cramps and complaint of being nauseated…..”
Tag V 559 - 494.90 (b) (3) POC
“….the facility failed to ensure that blood pressure and fluid management needs of 2 of 11 sampled patients…… were evaluated, reassessed and the plan of care adjusted when patients experienced signs and symptoms of hypotension (low blood pressure) during hemodialysis. ..(removal of waste from the blood) treatment which had the potential to result in delayed identification and treatment of abnormal signs and symptoms including low blood pressure, irregular heart rate, dizziness, etc……”
