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5/24/2010 Survey Tag 0504 Detail for:
PIKES PEAK DIALYSIS CENTER
Wednesday, October 23, 2019 12:17 AM

Survey Date: 5/24/2010

Regulation Number:0504

Regulation Title: PA-ASSESS B/P, FLUID MANAGEMENT NEEDS

Regulation Description: The patient's comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs.

Surveyor Findings:


Based on review of medical records, review of facility Policies and Procedures and staff interviews, the facility failed to appropriately document post-treatment assessment data in six (#3, #5, #6, #7, #9, & #10) of eight in-center hemodialysis patient medical records reviewed. The staff failed to follow facility policy for documentation of post-treatment data collection. This failure created the potential for patient care to be compromised.


The findings were:


The medical records of eight in-center hemodialyses patients were reviewed throughout the survey from 5/20/10 through 5/24/10. The following was revealed:

Sample #3 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the chairside computer documentation program (for recording data before, during, and after treatment) titled "ChairSide Snappy Flowsheet" revealed that in two (5/13/10, and 5/22/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 5 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in three (5/6/10, 5/15/10, and 5/20/10) of four reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 6 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in five (5/10/10, 5/12/10, 5/14/10, 5/17/10 and 5/19/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 7 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in five (5/10/10, 5/12/10, 5/14/10, 5/17/10 and 5/19/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 9 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in two (5/6/10 and 5/13/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 10 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in three (5/15/10, 5/18/10, and 5/22/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

The facilities Policies and Procedures were reviewed on 5/21/2010. The policy titled "Pre/Post Dialysis Treatment Data Collection" stated, in pertinent part:
"1. Patient data will be obtained and documented by the patient care staff...
5. Data collection may include the following:
Weight
Blood pressure
Cardiac status
Respiratory status
Peripheral edema
Vascular access
Mental status
Patient subjective statement
Ambulatory status..."

The policy titled "Post Treatment Patient Assessment" stated, in pertinent part:
"1. The patient care staff will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings...
6. All findings, interventions, and patient responses are documented in the patient's medical record."

An interview was conducted on 5/24/2010 at approximately 3:10 p.m. with the acting facility administrator. S/he stated that the standard of practice for the facility is to, at a minimum, place data in the data collection portion of the post-treatment data collection and assessment section. S/he stated that that data collection is usually completed by the patient care technician and placed into the ChairSide Snappy program by the technician. S/he also stated that "it is an issue that was identified and is being worked on."

Facility Plan of Correction:

V504
The Clinical Services Specialist (CSS) and FA reviewed Policy#1-03-10 “Pre/Post Treatment Data Collection” and #1-03-12 “Post Treatment Patient Assessment” with the teammates on 6/10 and 6/11/10. The focus of this review was the importance of obtaining and documenting basic data on each patient post dialysis. This information is to be compared with pre-dialysis findings and addressed as necessary. FA or designee to audit patient flow sheets on every patient weekly, utilizing the post treatment audit tool, for a period of 2 months, then 50% for 1 month. Thereafter, the post treatment audit tool will be used to conduct a random sampling of 10% of the post treatment sheets monthly by the FA/designee. The results of the audits will be reviewed at the monthly QA meetings. FA/designee is responsible for ongoing compliance with the above stated policy and procedure.

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Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
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