Health inspection·October 25, 2023

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 record review, policy review and staff interview, the facility failed to keep accurate records regarding peritoneal dialysis treatments. This affected one (#79) of three residents reviewed for dialysis. The facility census was 70. Residents Affected - Few Findings include: Review of the medical record for Resident #79 revealed admission [DATE] with diagnoses including but not limited to breakdown (mechanical) of intraperitoneal dialysis catheter, morbid obesity, chronic kidney disease stage five, hyperkalemia, bilateral osteoarthritis of hip, depression, hyperlipidemia, coronary artery disease, fibromyalgia, anxiety, end stage renal disease, atrial fibrillation, hypertension, and dependence on renal dialysis. Review of Quarterly Minimum Data Set (MDS) assessment for Resident #79 dated 08/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. No behaviors noted. Resident #79 required limited to supervision of one for Activities of Daily Living (ADL's). Review of care plan for Resident #79 dated 08/25/23 revealed resident had impaired genitourinary status related to end stage renal disease and dialysis dependence. Peritoneal dialysis in house. Interventions included but not limited to consult with urologist/nephrologist as needed, dialysis orders as indicated, call if systolic blood pressure is greater than 170, weight greater than five pounds over target weight of 216 pounds, diet as ordered, elevate feet when sitting up in chair to help prevent dependent edema, encourage fluids as tolerated unless contraindicated, monitor for signs and symptoms of dehydration, labs/diagnostic testing as ordered, medications per physician orders, monitor and report changes in mental status, monitor and report signs or symptoms of urinary tract infection, monitor and report signs and symptoms of acute renal failure, monitor dialysis catheter to right abdomen for length, signs and symptoms of infection, or clogged with fibrin, administer heparin as ordered, gentamycin cream to catheter site, periodically check vital signs and lung sounds, report any significant abnormal findings, report signs and symptoms of urinary retention/insufficiency to physician, treatments as ordered, weights as ordered, and monitor dialysis access site and report to physician signs and symptoms of bleeding, infection, redness, swelling, local warmth, or tenderness. Review of monthly physician orders for Resident #79 revealed call dialysis if weight is five pounds over target weight (TW) of 212 pounds and/or elevated blood pressure for new orders for peritoneal dialysis (PD). Sliding scale: monitor signs and symptoms fluid overload/dehydration systolic blood pressure (SBP) 90-100 and weight two pounds below TW equals (=) two one and a half percent (1.5%) dextrose and dwell bag (purple) SBP 110-140 and weight at TW = one 1.5% and one two and a half percent Page 1 of 3 365900 365900 10/25/2023 Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (2.5%) dextrose and dwell bag (purple) SBP 141-170 and weight two pounds above TW = two 2.5% dextrose SBP greater than 170 and/or weight greater than five pounds above TW call dialysis center for use of four and a half percent (4.5%) dextrose. Fax weekly dialysis sheets to dialysis center, for dialysis use 1.5%, 1.5%, and seven and a quarter percent (7.25%) for evening treatment, Heparin 30 milliliters (ml)/30,000 units, inject one ml/1000 ml dialysate bag daily and as needed daily to prevent fibrin, peritoneal dialysis one time daily. Review of the Home Treatment Record-CCPD for Resident #79 revealed no data for 10/03/23 and 10/19/23. Home treatment record also revealed several dates with duplicate entries, wrong solutions being marked on sheet that do not match what was given in the Treatment Administration Record (TAR). Review of the Treatment Administration Record (TAR) for October 2023 for Resident #79 revealed no signatures for 10/02/23, 10/03/23, 10/05/23, 10/10/23, 10/12/23, 10/16/23, and 10/17/23. Also revealed no place to record dwell and drain times. Interview on 10/24/23 at 12:22 P.M., with the Director of Nursing (DON) stated the facility is to fax over Resident #79's dialysis logs every Monday to the dialysis center. Stated if the dialysis center does not receive them, the facility will receive a call from the center or resident's daughter. Stated the facility does sometimes forget to send Resident #79's binder with her on appointments to the dialysis center. Interview on 10/24/23 at 2:02 P.M., with DON verified no information noted on the dialysis home treatment record for 10/03/23 and 10/19/23. Verified missing dialysis information on the TAR on 10/02/23, 10/03/23, 10/05/23, 10/10/23, 10/12/23, 10/16/23, and 10/17/23. Verified information was present on the home dialysis log on those days. Interview on 10/24/23 at 3:40 P.M., with DON verified staff are documenting incorrectly as far as percentage of dialysate bags are concerned on the home dialysis log. DON stated staff are going by the color of bag or box tape. DON stated she would put out education in the resident's room and dialysis binder regarding how to fill out the home dialysis logs, and documenting in the TAR starting today. Interview on 10/25/23 at 9:18 A.M., with Administrator of dialysis center #900 stated that the facility did not include on the home dialysis log when heparin was administered. Stated there is a section for medication added to the dialysate solution. The administrator stated they are unsure if it is being completed as it is not included on the form. Stated that they do not know how to do prescriptions due to poor documentation. Interview on 10/25/23 at 11:49 A.M., with DON stated the dialysis center will adjust the cycler machine without the facility knowing at times. Verified the missing information on the dialysis log and TAR's. Interview on 10/25/23 at 4:10 P.M., with Administrator and DON stated the dialysis machine is hooked up to the internet and all the information is sent to the dialysis center. Administrator stated that the home dialysis logs are not a part of the medical record as the nurses do not sign off on them. Review of undated policy titled Peritoneal Dialysis revealed the purpose of this procedure is to provide continuous ambulatory peritoneal dialysis that is safe and consistent with physician orders 365900 Page 2 of 3 365900 10/25/2023 Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380

F 0698 Level of Harm - Minimal harm or potential for actual harm and instructions from the contracted dialysis facility. Guidelines: This procedure must be performed by a nurse who has been specifically trained in peritoneal dialysis. Follow all existing orders and instructions for care pertaining to the resident's dialysis. Verify the following: dialysate solution/concentration, medications to be added, number of exchanges and infusion, dwell, and drain times, monitoring parameters; and lab orders. Residents Affected - Few This deficiency represents non-compliance investigated under Master Complaint Number OH00147659. 365900 Page 3 of 3