Davita Chinle Dialysis

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Management Plan, last facility review 05/31/24, (Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies identified the patient population that would be at risk during an emergent event, the services the facility could provide, or how the facility would continue operations during an emergency. This failure had the potential to affect the current 103 in-center patients receiving care in the facility. Findings include: Review of the facility’s EPP on 09/06/24 at 2:15 PM, with the Facility Administrator (FA) and Manager of Clinical Services (MCS), revealed that the EPP did not identify the patient population that would be at risk in the event of an emergency event, the services the facility would be able to provide during an emergency, or how the facility planned to continue operations during an emergency. During an interview on 09/06/24 at 1:50 PM while reviewing the EPP, the MCS pointed out on policy 04-07-01, under “Transfer Agreements” it stated: “3. Agreement(s) should: ...c. Take into account: i. Patient population ii. Ability of receiving facility to provide continuity of services . . .” During further interview on 09/06/24 at 2:28 PM the MCS stated there was only the transfer agreement area but that nothing about the continuance of operations and/or services was identified in the policies.”

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 28154 Based on interview and review of the facility’s Emergency Management Plan, last facility review 05/31/24 (Emergency Preparedness Plan (EPP), the facility failed to ensure the alternate means of communication addressed in the EPP was available in the facility for use during an emergency. This failure had the potential to affect the 103 current patients receiving care in the facility and could hinder the facility’s ability to communicate in an emergency. Findings include: Review of the facility’s EPP on 09/06/24 at 2:15 PM, with the Facility Administrator (FA) and Manager of Clinical Services (MCS) revealed that the EPP stated: “ ...7. Backup communications systems MAY be required in the event of an emergency based on severity of event, to include, but not limited to: ...b. Analog phone i. Facility will maintain an analog phone onsite for use with facility fax line . . .” In an interview on 09/06/24 at 2:59 PM, the MCS stated there was no analog phone in the facility available for emergency use.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 28154 Based on observation, interview, and facility policy review, the facility failed to ensure hand hygiene was performed during patient treatment. This failure had the potential to create cross contamination infection that could affect any of the 103 patients receiving in-center hemodialysis treatments. Findings include: Review of the facility policy titled “Infection Control for Dialysis Facilities,” reviewed April 2023, showed: “Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. . . . Hand Hygeine [sic] 1. All teammates, Physicians and Non-Physician [Practitioner] (NPP) will perform hand hygiene ...b. prior to gloving and immediately after removal of gloves, ...d. after patient and dialysis delivery system contact, ...f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. . . .” Observation of the treatment area on 09/05/24 at 4:57 PM showed Patient Care Technician (PCT)2 removed his/her gloves and was typing on keyboard at chairside, put gloves on, then removed tubing from a dialysis machine, took the bag of normal saline to the sink, cut it open and drained it in the sink. PCT2 removed his/her gloves, went to the computer at station at station 7, removed gloves, went to station 1 put one glove on touching dialysis machine screen, removed gloves and typed on the computer keyboard; removed gloves, went to the sink, and performed a hand wash. PCT2 then took a handful of gloves out of the box and laid them at chairside at station 1, went to the keyboard, typed then put on gloves at 5:03 PM. Observation of PCT2 removing the patient at station 1 from the dialysis machine found seven additional glove changes without hand hygiene. Observation of the treatment area on 09/06/24 at 12:20 PM showed PCT2 typing on the computer keyboard, put gloves on at 12:22 PM, went to the dialysis machine, lifted face mask up with gloved hands, went to the desk for a medication cup and test strips, back to the machine performed the test, took the strips back to the desk, removed gloves, typing on the keyboard, put gloves on then put the patient’s chair foot rest up and pushed down the back of the chair, then retrieved a thermometer, a set up pack for a central venous catheter (CVC) dialysis connection and set items on the chair side table. PCT2 went to the nurses’ station and performed a hand wash that had a ten second hand scrub, then drew up two syringes of heparin, and went back to the patient’s chairside. From removing the old dressing over the CVC, through the hooking up of the lines and the start of the treatment, PCT2 performed glove changes eight times without performing hand hygiene. During an interview on 09/06/24 at 4:35 PM, PCT2 stated he/she was told about the hand hygiene earlier that day. During an interview on 09/07/24 at 1:50 PM regarding hand hygiene, PCT1 stated “use alcohol based hand gel until dry, and wash hands. Use the alcohol before and after glove removal or touching dirty surfaces; in between patients, as well as during patient care.” Review of PCT2’s education showed the “Annual PCT Clinical Skills Checklist,” first section, “Demonstrates appropriate Hand Hygiene per policy as evidenced by: -Appropriate Handwashing technique per procedure -Appropriate use of alcohol-based hand rubs per procedure” was signed off by a preceptor on 04/07/24.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 28154 Based on medical record review, interview, and review of the facility’s policy, the facility failed to ensure a physician’s order was implemented as prescribed for three of 13 sampled patients (Patients (P) 2, P4, and P9). Failure to follow the physician’s dialysis prescription could negatively impact the effectiveness of the dialysis treatment for all 103 in-center hemodialysis patients receiving treatment at this facility Findings include: 1. Review of five of P2’s hemodialysis treatment records from 08/22/24 to 09/03/24 showed a prescribed blood flow rate (BFR) of 450 milliliters (mL)/minute and on 09/03/24 treatment started at 11:15 AM at a BFR of 450 mL/min then at 1:00 PM was dropped to 400 mL/min where it remained until the 3:00 PM treatment ending. Further review of the 09/03/24 treatment and other nurse documentation did not show a documented reason for the decreased BFR. 2. Review of seven of P4’s hemodialysis treatment records from 08/20/24 to 09/03/24 showed on 08/24/24 a prescribed BFR of 450 mL/min, the treatment started at 11:56 AM at the prescribed rate and at 1:32 PM the BFR was dropped to 400 mL/min where it stayed until the end of the treatment at 2:53 PM. Further review of the 09/03/24 treatment and other nurse documentation did not show a documented reason for the decreased BFR for P4. 3. Review of seven of P9’s hemodialysis treatment records from 08/20/24 to 09/03/24 showed a prescribed BFR of 400 mL/min and on 08/29/24 the treatment started at 11:46 AM at the prescribed rate until 12:31 PM when the BFR was dropped to 350 mL/min where it stayed until 1:08 PM when P9 took a restroom break. Further review of the 08/29/24 treatment and other nurse documentation did not show a documented reason for the decreased BFR for P9. During an interview on 09/07/24 at 4:20 PM, the Facility Administrator stated an expectation that the BFR would be at the prescribed rate or there would be a documented reason and the nurse informed. A review of the facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, showed: “Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge .... 3. Patient identity, prescription and machine settings ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by law .... Intradialytic Data Collection/Assessment ... 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: ... b. At a minimum, obtain and document the following: ... iii. Blood and dialysate flows ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed flood flow rate) the reason will be documented and the licensed nurse informed. . . .””

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 28154 Based on record review, interview, and review of the facility’s policy and procedure, the facility failed to ensure the staff reported and documented information for seven out of 13 sampled patients, (Patient (P) 1, P2, P3, P6, P7, P8, and P9), regarding the occurrence of blood pressure variances during a hemodialysis treatment. The facility failed to follow the policy and procedure for monitoring and reporting hypertensive (high blood pressure) or hypotensive (low blood pressures) during treatment. Failure to report and document these variant episodes had the potential to adversely affect any of the 103 current patients cardiovascular status and health. Findings include: A review of the facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, showed: “Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Policy: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: ...ii Measurement of patient Blood Pressure (BP) 1. Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet) ... Intradialytic Data Collection/Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: . . . b. At a minimum, obtain and document the following: i. Blood Pressure . . . 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notified the physician (or NPP [non-physician practitioner], if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record. Post Treatment Data Collection/Assessment 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body ...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record .... Blood Pressure: Pre-dialysis -Systolic greater than 180 mm/Hg [millimeters of mercury] or less than 90 mm/Hg -Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg Blood Pressure-Intradialytic: -Systolic greater than 180 mm/Hg or less than 90 mm/Hg -Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg Blood Pressure Post Treatment: -If the patient can stand: - - Standing systolic [first number] BP greater than 140 mm/Hg [millimeters of mercury] or less than 90 mm/Hg - - Standing diastolic [second number] BP greater than 90 mm/Hg or less than 50 mm/Hg ... -Sitting BP for patient’s that cannot stand: - - Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg - - Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg ...” 1. Review of seven of P1’s hemodialysis treatment records from 08/19/24 to 09/04/24 showed on 08/26/24 the following blood pressures with the relevant associated note (if any) 12:35 PM 209/97 12:59 PM 204/99 1:28 PM 212/98 “ ...uf [ultrafiltration] goal increased to 3.5L [liters] due to increasing pt [patient] bp [blood pressure]” 1:56 PM 212/98 2:27 PM 204/93 2:52 PM 195/97 3:25 PM 144/108 There was no documentation that the RN was notified regarding the blood pressures. On 08/30/24, P1’s blood pressures showed: 12:54 PM 203/100 1:28 PM 187/137 2:03 PM 184/100 2:27 PM 195/128 2:57 PM 203/99 4:12 PM 213/99 There was no documentation that the RN was notified regarding the blood pressures. On 09/02/24, P1’s blood pressures showed: 12:45 PM 207/99 1:00 PM 212/110 1:58 PM 207/105 2:24 PM 185/102 2:58 PM 184/105 There was no documentation that the RN was notified regarding the blood pressures. 2. Review of five of P2’s hemodialysis treatment records from 08/22/24 to 09/03/24 showed on 08/22/24 the following blood pressures with the relevant associated note (if any) 11:00 AM 188/131 11:34 AM 186/128 12:03 PM 194/135 12:37 PM 201/128 1:03 PM 210/137 1:32 PM 190/126 2:06 PM 190/126 2:33 PM 198/128 3:04 PM 189/122 There was no documentation that the RN was notified regarding the blood pressures. On 08/24/24: 10:46 AM 189/139 11:03 AM 189/138 11:30 AM 180/118 12:01 PM 177/121 12:28 PM 174/115 12:56 PM 180/110 1:33 PM 176/111 2:01 PM 170/104 2:27 PM 167/107 2:52 PM 167/113 There was no documentation that the RN was notified regarding the blood pressures. On 08/27/24: 11:25 AM 153/102 12:25 PM 159/107 12:58 PM 127/12 13:32 PM 174/107 1:56 PM 177/124 There was no documentation that the RN was notified regarding the blood pressures. On 08/31/24: 11:00 AM 184/120 11:35 AM 178/119 11:59 AM 173/114 12:32 PM 182/121 1:24 PM 192/126 There was no documentation that the RN was notified regarding the blood pressures. On 09/03/24: 11:15 AM 209/143 11:55 AM 239/151 12:25 PM 251/161 1:00 PM 229/152 1:30 PM 205/123 2:02 PM 205/126 2:28 PM 207/130 2:51 PM 202/123 “ ...pt c/o [complaining of] cramping; uf turned off rn [registered nurse, and initials] notified” 3:00 PM 199/132 There was no additional documentation that the RN was notified regarding the blood pressures. 3. Review of seven of P3’s hemodialysis treatment records from 08/20/24 to 09/03/24 showed on 08/20/24: 8:30 AM 173/108 9:25 AM 195/82 9:57 AM 185/79 10:20 AM 208/78 10:57 AM 197/76 11:10 AM 193/76 There was no documentation that the RN was notified regarding the blood pressures. On 08/24/24: 8:01 AM 202/78 8:27 AM 198/48 9:23 AM 209/82 9:57 AM 220/81 10:34 AM 236/87 10:56 AM 21/81 11:24 AM 226/83 There was no documentation that the RN was notified regarding the blood pressures. On 08/29/24: 7:36 AM 192/57 8:31 AM 201/79 9:02 AM 207/82 9:29 AM 205/76 10:00 AM 214/79 11:04 AM 217/82 11:17 AM 254/173 There was no documentation that the RN was notified regarding the blood pressures. On 08/31/24: 7:24 AM 201/89 7:56 AM 207/80 8:28 AM 215/87 8:58 AM 212/86 9:28 AM 221/87 9:52 AM 218/84 10:07 AM 216/82 There was no documentation that the RN was notified regarding the blood pressures. On 09/03/24: 8:00 AM 190/77 9:00 AM 188/109 9:27 AM 211/79 9:54 AM 204/81 11:00 AM 211/87 11:14 AM 221/87 There was no documentation that the RN was notified regarding the blood pressures. 4. Review of eight of P6’s hemodialysis treatment records form 08/19/24 to 09/04/24 showed on 08/19/24: 1:29 PM 179/103 1:59 PM 171/106 2:28 PM 188/107 3:11 PM 165/102 3:25 PM 178/104 4:04 PM 176/102 4:33 PM 177/106 There was no documentation that the RN was notified regarding the blood pressures. On 08/21/24: 11:59 AM 196/102 12:24 PM 180/102 12:58 PM 181/108 1:28 PM 188/111 (although it showed as an update at 2:59 PM) 1:56 PM 188/103 2:58 PM 192/114 3:36 PM 167/102 There was no additional documentation that the RN was notified regarding the blood pressures. On 08/23/24: 11:56 AM 185/101 12:26 PM 187/102 12:56 PM 183/102 1:24 PM 181/113 3:02 PM 169/101 3:26 PM 179/105 There was no documentation that the RN was notified regarding the blood pressures. On 08/30/24: 12:53 PM 196/108 “ ...PT [patient] UF goal set for 5.0 KG due to PT being over TW [target weight] by 10.9 KG; RN [initials] aware” 1:28 PM 187/108 2:03 PM 188/106 2:27 PM 179/103 2:56 PM 196/114 3:30 PM 193/107 4:00 PM 187/112 4:30 PM 192/108 4:53 PM 193/111 There was no documentation that the RN was notified regarding the blood pressures. 5. Review of eight of P7’s dialysis treatment records from 08/19/24 to 09/04/24 showed on 08/19/24: 3:01 PM 157/100 3:31 PM 155/127 4:00 PM 155/127 There was no documentation that the RN was notified regarding the blood pressures. On 08/31/24: 1:53 PM 185/108 2:24 PM 180/103 3:00 PM 175/105 4:28 PM 180/103 4:52 PM 202/110 There was no documentation that the RN was notified regarding the blood pressures. 6. Review of eight of P8’s dialysis treatment records from 08/19/24 to 09/04/24 showed on 08/19/24: 8:04 AM 186/102 8:34 AM 186/104 8:55 AM 175/103 9:27 AM 161/100 There was no documentation that the RN was notified regarding the blood pressures. On 08/21/24: 7:34 AM 190/103 8:04 AM 183/122 8:30 AM 184/109 8:54 AM 176/102 9:22 AM 182/101 There was no documentation that the RN was notified regarding the blood pressures. On 08/26/24: 8:07 AM 190/100 8:23 AM 189/112 9:06 AM 197/108 9:22 AM 184/102 10:51 AM 96/70 “uf off hypotension; cn [charge nurse] noted” There was no additional documentation that the RN was notified regarding the blood pressures. On 08/28/24: 8:59 AM 179/101 9:28 AM 162/101 10:02 AM 99/87 “Patient reports cramping; uf off; goal to 2.8 kilos; CN noted” There was no documentation that the RN was notified regarding the blood pressures. On 09/02/24: 7:32 AM 198/102 8:01 AM 189/100 8:27 AM 189/100 10:34 AM 167/102 There was no documentation that the RN was notified regarding the blood pressures. 7. Review of seven of P9’s hemodialysis treatment records from 08/20/24 to 09/03/24 showed on 08/20/24: 12:06 PM 241/157 12:30 PM 183/124 12:44 PM 206/114 1:09 PM 181/115 1:23 PM 172/113 2:07 PM 190/113 2:36 PM 176/110 3:20 PM 136/111 3:42 PM 184/120 There was no documentation that the RN was notified regarding the blood pressures. On 08/22/24: 1:25 PM 160/114 2:30 PM 152/100 2:57 PM 152/100 There was no documentation that the RN was notified regarding the blood pressures. On 08/24/24: 8:54 AM 190/120 9:25 AM 167/117 9:58 AM 143/104 10:58 AM 175/113 There was no documentation that the RN was notified regarding the blood pressures. On 08/27/24: 11:36 AM 167/105 11:59 AM 171/110 12:30 PM 169/107 1:00 PM 132/114 1:30 PM 168/114 2:26 PM 166/109 2:55 PM 156/101 3:26 PM 140/100 There was no documentation that the RN was notified regarding the blood pressures. On 09/03/24: 2:27 PM 176/104 2:56 PM 185/108 3:00 PM 169/106 “Treatment paused; patient using restroom” 3:09 PM 169/103 “Treatment resumed; patient states no complaints” 3:29 PM 155/129 3:56 PM 169/108 4:46 PM 184/118 There was no documentation that the RN was notified regarding the blood pressures. During an interview on 09/07/24 at 1:50 PM, Patient Care Technician (PCT) 1 stated the nurse should be notified of low or high blood pressures. “During the treatment notify the nurse for systolic blood pressures over 180 and under 100, diastolic above 100 and below 80, blood pressures were to be monitored every 30 minutes, but if low or high blood pressures the nurse may have us do it every 15 minutes.” During an interview on 09/07/24 at 4:20 PM, the Facility Administrator stated that blood pressures would be monitored, nurses notified, nurses assess and document.”

“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: 28154 Based on record review, interview, and policy review, the facility failed to ensure patients were monitored per policy and/or the charge nurse and/or physician were notified regarding not achieving a post hemodialysis treatment (the mechanical removal of toxins when kidneys fail) treatment weight within one kilogram (kg) for six of 13 patients (Patient (P) 2, P4, P5, P6, P8 and P9) reviewed. This failure had the potential to affect the efficacy and safety of treatment for any of the 103 patients receiving hemodialysis treatment in the facility. Findings include: A review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, indicated, “Policy: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. . . . Intradialytic Data Collection/Assessment ...2. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: Vital signs and treatment monitoring ... iii. Non-nocturnal treatments are completed at least every thirty (30) minutes. Post Treatment Data Collection/Assessment 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP [non-physician practitioner] as applicable) is necessary prior to discharge of the patient from the facility. Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body ...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record .... Fluid Status: ... Post-treatment: -If patient is above or below 1 kg [kilogram] from the target weight.” 1. Review of five of P2’s hemodialysis treatment records from 08/22/24 to 09/03/24 showed on 08/22/24 a prescribed target dry (post-treatment) weight of 55.0 kg and an actual dry weight achieved of 61.7 kg; on 08/24/24 a target weight of 55.0 kg and an actual dry weight of 58.3kg; on 08/27/24 target weight of 55.0 kg with an actual post weight of 60.1 kg; on 08/31/24 target weight of 55.0 kg with an actual post weight of 64.1; on 09/03/23 target weight of 55.0 kg with an actual post weight of 63.9 kg with no documentation found regarding the nurse or physician being notified of the post weight being over one kg above prescription. 2. Review of seven of P4’s hemodialysis treatment records from 08/20/24 to 09/03/24 showed on 08/20/24 a prescribed target dry weight of 61.0 kg and a post treatment weight of 62.2 kg; on 08/24/24 a target dry weight on 61.0 kg and a post weight of 62.6 kg; on 08/27/24 a target dry weight of 61.0 kg and a post treatment weight of 62.4 kg; on 08/31/24 a target dry weight of 61.0 kg and a post treatment weight of 63.1 kg; and on 09/03/24 a target dry weight of 61.0 kg with a post treatment weight of 63.5 kg with no documentation found regarding the nurse or physician being notified of the post weight being over one kg above prescription. Review of P4’s 08/27/24 hemodialysis treatment record showed a monitoring time of 11:16 AM with the next time at 12:01 PM; and then at 1:32 PM with the next time at 2:20 PM. 3. Review of five of P5’s hemodialysis treatment records from 08/20/24 to 09/03/24 showed on 08/20/24 a prescribed target dry weight of 40 kg and a post treatment weight of 46.9 kg; on 08/22/24 a target dry weight of 40 kg and a post treatment weight of 47.6 kg; on 08/29/24 a target dry weight of 40 kg and a post treatment weight of 46.2 kg; on 08/31/24 a target dry weight of 40 kg and a post treatment weight of 45.9 kg; and on 09/03/24 a target dry weight of 40 kg with a post treatment weight of 44.9 kg with no documentation found regarding the nurse or physician being notified of the post weight being over one kg above prescription. Review of P5’s 08/20/24 hemodialysis treatment record showed monitoring at 2:45 PM and the next entry was at 3:24 PM. 4. Review of eight of P6’s hemodialysis treatment records from 08/19/24 to 09/04/24 showed on 08/19/24 a prescribed target dry weight of 70 kg with a post treatment weight of 76.5 kg; on 08/21/24 a target dry weight of 70 kg with a post treatment weight of 73.9 kg; on 08/23/24 a target dry weight of 70 kg with a post treatment weight of 75.2 kg; on 08/26/24 a target dry weight of 70 kg with a post treatment weight of 75.8 kg; on 08/28/24 a target dry weight of 70 kg with a post treatment weight of 74.5 kg; on 08/30/24 a target dry weight of 70 kg with a post treatment weight of 76.2 kg; on 09/02/24 a target dry weight of 70 kg with a post treatment weight of 75.8 kg; and on 09/04/24 a target dry weight of 70 kg with a post treatment weight of 76.7 kg with no documentation found regarding the nurse or physician being notified of the post weight being over one kg above prescription. 5. Review of eight of P8’s hemodialysis treatment records from 08/19/24 to 09/04/24 showed on 08/19/24 a prescribed target dry weight of 77 kg with a post treatment weight of 78.4 kg; on 08/23/24 a target dry weight of 77 kg with a post treatment weight of 78.7 kg; on 08/26/24 a target dry weight of 77 kg with a post treatment weight of 78.8 kg; on 08/28/24 a target dry weight of 77 kg with a post treatment weight of 78.5 kg; and on 09/02/24 a target dry weight of 77 kg with a post treatment weight of 79.1 kg with no documentation found regarding the nurse or physician being notified of the post weight being over one kg above prescription. 6. Review of seven of P9’s hemodialysis treatment records from 08/20/24 to 09/03/24 showed on 08/20/24 a prescribed target dry weight of 60 kg with a post treatment weight of 63.3 kg; on 08/22/24 a target dry weight of 60 kg with a post treatment weight of 62.9 kg; on 08/24/24 a target dry weight of 60 kg with a post treatment weight of 61.5 kg; and on 09/03/24 a target dry weight of 60 kg with a post treatment weight of 62.5 kg with no documentation found regarding the nurse or physician being notified of the post weight being over one kg above prescription. During an interview on 09/07/24 at 1:50 PM, Patient Care Technician (PCT) 1 stated patients were to be monitored during treatment every 30 minutes - “but if low or high blood pressures the nurse may have us do it every 15 minutes.” During an interview on 09/07/24 at 4:20 PM, the Facility Administrator verified that there was no documentation regarding whether the nurse or physician was notified of these seven patients’ dry weights being over 1 kilogram. The Facility Administrator stated that the expectation was if the post weight was outside the one kilogram that there would be documentation.”