Volume 2024 | No. 2
SURVEYOR
RENAL DIALYSIS
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT RD5-G Overview of the requirement: Policies and procedures define the components each patient’s individualized assessment and the interdisciplinary approach used to complete the assessment. Comment on deficiencies: Evaluation of compliance comes from review of policies and procedures, review of patient records, and response to interview. Surveyors noted non-compliance with guidelines, poor documentation practices, and delays in patient assessments and care plan updates.
RD5-J Overview of the requirement:
The comprehensive assessment drives an individualized plan of care. Minimum requirements for the plan of care are detailed in the standard. Evaluation of compliance comes from review of policies and procedures, review of client/patient records, and response to interviews. Many findings related to an inadequate level of detail in the plan of care, or treatment that failed to follow the organization’s policies.
Comment on deficiencies:
Frequency of citation:
68%
Examples of surveyor findings:
n Records did not demonstrate that the plan of care adequately addresses the patient’s dialysis blood flow rate (BFR) and/or dialysate flow rate (DFR). BFRs were reduced during treatment without a documented reason. n Plans of care were not signed by the patient. If the patient chooses not to sign the plan of care, this choice must be documented. n Records did not contain evidence that blood pressure and fluid management needs were addressed. Multiple medical records noted blood pressure fluctuations without evidence of interventions including notification of the MD per facility policy. n There was no evidence that home dialysis patients were evaluated by the facility for the ability to safely, aseptically, and effectively administer erythropoiesis- stimulating agents and store this medication under refrigeration, if necessary. Per interview with the CNM, the patients have been evaluated and trained, however there is no evidence of documentation of the evaluation or training. n Ensure the plan of care for each patient reflects a current assessment and is adjusted as needed. n Audit care notes against orders for consistency and alignment with organizational policies. Reeducate staff on the individualized nature of plans of care. If the expectation is that care is standardized within the center, individual variations are less likely to be noted.
Frequency of citation:
47%
Examples of surveyor findings:
n Assessments lacked evaluation of current health status, co-morbidities, nutritional status, psychosocial needs, and/or physical activity levels. n Assessment documentation did not include immunization history. n Policies related to addressing care protocols (e.g., hypertension, dysrhythmias, and patient falls) were not followed. n There were delays in reassessing and updating the plan of care for unstable patients. n Patient assessments did not include evidence of involvement by an interdisciplinary team (social workers, dietitians, physicians). n Review policies for patient assessment to ensure all required participants and all required elements are identified. n Create templates for patient assessments to ensure each required element is addressed in every patient record.
Tips for compliance:
Tips for compliance:
Complete initial assessments within 30 days or 13 treatments.
n Conduct reassessments for unstable patients at least monthly. n Audit patient records for inclusion of complete assessments. n Reeducate staff as needed to ensure full documentation is completed.
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