Rcg Clanton

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 46293 Based on review of medical records (MR), facility policies, and interview with staff, it was determined the facility failed to ensure: a. All patients received immunizations for Pneumococcal disease or completed a vaccine declination. b. Tuberculin skin testing was performed on admission. This did affect three of seven MRs reviewed including Patient Identifier (PI) # 1, PI # 6 and PI # 4, and had the potential to affect all patients dialyzing at this facility. Findings include: Facility Policy: Pneumococcal Vaccine for Adults Reference Number: 47714 Published: 7/3/2025 Version: 7 Purpose: The purpose of this policy is to reduce the incidence of Pneumococcal disease by providing immunization to eligible patients. Background: Pneumococcal vaccination is recommended for adults with chronic renal failure... Policy: ...Obtain a declination statement for any patient who declines the Pneumococcal vaccine. Patients should be offered pneumococcal vaccination on an annual basis, at minimum...The vaccine declination must be signed by the patient for each refusal and documented in the patient’s MR. Policy: Patient Tuberculosis Testing Reference Number: 47628 Published: 5/2/2025 Version: 6 Purpose: The purpose of this policy is to provide guidance on tuberculosis (TB) testing. Background: Patients with End Stage Renal Disease (ESRD) should have at least one test for Mycobacterium tuberculosis infection to screen for tuberculosis. New Admission Screening: The Mantoux Tuberculin Skin Test (TST) or the Interferon-Gamma Release Assay (IGRA) blood tests can be used to test for Mycobacterium tuberculosis... On admission, review the MR of each patient to determine if they have received TB testing within the last year... Patients who have no documented TB test within the last year will be tested using the TST... 1. PI # 1 was admitted to the facility on 11/18/25 with a diagnosis of ESRD. MR review revealed no documentation PI # 1’s immunization history, to include Pneumococcal vaccination status, was assessed and the pneumococcal vaccine was administered or declined by PI # 1. Further MR review revealed no documentation of TB assessment and/or testing upon admission. An interview was conducted on 1/15/26 at 2:18 PM with Employee Identifier (EI) # 1, Clinical Manager, who confirmed the facility failed to ensure staff followed the policies for assessing vaccination status and testing for patients. 47295 2. PI # 6 was admitted to the facility on 4/14/25 with a diagnosis of ESRD. MR review revealed no documentation of TB assessment and/or testing upon admission. Further MR review revealed no documentation PI # 6’s immunization history, to include Pneumococcal vaccination status, was assessed and the pneumococcal vaccine was administered or declined by PI # 6. An interview was conducted on 1/15/26 at 2:42 PM with EI # 1, who confirmed the facility failed to ensure staff followed the policies for assessing vaccination status and testing for patients. 41624 3. PI # 4 was admitted to the facility on 7/28/25 with a diagnosis of ESRD. MR review revealed no documentation of TB assessment and/or testing upon admission. Further MR review revealed no documentation PI # 4’s immunization history, to include Pneumococcal vaccination status, was assessed and the pneumococcal vaccine was administered or declined by PI # 4. An interview was conducted on 1/15/26 at 2:05 PM with EI # 1, who confirmed the facility failed to ensure staff followed the policies for assessing vaccination status and testing for patients.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 41624 Based on medical record (MR) review, facility policy, and interview, it was determined the dialysis staff failed to document the amount of saline prime and/or rinse back fluid administered with each dialysis treatment. This deficient practice affected six of seven MRs reviewed, including Patient Identifier (PI) # 7, PI # 4, PI # 1, PI # 3, PI # 5, and PI # 6, and had the potential to affect all patients dialyzing at this facility. Findings include: Facility Policy: Initiation of Treatment Using an Arteriovenous Graft or Fistula and Optiflux Single use Ebeam Dialyzer Policy Number: 45650, Version 6 Published Date: 05/05/2025 Prior to Initiation: Assessment and Treatment Parameters: ...6. Add any fluid to be given during the treatment such as, saline prime/rinse back...during treatment. Documentation: Document the time dialysis started and all required patient and machine data in the patient’s hemodialysis treatment sheet or electronic medical record. 1. PI # 7 was admitted to the facility on 1/29/21 with a primary diagnosis of End Stage Renal Disease (ESRD). Review of the Treatment Sheet (TS) dated 1/5/26 revealed there was no documentation of the amount of prime fluid administered. An interview was conducted on 1/15/26 at 2:34 PM with Employee Identifier (EI) # 1, Clinic Manager, who confirmed there was no documentation for the amount of prime administered. 2. PI # 4 was admitted to the facility on 7/28/25 with a primary diagnosis of ESRD. Review of the TS dated 12/30/25, 1/2/26, 1/7/26, and 1/9/26 revealed there was no documentation of the amount of prime fluid administered. Review of the TS dated 1/5/26 revealed there was no documentation of the amount of rinse back administered. An interview was conducted on 1/15/26 at 2:05 PM with EI # 1 who confirmed there was no documentation of the amount of prime and/or rinse back administered on those dates. 46293 3. PI # 1 was admitted to the facility on 11/18/25 with a primary diagnosis of ESRD. Review of the TS dated 12/31/25 revealed there was no documentation of the amount of prime fluid administered. An interview was conducted on 1/15/26 at 2:18 PM with EI # 1, who confirmed there was no documentation of the amount of prime fluid administered. 4. PI # 3 was admitted to the facility on 12/30/22 with a primary diagnosis of ESRD. Review of the TS dated 1/5/26 revealed there was no documentation of the amount of prime fluid administered. An interview was conducted on 1/15/26 at 1:49 PM with EI # 1, who confirmed there was no documentation of the amount of prime fluid administered. 47295 5. PI # 5 was admitted to the facility on 3/16/21 with a diagnosis of ESRD. Review of the TS dated 12/31/25 revealed no documentation of the amount of prime fluid administered. An interview was conducted on 1/15/26 at 1:55 PM with EI # 1, who confirmed there was no documentation of the amount of prime fluid administered. 6. PI # 6 was admitted to the facility on 4/14/25 with a diagnosis of ESRD. Review of the TS dated 12/26/25 revealed no documentation of the amount of prime fluid administered. An interview was conducted on 1/15/26 at 2:42 PM with EI # 1, who confirmed there was no documentation of the amount of prime fluid administered.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 41624 Based on medical record (MR) review, facility policy, and interview, it was determined the dialysis staff failed to obtain and complete an Early Termination Against Medical Advice (AMA) form signed by the patient for treatment times less than prescribed. This deficient practice affected Patient Identifier (PI) # 7, PI # 4, PI # 5, and PI # 6, four of seven MRs reviewed, and had the potential to affect all patients dialyzing at this facility. Findings include: Facility Policy: Early Termination or Arriving Late for Treatment Policy Number: 45263, Version 4 Published: 6/18/2025 Early Termination: If a patient insists on terminating treatment early and this has not been previously approved by the patient’s provider, the patient must take full responsibility for consequences of the missed or shortened treatment. If a patient requests to leave treatment early: ...The registered nurse (RN) will evaluate the patient and discuss with the patient their reasons for requesting to terminate their treatment earlier than prescribed... The RN is responsible to notify the provider, and document on the AMA form. AMA Forms: AMA forms are...signed with each early termination event and filed in the patient’s MR. 1. PI # 7 was admitted to the facility on 1/29/21 with a primary diagnosis of End Stage Renal Disease (ESRD). Review of the Treatment Sheet (TS) dated 1/5/26, and Orders Summary Report (OSR) dated 1/5/26, revealed dialysis treatment orders which included four hour dialysis treatments three times a week. Further review of the TS dated 1/5/26 revealed PI # 7 began treatment at 12:34 PM, treatment ended at 4:04 PM, which was three hours and 30 minutes. Review of the TS dated 1/7/26 revealed PI # 7 began treatment at 12:25 PM, treatment ended at 3:57 PM, which was three hours and 32 minutes. Review of the MR revealed no documentation of a signed AMA for the treatments ending earlier than the prescribed time on 1/5/26 and 1/7/26. An interview was conducted on 1/15/26 at 2:34 PM with Employee Identifier (EI) # 1, Clinic Manager, who confirmed there was no signed AMA for the treatment times less than prescribed. 2. PI # 4 was admitted to the facility on 7/28/25 with a primary diagnosis of ESRD. Review of the TS dated 12/29/25 and OSR dated 1/7/26 revealed dialysis treatment orders which included four hour and 30 minute dialysis treatments three times a week. Further review of the TS dated 12/29/25 revealed PI # 4 began treatment at 11:08 AM, treatment ended at 2:06 PM, which was two hours and 58 minutes. Review of the TS dated 1/9/26 revealed PI # 4 began treatment at 10:06 AM, treatment ended at 1:03 PM, which was two hours and 57 minutes. Review of the MR revealed no documentation of a signed AMA or the treatments ending earlier than the prescribed time on 12/29/25 and 1/9/26. An interview was conducted on 1/15/26 at 2:05 PM with EI # 1 who confirmed there was no signed AMA for the treatment times less than prescribed. 47295 3. PI # 5 was admitted to the facility on 3/16/21 with a diagnosis of ESRD. Review of the OSR dated 11/13/25 and TS dated 12/27/25 revealed dialysis treatment orders which included four hour dialysis treatments three times a week. Review of the TS dated 12/27/25 revealed PI # 5 began treatment at 7:09 AM and treatment ended at 10:18 AM, which was three hours and nine minutes. Review of the MR revealed no documentation of a signed AMA for the treatment ending 51 minutes earlier than the prescribed time. An interview was conducted on 1/15/26 at 1:55 PM with EI # 1, who confirmed there was no signed AMA for early termination of treatment. 4. PI # 6 was admitted to the facility on 4/14/25 with a diagnosis of ESRD. Review of the TS dated 12/21/25 and the OSR dated 1/7/26 revealed dialysis treatment orders which included four hour and fifteen minute dialysis treatments three times a week. Further review of the TS dated 12/21/25 revealed PI # 6 began treatment at 11:14 AM and ended treatment at 3:04 PM, which was three hours and fifty minutes. Review of the TS dated 12/30/25 revealed PI # 6 began treatment at 1:17 PM and ended treatment at 4:23 PM, which was three hours and six minutes. Review of the TS dated 1/7/26 revealed PI # 6 began treatment at 12:24 PM and ended treatment at 4:27 PM, which was four hours and three minutes. Review of the MR revealed no documentation of a signed AMA for early termination of treatment on 12/21/25, 12/30/25, or 1/7/26. An interview was conducted on 1/15/26 at 2:42 PM with EI # 1, who confirmed there was no signed AMA forms for early termination of treatment.”