This week on the CMSCG Blog “Ftag of the Week,” CMS Compliance Group Clinical Consultant Mary Quinn continues with a review of F698 Dialysis and the associated regulatory requirements in Appendix PP. Let’s start with some areas where issues are prone to be identified – physician orders and medication orders. These sound like they should be no problem, right? Well, Mary has some thoughts and recommendations based on issues we commonly identify in client buildings.
Physician Orders for Dialysis
It goes without saying that a physician order is needed for a resident to receive dialysis. However, there are several items that it’s recommended are included in the dialysis order. These include:
- Type of dialysis – individualized dialysis prescriptions (i.e., days of the week, length of treatment time, type of dialyzer, fluid restriction)
- Location/site of dialysis
- Time – including transportation pick up time. Communicating this information to the direct caregiver facilitates residents’ timely transportation to services.
- Type and location of access device – Don’t forget assessment/monitoring.
- Order sets are frequently utilized to ensure all elements are included.
Pay attention to scheduling changes on readmission. Orders for dialysis sometimes are not entered on readmission and/or the dialysis schedule changes with no corresponding change in the orders. There always needs to be a current order for dialysis.
Medication Orders
Medications are another area that needs to be clearly spelled out – otherwise you are asking for confusion, potential for a negative outcome, and even possibly a survey citation. Here are some tips:
- It should be clearly documented which/ if any medications are being administered at the dialysis facility.
No problem, right? Well, here are two ways that things can go wrong:
- Medications administered at the dialysis facility are scheduled/signed by SNF staff on the MAR – try to figure out why a facility would do that.
- The medical record doesn’t include medications administered at the dialysis center
Another important thing to remember is the medication schedule.
- The schedule for medication administration must be adjusted related to dialysis days and times.
Nursing staff need education related to medication administration on days/times that resident is out of the facility for dialysis services and adherence to this scheduling needs to be monitored for compliance. We often identify documentation that indicates medications not administered due to “off unit” or medications are signed for at a time when the resident is not present in the facility. This includes items such as AC FSBG/ insulin and supplements.
- If the physician is in agreement, it may be appropriate to administer certain medication only on non-dialysis days or to schedule medication when the resident returns from dialysis.
Meals/ Fluid Restrictions/ Weights
Meals
If a resident is out of the facility during a regularly scheduled meal, arrangements must be in place to ensure no meals are missed. You have options to address this, so take advantage of them:
- Early trays can be made available- make sure it is offered/provided – residents sometimes are observed to have left for dialysis and the meal tray remains at the nursing station because no one delivered it to the resident’s room.
- Food may be transported with the resident – make sure appropriate for transport (i.e., perishables, correct texture). Food Services staff can easily be made aware of the need for a “brown bag’ lunch.
- If a tray remains on the unit for consumption on return to the facility (not the best practice) is it refrigerated until return? Do staff have directives and are they familiar with reheating policies?
Fluid Restrictions
Another area to pay attention to is when there is a directive for a fluid restriction. While orders for fluid restrictions are not typically commonplace, when they are deemed necessary by the physician, they must be monitored and documented accurately. Here are some tips and reminders:
- Additional fluids should not be available to residents (i.e., water pitchers at the bedside)
- Family education is necessary to ensure additional fluids are not being requested and provided by family unwittingly.
- The actual provision of fluid during meals needs to be monitored to ensure the correct amount of fluids allowable for each meal is adhered to – nothing more than what is noted on the meal ticket. Staff distributing trays that include fluids provided directly from the kitchen should watch that what is provided is consistent with the meal ticket. Likewise, if unit or dining room staff provide fluids to a resident on a fluid restriction, the staff member needs to ensure that what is provided is consistent with the fluid restriction noted on the meal ticket – 6 oz. of coffee is not the same as filling up a 10 oz. coffee mug which is often observed or providing that second cup of coffee or juice upon resident request.
- Accurate recording of fluid intake needs to be monitored – documentation often reveals intake in excess of the ordered restriction.
- Non-compliance needs to be addressed with documentation inclusive of physician notification, and ongoing education inclusive of risks.
Weights
Weights are another area that is potentially problematic even without adding dialysis into the mix. Weights must be obtained/recorded per physician orders. Don’t forget:
- Some facilities utilize post dialysis weights documented by the dialysis facility which is an acceptable practice – make sure your practice is reflected in your policy.
- Weight loss needs to be thoroughly addressed and not just assumed to be fluid shifts related to dialysis.
That’s a lot to have in place, but we’re not done yet! We will wrap up our “Ftag of the Week” for dialysis next week, where we will discuss communication, documentation and care planning, and competencies/training.
