Dialysis Critical Element Pathway

Transcription

1 Use this pathway fr a resident identified as receiving hemdialysis (HD), hme hemdialysis (HHD) r peritneal dialysis (PD) at any lcatin. Review the fllwing in Advance t Guide Observatins and Interviews: Review the mst current cmprehensive (if the cmprehensive isn t the mst recent assessment) MDS/CAAs fr Sectins C - Cgnitive Patterns, G - Functinal Status, H Bladder and Bwel, J Health Cnditins (Pain), K Swallwing/Nutritinal Status, M - Skin Cnditins, N - Medicatins, O Special Treatments, Prcedures, and Prgrams (Dialysis). Physician s rders (dialysis access care, dialysis schedule, individualized dialysis prescriptin such as the number f treatments per week; length f treatment time, type f dialyzer, specific parameters f the dialysis delivery system [electrlyte cmpsitin f the dialysate, bld flw rate, and dialysate flw rate], anticagulatin; fluid restrictins, target weight, bld pressure mnitring). Pertinent diagnses. Care Plan Has staff evaluated the resident s respnse t dialysis and develped/revised the care plan in cllabratin with the dialysis facility: Mnitring vital signs, weights, nutritinal, and fluid needs r any restrictins, lab results, and wh t ntify with cncerns; Specific type and lcatin f dialysis services, transprtatin arrangements, and the interventins and gals based upn the type f dialysis; If the resident receives Erythrpiesis-Stimulating Agent (ESA) therapy, what t mnitr and when and t whm t reprt results; Fr HD/HHD, which arm t use fr bld pressure mnitring; Fr HHD, the number f treatments, length f treatment time, dialyzer, and specific parameters f the dialysis delivery system (e.g., electrlyte cmpsitin f the dialysate, bld flw rate, and dialysate flw rate), anticagulatin, the resident s target pre- and pst-weights, vital signs, r ther mnitring required during the prvisin f the dialysis treatment and that the trained staff must remain with the resident thrughut the treatment and have visual bservatin f the access site; Fr PD, the number f exchanges r cycles t be dne during each dialysis sessin, the vlume f fluid with each exchange, duratin f fluid in the peritneal cavity, the cncentratin f glucse r ther smtic agent t be used fr fluid remval, and the use f an autmated, manual, r a cmbinatin f the techniques, the target pre- and pst-weights, vital signs, r ther mnitring required during the prvisin f the dialysis treatment; Wh t cntact, such as the attending practitiner(s), nephrlgist, and dialysis staff, fr dialysis-related emergencies, cncerns r cmplicatins; Equipment needed t prvide dialysis such as a peritneal pump and alarm, access catheters, and equipment necessary t address a ptential medical cmplicatin, and wh t cntact fr equipment prblems; Mnitring fr risk factrs and managing cmplicatins such as hemrrhage, access site infectin, hyptensin, and t whm t reprt cncerns; Assessment and care f the access site, including the use f PPE as necessary, and ther infectin cntrl measures; Apprach t administering medicatins befre, during, r after dialysis accrding t practitiner s rders; and Advance directives, if any, as allwed by State Law. Frm CMS (5/2017) 1

2 Observatins: Infectin preventin and cntrl plicies and prcedures must be implemented (i.e., hand hygiene immediately befre and after cntact with a resident r any equipment used n resident, access site care fr hemdialysis and catheter site care fr peritneal dialysis). Is sap, water, and a sink readily accessible in lcatins where dialysis care is prvided? Des staff perfrm hand hygiene (even if glves are wrn) in a manner cnsistent with the current standards f infectin cntrl practices? Is PPE apprpriately implemented? Are qualified persnnel accessing and prviding maintenance f central venus catheters (CVCs), shunts, fistulas, r ther vascular access catheters using aseptic technique: The access insertin date is dcumented and the indicatin fr use is dcumented and assessed regularly; Dialysis access site dressings are clean, dry, and intact and the dressing is changed with clean (aseptic) technique using clean glves r sterile glves; Only sterile devices are used fr dialysis vascular access. Des the resident require injectins related t dialysis care: Injectins are prepared using aseptic technique in an area that has been cleaned and is free f cntaminatin (e.g., visible bld, r bdy fluids); The rubber septum n any med vial, whether unpened r previusly accessed, is disinfected with alchl prir t piercing; Med vials are entered with a new needle and a new syringe; and Med administratin tubing, cnnectrs, and bags f IV slutins are used fr nly ne resident (and nt as a surce f flush slutin fr multiple residents). Are care-planned and rdered interventins in place and fllwed? Fr a resident receiving dialysis at a certified dialysis facility, did the nursing hme: Assess and dcument vital signs, including the bld pressure in the arm where the access site is nt lcated, weights if rdered and cmmunicate the infrmatin including the resident s status with the dialysis facility prir t and pst dialysis; Prvide assistance and safe transprtatin t and frm dialysis; Administer meds r meals befre r after dialysis as rdered; Prvide direct visual mnitring f the access site befre and after dialysis; and Prvide nging mnitring and care f the resident s vascular access (fistula, graft, r central venus catheter) fr HD, catheter fr PD as rdered, and prvide nging mnitring fr dialysis related cmplicatins (e.g., bleeding, access site infectin, r hyptensin). Frm CMS (5/2017) 2

3 Fr a resident receiving HHD r PD in the nursing hme prvided by staff r ther qualified individuals, bserve if: There are dialysis trained and qualified staff prviding the treatment; Staff use apprpriate cleaning prcedures fr furnishings, equipment cntaminated with bld r ther bdily substances, spills and splashes f bld and effluent based n current standards f infectin cntrl practices, and are cleaned after each treatment; If there is a rmmate, whether access t his/her rm r pssessins is restricted r if there are cncerns related t ptential cmmunicable diseases; Emergency supplies r equipment are readily available; During the prvisin f HHD treatments, the nursing hme must ensure that: The HHD treatment is prvided accrding t practitiner and dialysis facility rders and nly by trained/qualified caregivers (as allwed by State law and nursing hme plicy) wh received direct training by the dialysis facility trainer; Direct bservatin f the vascular access site and bldline cnnectin is prvided by the dialysis trained caregiver wh must be physically present thrughut the HHD; Infectin cntrl practices are implemented, including the use f glves, masks, and ther persnal prtective equipment, methds fr hand hygiene, vascular access and dressing changes; The dialysis treatment fllws the dialysis prescriptin; Staff recgnize, manage, and reprt vascular access prblems, difficulty with cannulatin, a change in bruit r thrill; Bld pressure (nt taken n arm with access site) is taken and mnitred prir t, during and after the dialysis treatment and actin is taken t address excessively high r lw bld pressures during treatment; Onging assessment and mnitring ccurs during the treatment, including vital signs, mnitring level f cnsciusness, muscle Frm CMS (5/2017) 3 Observe the resident s rm and/r designated area fr HHD/PD t determine whether it is equipped t affrd privacy, has sufficient space, functining call system within reach; and based upn prfessinal standards f practice, the maintenance f effective infectin cntrl practices and measures. This includes ensuring that a resident wh is hepatitis B+ is nt dialyzed in the same lcatin as resident wh is nt hepatitis B+. Staff respnd apprpriately in the event f an emergency, a pwer utage, r ther situatins in which dialysis may need t be interrupted; Safe, secure, and sanitary strage, handling and access f dialysis equipment and supplies; and Bi-hazardus waste dispsal is available and used. Medicatins are administered as rdered, (if an Erythrpiesis- Stimulating Agent (ESA) is rdered, it is prvided, in accrdance with State laws and State scpe f practice); Medical emergencies such as cardiac arrest, air emblism, drug reactins, suspected pyrgen reactins, prfund hyptensin r hypertensin, significant bld lss, hyperkalemia, changes in level f cnsciusness r pain are recgnized, immediately reprted, and interventins/actins are prvided as rdered; After the treatment, staff btain vital signs, assess the resident s stability and mnitr fr pst-dialysis cmplicatins and symptms such as dizziness, nausea, vmiting, fatigue, r hyptensin and symptms that may be assciated with water and dialysate cntaminatin that cannt be readily attributed t ther causes (e.g., chills, shaking, fever, vmiting, headache, dizziness, muscle weakness, skin flushing, itching, diarrhea, hyper/hyptensin, hemlysis and anemia). If such symptms are present, determine whether the symptms are immediately reprted t the attending practitiner and nephrlgist r dialysis team t determine apprpriate actin; Staff use apprpriate infectin cntrl cleaning and disinfecting

4 cramping, itching, cmfrt r distress and must reprt identified r suspected cmplicatins t the attending practitiner and dialysis staff t enable timely interventins; As rdered, the weight is taken prir t and pst-treatment; Recgnize, manage and immediately reprt t the dialysis facility, pwer utages, failure f the HD machine, failure f water treatment cmpnents (e.g., chlrine/chlramine breakthrugh), cltting f the hemdialysis circuit, dialyzer bld leaks, line discnnectin, water supply prblems r leaks, and prblems with supply delivery; prcedures fr furnishings, equipment cntaminated with bld, r ther bdily substances, fr spills and splashes f bld r effluent; and Staff prperly dispse f needles, effluents, dispsable items, and tubing and t minimize risks f infectin r injury t self and thers and t prevent envirnmental cntaminatin (e.g., using impervius puncture resistant cntainers fr dispsal f sharps, placing empty dialysate bags and tubing in intact plastic bags befre discarding. During the prvisin f PD treatments, the nursing hme must ensure that: Individuals perfrming PD, receive dialysis training frm the certified dialysis training staff(as allwed by State law and nursing hme plicy); The PD treatment fllws the prescriptin; Befre, during, and after receiving the PD, btain and dcument vital signs and weights based n practitiner and dialysis rders, assess the resident s stability and mnitr fr emergencies r cmplicatins such as dizziness, nausea, fatigue, r hyptensin; Staff recgnize, dcument, manage, and reprt dialysis cmplicatins, including catheter, tunnel r exit site infectin, symptms f peritnitis, catheter disldgement, hyptensin, hypkalemia, r failure f sufficient dialysate t drain frm the peritneal space; Recgnize, manage, and reprt pwer utages, failure f the PD cycler t the dialysis facility; Prvide peritneal catheter care and dressing changes accrding t the treatment plan and rders; The resident s recrd must include dcumentatin f nging evaluatin f the peritneal catheter, including assessment f catheter related infectins (e.g., exit site acute and chrnic infectins) and tunnel fr cnditin, mnitring fr patency, leaks, infectin, and bleeding at the site. In additin, staff shuld be mnitring fr cmplicatins such as peritnitis (e.g., abdminal pain/tenderness/distentin, cludy PD fluid, fever, nausea and vmiting; Staff prperly dispse f needles, effluents, dispsable items, and tubing and t minimize risks f infectin r injury t self and thers and t prevent envirnmental cntaminatin (e.g. using impervius puncture resistant cntainers fr dispsal f sharps, placing empty dialysate bags and tubing in intact plastic bags befre discarding; and Use apprpriate cleaning prcedures fr furnishings, equipment cntaminated with bdily substances, spills and splashes f effluent based n current standards f infectin preventin and cntrl practices. Frm CMS (5/2017) 4

5 Resident, Resident Representative, r Family Interview: Hw were yu invlved in the develpment f the care plan and gals specific t dialysis? D the interventins reflect yur chices and preferences? D yu have any cncerns with yur dialysis treatment? D yu knw wh t discuss the cncerns with? Were yur cncerns addressed? If nt, why nt? Are yu n fluid r fd restrictins? If s, hw des staff mnitr yur intake? D yu fllw yur restricted diet and fluids? If nt, has staff prvided educatin abut the risks and tried t prvide alternatives? Are yu allwed t have meals r snacks during yur dialysis treatments? If s, hw are meals r snacks prvided? If nt, hw and when d yu receive meals n dialysis days? When d yu take yur medicatins n dialysis treatment days? Have yu missed any medicatins n dialysis treatment days? Hw ften d yu receive treatments? Have treatments been cancelled r missed? If s, why? Were they rescheduled and by whm? Frm CMS (5/2017) 5

6 Staff Interviews (As apprpriate, Nurse Aides, Nurse, DON, Practitiner, Dietitian, Pharmacist, Nephrlgist, Dialysis Staff, Medical Directr): What type f staff training fr dialysis care and services did yu If care plan cncerns are nted, interview staff respnsible fr care receive and wh prvided the training? planning as t the ratinale fr the current care plan. What type f dialysis is the resident receiving? Hw d yu care fr Hw is medicatin administratin mnitred t assure meds are the access sites and dressing changes? When d yu mnitr vital administered timely r held accrding t rders? signs and weights? Are there any restrictins fr fd r fluids and Hw and when are diagnstic tests btained and wh is respnsible hw is it tracked? fr cllecting, reprting, and reviewing the results? What d yu d if the resident declines a dialysis treatment, is ill, r If the resident is receiving an ESA, hw has the dialysis and facility if treatments are cancelled? crdinated btaining and reprting test results (i.e., hemglbin Has the resident had any dialysis-related cmplicatins (e.g., and hematcrit) t the practitiner? dizziness, falls, bleeding)? T whm d yu reprt pssible If the pharmacist reprts irregularities f ESA prescribing and cmplicatins r changes in cnditin? ptential medicatin-related adverse cnsequences, hw have the What d yu d if there is an emergency r cmplicatin including recmmendatins been crdinated with dialysis? equipment failure? Has the facility established plicies and prtcls fr the dispensing, Hw is care crdinated and cmmunicated between dialysis staff administratin, and strage f ESA? and the facility, including dcumentatin f the resident s status, If the interventins r care prvided d nt appear t be cnsistent nutritin, adequate hydratin, psychscial and nursing needs, with standards f practice, ask the medical directr: current dialysis treatment, and the pssible need t mdify the Hw are yu invlved in develping r implementing plicies current interventins? and prcedures regarding HD/HHD/PD, including emergency Has the resident had a change in md r behavir? Has the resident prcedures, medicatin administratin, prcedures fr use f refused t participate in activities that he/she had previusly shwn ESAs, and emergency medicatins; and interest, expressed feelings f hpelessness r anger ver health and need fr dialysis treatments? Hw is this addressed and by whm? Were yu asked t address cncerns regarding dialysis-related care with the attending practitiner and ESRD practitiners? Has the resident had pain r anxiety related t dialysis treatments? Hw is this being addressed? Ask abut identified cncerns. Frm CMS (5/2017) 6

7 Recrd Review: If facility staff prvide the HHD r PD treatments, request dcumentatin t assure that training meets the current standards f practice, State law and practice acts, and is prvided directly by dialysis facility staff t the individual prviding the treatment; Did the recrd reflect the resident s dialysis needs, such as: Identificatin f individualized risk factrs and ptential cmplicatins related t dialysis (e.g., bleeding, infectin, skin integrity, and the effects f dialysis n medicatin therapy); Chices r preferences including advance directives, if any; Medical status including status f cmrbid cnditins, frequency f vital signs, weights, and mnitring fluids as rdered; Identificatin f the type f dialysis, where prvided and by whm, hw ften and if the treatment is in accrdance with the dialysis prescriptin; Supervisin and mnitring during HHD r PD, including direct bservatin f the access site during HHD; Identificatin f apprpriate PPE fr type f dialysis treatments and care prvided, identificatin f specific infectin cntrl practices t use prir t, during and/r after the treatments, including care f equipment and supplies; Labratry tests needed t manage and mnitr dialysis; Pneumcccal and influenza immunizatins, hepatitis immunizatin, and screening fr tuberculsis (per CDC); Cmmunicatin and crdinatin with the dialysis team t meet nutritin and hydratin needs; Psychscial needs such as anxiety, depressin, cnfusin r behaviral symptms that might interfere with treatments and interventins t address the identified needs; Des the recrd reflect the crdinatin and cllabratin with the dialysis facility including exchange f pertinent infrmatin befre, during (if HHD prvided by the nursing hme), and pst dialysis? Was there a "significant change" in the resident's cnditin If s, was a significant change cmprehensive assessment cnducted within 14 days? If cncerns are identified related t the prvisin f dialysis care, review the apprpriate facility plicies regarding dialysis. Critical Element Decisins: NOTE: If at any time during the survey, a cncern r issue arises regarding the dialysis services prvided by the dialysis facility, the survey team shuld reprt this as a cmplaint t the State Agency survey unit respnsible fr versight f the Medicare certified ESRD entity. Identify the specific resident(s) invlved and the cncerns identified. 1) Did the facility prvide dialysis care and services t meet the needs f the resident? If N, cite F698 2) Did the facility use apprpriate hand hygiene practices and PPE when prviding wund/dressing care, central line care, and/r administering IM/IV medicatins? If N, cite F880 Frm CMS (5/2017) 7

8 3) Fr newly admitted residents and if applicable based n the cncern under investigatin, did the facility develp and implement a baseline care plan within 48 hurs f admissin that included the minimum healthcare infrmatin necessary t prperly care fr the immediate needs f the resident? Did the resident and resident representative receive a written summary f the baseline care plan that he/she was able t understand? If N, cite F655 NA, the resident did nt have an admissin since the previus survey OR the care r service was nt necessary t be included in a baseline care plan. 4) If the cnditin r risks were present at the time f the required cmprehensive assessment, did the facility cmprehensively assess the resident s physical, mental, and psychscial needs t identify the risks and/r t determine underlying causes, t the extent pssible, and the impact upn the resident s functin, md, and cgnitin? If N, cite F636 NA, cnditin/risks were identified after cmpletin f the required cmprehensive assessment and did nt meet the criteria fr a significant change MDS OR the resident was recently admitted and the cmprehensive assessment was nt yet required. 5) If there was a significant change in the resident s status, did the facility cmplete a significant change assessment within 14 days f determining the status change was significant? If N, cite F637 NA, the initial cmprehensive assessment had nt yet been cmpleted; therefre, a significant change in status assessment is nt required OR the resident did nt have a significant change in status. 6) Did staff wh have the skills and qualificatins t assess relevant care areas and wh are knwledgeable abut the resident s status, needs, strengths and areas f decline, accurately cmplete the resident assessment (i.e., cmprehensive, quarterly, significant change in status)? If N, cite F641 7) Did the facility develp and implement a cmprehensive persn-centered care plan that includes measureable bjectives and timeframes t meet a resident s medical, nursing, mental, and psychscial needs and includes the resident s gals, desired utcmes, and preferences? If N, cite F656 NA, the cmprehensive assessment was nt cmpleted. 8) Did the facility reassess the effectiveness f the interventins and review and revise the resident s care plan (with input frm the resident r resident representative, t the extent pssible), if necessary t meet the resident s needs? If N, cite F657 NA, the cmprehensive assessment was nt cmpleted OR the care plan was nt develped OR the care plan did nt have t be revised. Frm CMS (5/2017) 8

9 Other Tags, Care Areas (CA), and Tasks (Task) t Cnsider: Dignity (CA), Right t be Infrmed F552, Right t Refuse F578, Advance Directives (CA), Ntificatin f Change F580, Accmmdatin f Needs, Call System (Envirnment Task), Qualified Persns F659, Pressure Ulcer (CA), Nutritin (CA), Hydratin (CA), Sufficient and Cmpetent Staffing (Task), Unnecessary Medicatins (CA), Other Infectin Cntrl Cncerns (Task), Facility Assessment F838, Medical Directr F841, Resident Recrds F842, QAA/QAPI (Task). Frm CMS (5/2017) 9