Health inspection·August 15, 2024

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure communication and continuity of care between the facility and dialysis center for 1 of 3 residents (R2) reviewed for dialysis in the sample of 6. Residents Affected - Few Findings include: R2's Physician Order Sheet (POS) for [DATE] documents diagnoses of end stage renal disease, atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellites with hyperglycemia, cardiomyopathy, peripheral vascular disease, chronic systolic (congestive) heart failure, unspecified essential (primary) hypertension, need for assistance with personal care, difficulty in walking, gout, primary pulmonary hypertension, paroxysmal atrial fibrillation, systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction. R2's POS also documents she is to receive dialysis one time a day every Monday, Wednesday, and Friday for kidney disease. R2's Care Plan dated [DATE] documents problems: ESRD (end stage renal disease), Short term goal remain free from complications of dialysis. Dialysis three times a week. CHF (congestive heart failure) remain free from complications of cardiac, monitor for /ss (signs and symptoms) of CHF (example SOB [shortness of breath]). R2's Minimum Data Set, dated [DATE] documents she is cognitively intact for decision making for activities of daily living. R2's Health Status Note dated [DATE] at 7:38 AM, Note Text: resident was brushing hair and talking with staff when she went unresponsive. Resident slumped towards right side in wheelchair and would not respond to verbal or physical stimuli. 911 called. Resident became alert and responsive after a few minutes. Notified 911 of current status. EMS (emergency medical services) arrived at 7:25 AM, times two attendants. Resident evaluated by EMS, resident refused transport to ER (emergency room). VS (vital signs) 96/62 64 20 97.5 92% on 3 lpm. BS (blood sugar) 144. NP (Nurse Practitioner) notified of episode. No new orders at this time. Will continue to monitor for change in condition. R2's Progress Notes dated [DATE] at 12:12 PM, Note Text: Message from resident's Dialysis center that resident coded while at Dialysis. Resident currently being taken to (Hospital) for treatment. On [DATE] at 1:11 PM V5, Licensed Practical Nurse (LPN) stated she remembered (R2) because she was the one that I called 911 after (R2) became unresponsive and then when the EMT (Emergency Medical Technician) got here she started doing her hair, laughing, and joking. When the EMT got here she refuses to go, and she even signed a paper refusing to go out. I am not sure of the name of the ambulance Page 1 of 2 145651 145651 08/15/2024 LA Bella of Alton 3490 Humbert Road Alton, IL 62002

F 0698 but learned later she passed away when she was out on dialysis. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 12:42 PM, V17, Certified Nursing Assistant (CNA) stated, I was the CNA that morning when (R2) was not acting herself. She was just off a little. I went and told the nurse and as I was getting her ready, she then went unconscious. We immediately called the ambulance but by the time they got there she was awake, and she told them she felt better and did not want to go out. Later, I found out she coded when she went out to dialysis. One can never forget that. Residents Affected - Few On [DATE] at 1:11 PM, V18, Registered Nurse (RN) Clinical Manager of Dialysis stated, The fact that (R2) was unconscious earlier in the day, this should have been communicated to us 1 million percent. Dialysis is a four-hour long procedure and the resident coded while she was with us. If we would have known (R2) may have had a better outcome. I did not know she even had anything going on with her until the EMS arrived and told me they had been to the facility earlier that day because (R2) had been unconscious. While the EMT were giving CPR to (R2) I found out she had been acting unusual earlier in the day. It's essential that the facility communicate with us any changes or decline in conditions that may or may not be related to dialysis so that we can implement the appropriate interventions. We did not have any communication and the facility never told us anything about (R2) not feeling ill, acting strange and/or being unconscious. If we would have known she was unconscious earlier, we would not have had her come to dialysis and would have rescheduled the appointment. If we would have known she may have had a better outcome. On [DATE] at 9:02 AM, V2, Director of Nursing (DON) stated, I was not the DON in April. We have a form that staff are supposed to fill out it is a communication form. The form is filled out by staff and then given to the dialysis center. Our copy is in the computer and then the form goes to the dialysis center. It lists all medications and if there are any changes with the patients. I would expect this form to be completed on all dialysis residents before their appointments and given to the staff at the dialysis center. I cannot confirm or deny if there was a form given to the dialysis center indicating (R2) had a been unresponsive before the treatment. If the form was completed it should be available. Let me go back and look. On [DATE] at 10:24 AM, V19, Dialysis Medical Director, stated, I would have expected the facility to notify us especially since she was found at the facility unconscious earlier in the day. If we would have known that detail, we would have advised (R2) to be evaluated at the hospital before we even started treatment. We would ensure all was well before we started the dialysis treatment. This was (R2's) first dialysis treatment and there was no continuity of care from the facility. We should have been given this information and it absolutely would have affected our treatment for (R2). It is my understanding she expired in the emergency room. I cannot not say one way or the other whether the outcome would have been different it's impossible to know that absolute. I only know if we had been given that information, we would have sent her out. On [DATE] at 11:32 PM, V1, Administrator stated We have no documentation for (R2) that we provided on [DATE] to the dialysis center. The Facility Dialysis contract dated [DATE] documents, Long Term Care Facility shall ensure that each Resident is prepared to spend an extended length of time at Dialysis Facility, as necessary for the administration of Resident's prescribed treatment, and has received proper nourishment and any necessary medications before arriving. 145651 Page 2 of 2