Complaint Summary for Public Viewing Reports for:
RENAL CARE GROUP - EAST DENVER
Thursday, December 23, 2010 12:18 PM

Intake ID:   CO00012232
Facility:   RENAL CARE GROUP - EAST DENVER
Date of Complaint:   8/28/2010
Date of Investigation:   10/20/2010
Total Number of Allegations for Complaint: 3

Allegation: 1

Type: Nursing Services

Findings: Unsubstantiated

Allegation Detail: The Health Facilities and Emergency Medical Services Division received a complaint on 8/26/10.

The complainant alleged the facility failed to provide adequate nursing oversight. The complainant stated there were 2 nurses for 18 patients. The complainant stated the facility's policy mandates 1 tech per 4 patients.

Findings Detail: An unannounced onsite survey, authorized by Centers for Medicare and Medicaid (CMS), was conducted by one state surveyor on 10/21/10. Interviews and observations were conducted, policies, procedures and staffing schedules were reviewed.

Interviews were conducted with --- ----

An interview was conducted with --- ----

Interviews were conducted with the patients on 10/20/10 between 6:00 p.m. and 7:45 p.m. Interviews were conducted with five patients and the question of how safe they felt with the staffing was posed to each one. The comments were, "I feel very safe," "staff is always nearby when I need them" and "if I didn't feel safe I would go somewhere else to dialyze."

Observations were made on 10/20/21 between 6:00 p.m. and 7:45 p.m. The treatment floor was very organized, the patients were being put on the machines in an orderly manner with nurses performing the assessments and neither the patient care technicians or nurses were being rushed.

The allegation that the facility failed to provide adequate nursing oversight was not substantiated. No deficient practice was cited.

Allegation: 2

Type: Nursing Services

Findings: Unsubstantiated

Allegation Detail: The complainant alleged the facility failed to provide the necessary nursing oversight. The complainant stated nurses at the facility do not monitor patients but spend their time filling out paperwork.

Findings Detail: An interview was conducted with --- ---- RN on 10/20/10 at approximately 6:45 p.m. The RN stated that the nurses split the rounds with the patient care technicians (PCTs). Every thirty minutes the safety checks are done which includes checking the access, blood lines and needles, and viewing the patient. Every hour the vital signs are taken and safety checks again are performed. The RN further stated there are also the usual nursing duties on the nocturnal shift as there are during the other shifts. Flu shots were scheduled for several patients this evening, nursing assessments on every patient are performed, medications are administered, care plans updated, calls from physicians, orders to take off, etc. The RN also stated that nurses and techs get a thirty minute break sometime during the shift. However, only one staff can take a break at a time as three staff members must always be on the floor. Everyone must stay in the building during there break and be available in case of an emergency.

The allegation that the facility failed to provide the necessary nursing oversight was not substantiated. No deficient practice was cited.

Allegation: 3

Type: Other

Findings: Unsubstantiated

Allegation Detail: The complainant alleged the facility failed to maintain accurate and up to date medical records. The complainant stated laboratory tests are completed, but the results are not put in the patient's medical record.

Findings Detail: An interview was conducted with --- ---- on 10/20/10 at approximately 5:15 p.m. The Manager stated that the majority of the medical record is electronic so laboratory tests results would not be in the paper medical record but in the EMR (electronic medical record.) However, it is accessible on-line at any time. There is some paper in the hard copy such as items that require a signature: consent forms, care plans and rounding reports used by the physicians.

The allegation that the facility failed to maintain accurate and up to date medical records was not substantiated. No deficient practice was cited.

http://www.hfemsd1.dphe.state.co.us/hfd2003/compreport.aspx?id=12N614&ft=esrd&comp=CO00012232&bk=

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3/31/2009 Survey Tag 0626 Detail for:
CHILDREN'S HOSPITAL KIDNEY CENTER
Thursday, December 23, 2010 5:47 AM


Survey Date: 3/31/2009

Regulation Number:0626

Regulation Title: QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL

Regulation Description: The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility's organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS.

Surveyor Findings:


Based on staff interview, medical record review and review of the facility's QAPI (Quality Assessment and Performance Improvement) program, the facility failed to implement and maintain an effective, data-driven assessment and performance improvement program. This failure created the potential for lack of improvement in patient care and outcomes.

The findings were:

A review of the QAPI program was performed on 3/30/09. There was no evidence the facility was monitoring any of the ten (nine are pertinent to this facility) areas that are specifically required to be continuously assessed, trended and reviewed.

According to the 2008 (DFR) Dialysis Facility Report for this facility, the statistics for anemia management and high catheter rate far exceeded the national average. The facility's hemoglobin rate was 43% between 10-12 g/dL compared to 54% nationally. The catheter rate for prevalent patients receiving hemodialysis treatment in the facility was at 47% compared to 12% nationally.

Three medical records of hemodialysis patients were reviewed on 3/30/09. Two of the three patients had a catheter in place for their vascular access. One of the three patients had a fistula. According to the laboratory results of 3/2/09, two of three patients had low hemoglobins. One patient had a hemoglobin of 8.9 g/dL and another patient was at 10.1 g/dL.

The clinical manager was interviewed, on 3/30/09 at approximately 11:45 a.m. The manager stated that he/she was aware of the regulations pertaining to the QAPI program and was in the process of establishing the criteria. However, it was not implemented at this time.

Facility Plan of Correction:

The Children’s Hospital acknowledges that our Quality Assessment and Performance Improvement processes needed to be more formalized and leadership-driven; however, it is important to note that our pediatric patient population is unique; specifically, the rate of catheter placement in pediatric patients is significantly different from adults.

How the Facility will CORRECT the deficient practice:

The Kidney Center has developed a Quality Assessment/Performance Improvement program and policy that outlines the purpose, scope, personnel, responsibilities, organization, and procedures for monitoring and evaluating the key indicators related to assessing and improving health outcomes and decreasing or preventing medical errors as outlined on the Measures Assessment Tool (MAT).

How the facility will IDENTIFY areas of deficient practice:

The Clinical Manager in conjunction with the Medical Director and members of the Quality and Patient Safety Department have developed a quality scorecard to enable timely tracking of these key indicators for further analysis, prioritization of improvements, reviewing adverse events, and developing, implementing, evaluating, and revising plans to improve patient care.

What will the facility do to PREVENT the same deficiency from recurring?

These quality indicators will be reviewed MONTHLY by the Kidney Center Quality Assurance interdisciplinary team that consists of the Medical Director, other physicians as indicated, the Clinic Manager (RN), a masters-prepared social worker, a registered dietician, a quality improvement specialist, and other team members, as applicable.

How will the facility MONITOR the implementation of the plan of correction to ensure the problems remain corrected?

In addition to the monthly monitoring, the Kidney Center quality indicators will be reviewed twice each year by the Clinical Effectiveness and Improvement Committee (a multi-disciplinary hospital-wide quality improvement committee that is primarily focused on patient outcomes).


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0626&eid=6GUG11&ft=esrd&id=120402&bdg=00&reg=FV10


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3/31/2009 Survey Tag 0712 Detail for:
CHILDREN'S HOSPITAL KIDNEY CENTER
Thursday, December 23, 2010 11:56 AM

Survey Date: 3/31/2009

Regulation Number:0712

Regulation Title: MD RESP-QAPI PROGRAM

Regulation Description: Medical director responsibilities include, but are not limited to, the following: (a) Quality assessment and performance improvement program.

Surveyor Findings:


Based on review of the QAPI (Quality Assessment and Performance Improvement) program, the facility failed to ensure the medical director was assigned operational responsibility for the QAPI program. This failure created the potential to affect all the patient health outcomes in the facility.

The findings were:

The QAPI program was reviewed on 3/30/09. There was no evidence the medical director was providing guidance in the development of the specific quality indicators that must be implemented in the QAPI program. Furthermore, the operational responsibility included educating and encouraging the facility and medical staff regarding the objectives, assessment of the effectiveness of the plan and communication with the governing body regarding the needs that were identified. There was no oversight of implementation of the facility's trends, analysis, plans or timetables.

In summary, oversight by the medical director in developing a viable QAPI program for the facility was not evident.

Facility Plan of Correction:

How the facility CORRECT the deficient practice?

The Medical Director for the Kidney Center is responsible for chairing the Quality Assurance and Performance Improvement (QA/PI) Committee for the Kidney Center which includes an interdisciplinary team consisting of other physicians as indicated, the Clinic Manager (RN), a masters-prepared social worker, a registered dietician, a Quality Improvement specialist, and other members of the Kidney Center, as applicable.

How will the facility IDENTIFY areas of deficient practice?

The Kidney Center QA/PI Committee is responsible for reviewing on a monthly basis the quality indicators as outlined in the Measures Assessment Tool (MAT) on a per patient basis and as an aggregate for the center; these indicators will be displayed on a scorecard that was developed in conjunction with the Medical Director, the Clinical Manager and members of the Quality and Patient Safety Department.

What will the facility do to PREVENT the same deficiency from recurring?

The TCH Chief Medical Officer, to whom the Kidney Center Medical Director reports, and the TCH Chief Quality Officer who oversees the system wide quality program will assure continuous leadership by the Medical Director and reporting of data..

How will the facility MONITOR the implementation of the plan of correction to ensure the problem remains corrected?

These quality indicators will be reviewed MONTHLY. Additionally, bi-annually, the Medical Director for the Kidney Center will present the quality indicators as illustrated on the Kidney Center Scorecard to the Clinical Effectiveness and Improvement Committee, a multi-disciplinary hospital-wide quality improvement committee that is primarily focused on patient outcomes. The QAPI committee met preliminarily on April 20, 2009 and will have its first scheduled meeting during the month of May 2009.

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0712&eid=6GUG11&ft=esrd&id=120402&bdg=00&reg=FV10

 

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