Description of Event or Problem · 1
ON (B)(6) 2016, PT DIALYZED 3 HRS 18 MINUTES OF ORDERED 3 HR 15 MINUTES DIALYSIS TREATMENT. PRE DIALYSIS PULSE 103. DURING TREATMENT, PULSES RANGED FROM 52 82; SBT FROM 110-137; DBP FROM 20-65. POST DIALYSIS VS: SITTING B/P 137/65; STANDING B/P 135/51; PULSE 87 REGULAR; RESP 16; TEMP 97.9; 3.1 KG REMOVED. PRE ASSESSMENT: "TIRED, ORIENTED, SOB, CRACKLES NOTED THROUGHOUT - SAYS JUST IN HER THROAT, SAYS TOOK 12H MEDICINE, DRY COUGH, MILD FACIAL AND BLE EDEMA, GOAL SET TO PULL 3KG AS TOLERATED." IN ADDITION, PULSE WAS DOCUMENTED AT 103 REGULAR, TACHYCARDIA, THREADY, AND PT WAS NOTED TO BE ANXIOUS BUT PLEASANT. POST ASSESSMENT INDICATES PT WAS RESTLESS AND AMBULATED WITHOUT ASSISTANCE, NO UNUSUAL FINDINGS NOTED. PT WAS FOUND DECEASED IN HER HOME ON (B)(6) 2016 WHEN STAFF REQUESTED POLICE TO PERFORM A HEALTH AND WELFARE CHECK AFTER SHE DID NOT ARRIVE TO THE DIALYSIS CLINIC FOR HER SCHEDULED TREATMENT. THE PT WAS FOUND ON THE FLOOR IN HER BEDROOM, DECEASED WITH NO MARKS OR BRUISES ON HER. ON 12/27/2016, IT WAS DISCOVERED THAT GRANUFLO 2.0K WAS BEING DELIVERED TO PATIENTS WITH ORDERS FOR 2.0K DIALYSATE. UPON INVESTIGATION, IT WAS DETERMINED THAT THIS HAD BEEN OCCURRING FROM (B)(6) 2016. ORDERED DIALYSATE FOR THIS PT WAS G2231. THE PT DIALYZED ON G3231 FROM (B)(6) 2016. LOT NUMBERS FOR G3231: (B)(6) - 16HXGF021. (B)(6): 16HXGF021, EXPIRATION DATE: 6/30/2017. ON (B)(6) - 16NXGF002. ADD'L EXPIRATION DATE: 10/31/2017.