Go to the State of Colorado Web
5/25/2010 Survey Tag 0504 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Wednesday, October 23, 2019 12:19 AM

Survey Date: 5/25/2010

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 three (#1, #3 & #6) of six 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 six patients were reviewed throughout the survey. The following was revealed:

Sample #1 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 three (5/10/10, 5/12/10 and 5/14/10) of four reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample #3 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in two (4/28/10 and 5/3/10) of six 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 two (2/22/10 and 3/3/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

The facilities Policies and Procedures were reviewed on 5/19/2010. 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 5/25/2010 at approximately 3:10 p.m. with the 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 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 6/10/10. 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 predialysis
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 1 month. Thereafter, a
random sampling of 10% of the post
treatment sheets will be done by the FA/
designee and reviewed at the monthly QA
meetings. FA/designee is responsible for
ongoing compliance with the above stated
policy and procedure.

Back to Survey Tag Summary for:PRINTERS PLACE DIALYSIS CENTER

Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

Return to Health Facilities Main Page