Looking Deep Into the Survey

What is Quality Safe Care? 

To read a copy of this facility's Dialysis Facility Report (DFR) (released to the public by Propublica.

http://propublica.s3.amazonaws.com/assets/dialysis/facility-reports/CA/2010/CA_052513_2010.pdf

To read other Dialysis Facility Reports for other dialysis facilities

http://projects.propublica.org/dialysis/

In order to support our beliefs about certain dialysis facilities, we give the following example.

Fresenius Santa Barbara dialysis facility located at 222 Pesetas, Santa Barbara, California, had a recertification survey conducted on 1/21/2010. The survey showed that there were 4 Conditions (regulations) 'not' met in the areas of Infection Control, Patient Assessment, Patient Plan of Care and Quality Assessment and Performance Improvement.  On 3/18/2010, the California Deparment of Public Health, Licensing & Certification Division, returned  to conduct a  first 'revisit' survey due to the facility's noncompliance with the regulations. It appears that CMS approved the facility's plan of correction, however, as it appears this was not an onsite visit but an approval of the facility's plan of correction via reading only.

We believe  the following supports our opinions that the foundation for quality safe patient care starts with fully educating staff which includes appropriate training that includes the rationale for policies and procedures, along with  staff having a full understanding of possible consequences to patients (negative outcomes, including death) as a result of regulatory and/or facility policy/procedure noncompliance. In addition to the aforementioned, noncompliance continues if there is ineffective unit-level supervision. This supervision includes ensuring that patients are receiving safe delivery of care. However, what is forefront is that the supervisory staff must be thoroughly educated and trained in order to carry out such responsibilities.  One must ask the question, "If those staff, who are delivering patient care, are aware of correct practices, but do not implement such, is this considered an intentional act of placing a patient in a situation to experience a potential or actual negative outcome?" If a negative outcome occurs should revocation of the dialysis technician's certification, or the nurses license be revoked? Should the nursing and/or certification oversight agency conduct an investigation and act in accordance? (these are questions that are often asked of us)The survey process  allows for a 'sample' of patients. Therefore, we ask, if serious deficiencies are cited, for 'sampled' patients, are these same deficiencies happening with non-sampled patients?"

The following were cited as 'repeat' deficiencies, therefore, the facility was not following their 'plan of correction/corrective actions'.  This, in our opinion, is serious and continues to place patients in unsafe situations.

(1) "....the facility failed to follow the manufacturer's directions on how to properly disinfect cloth (Dacron polyester) blood pressure cuffs. The failure has the potential for transmission of blood borne illnesses for all the patients in the facility."

(2) "... the facility failed to evaluate the appropriateness of the dialysis prescription for two of five patients.............in order to meet their individual needs." "...... the EDW was not evaluated to determine the appropriateness of the dialysis prescription. Additionally, during the two treatments, the BFR was not administered as ordered by the physician." ".... the DRF was not followed as ordered by the physician. The failure had the potential for Patients 15 and 16 not receiving dialysis treatments that will meet their needs".

(3) "... the facility failed to adequately evaluate two of five patients (Patients 15 and 14) for blood pressures, interdialytic weight gains, EDW and related intradialytic symptoms that included hypertension and hypotension along with an analysis for potential root causes. The failures resulted in the potential for patients not being reassessed for target weights and blood pressure problems during treatment, not discovering the root causes of the problems and not implementing additional care plans."

(4) "....the facility failed to develop a plan of care for one of five patients (Patient 12) to address a change in his treatment time. Patient 12's treatment time was changed from 3 hours 15 minutes to 3 hours 45 minutes without an explanation to him, a plan of care and physician's order."

(5) "..the facility failed to have a system in place to ensure medical records were complete and accurate for four of five patients....." "The facility failed to have accurate physician orders, di dnot have interventions charted when patients had hypotensive and hypertensive events while receiving treatments. Physician orders were not followed for monitoring of vita signs during  treatment, and not followed for BFR, DFR, medication/vaccination administration, diabetic foot checks and blood glucose levels. The patients records did not have monthly dietician progress notes and laboratory values filed in the medical record. These failures had the potential for each patient in the facility to not have a clear portrait of what is happening to each patient while receiving dialysis treatment in the facility."

Note: the facility determined there was a lack of proper oversight.

Added Note: Our opinion... when staff do not completely document that which occurs during a dialysis treatment, this results in physicians not having needed information in order to accurately prescribe. We, further, believe this is a common problem in many facilities. 

What is quality?  According to CMS' Dialysis Facility Compare website, FMC Santa Barbara Dialysis Facility had a 95% for Dialysis Adequacy which was the same as the state average and one percent under the national average. The facility was 3% lower than the state and national level for Medicare patients with hemoglobins above 12 and for hemoglobins less than 10, the facility was 6% over the state average and 5% over the national level. In reality, these numbers are not bad. HOWEVER, the facility survey has a voice that speaks loud and clear on the level of care that patients received. And, how many patients suffered through their treatment due to the above deficiencies? We wonder how many patients were hospitalized for preventable errors.