032522 Parker Dialysis Center (Fmc)

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 22198 Based on observations, interviews, and policy and manufacturer’s instructions for use (IFU) review, the facility failed to meet the Condition for Coverage (Cfc) for V400 Physical Environment when it: 1. failed to maintain a clean and safe environment, and 2. failed to follow manufacturer’s instructions for use of Tuberculin Purified Protein for tuberculosis screening. This systemic failure prevented the facility to maintain a functional safe environment for the patients and staff at this facility. Findings include: 1. The facility failed to maintain a safe, functional, and comfortable treatment environment for its patients and staff when: 1. standing water was observed in the water room, and 2. rust was identified on the water room equipment stands, the back flow preventor, the metal door frames and door jam, 3. gouges were observed in the dry wall on the treatment room floor behind the dialysis stations, 4. the dialysis floor was discolored, had cracks, and was buckling up, 5. the two sinks were discolored, and 6. the temporary scale did not fit properly in the space designated for the patient scale making it a trip hazard. Cross Reference: V401. 2. The facility failed to follow the manufacturer’s recommendations for two of two items (one vial of Tuberculin Purified Protein multi-dose. Cross Reference:V403.”

“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: 22198 Based on observations, interviews, and policy review, the facility failed to ensure staff performed hand hygiene between glove changes; used the appropriate hand covering while working on a dialysis machine, and changed gloves between tasks to ensure hands were properly disinfected between patient care; completed Arteriovenous Fistula cannulation in a manner to prevent cross-contamination when staff cleaned the arterial site, palpated the area, and then completed needle insertion without cleaning the area again. This has the potential to affect all 44 patients receiving dialysis treatment in this facility. Findings include: 1. During an observation of Central Venous Catheter (CVC) care on 09/03/24 at 10:05 AM, after cleaning the CVC site and allowing the cleanser to dry, Patient Care Technician (PCT) 8 removed his/her gloves and donned a new pair of gloves without performing hand hygiene. After applying the dressing over the CVC site, PCT8 failed to remove his/her gloves and perform hand hygiene before starting the initiation of dialysis. During an interview on 09/03/24 at 10:56 AM PCT8 confirmed that he/she did miss opportunities for hand hygiene and glove changes during the CVC care and dialysis initiation. 2. During an observation on 09/03/24 at 11:09 AM Registered Nurse (RN) 6 was observed at Station 4 reaching under her protective gown using the gown as a barrier between RN6’s right hand and the dialysis machine that was in use to silence the alarms. During an interview of 09/03/24 at 11:10 AM when RN6 returned to the nursing station was asked if lifting the protective gown and using the gown and not gloves was an acceptable practice in the dialysis unit, RN6 replied “yes” the practice is allowed on the dialysis floor, stating “I did not touch the machine with my bare hands.” Review of the facility’s policy titled, “Hand Hygiene,” dated 11/06/23, revealed, “The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. Hand Hygiene is done ... When ...Immediately after removing gloves ... After contact with inanimate objects ... After contact with other objects within the patient station or treatment area.” 3. During an observation on 09/02/24 at 9:57 AM, PCT11 was performing dialysis initiation for Patient 6. After cleaning the arterial needle insertion site with a skin cleanser, PCT11 palpated the arterial site and inserted the arterial needle. PCT11 did not reclean the insertion site after palpating the site. During an interview on 09/02/24 at 10:00 AM, PCT 11 confirmed he/she should have recleaned the insertion site after palpating it. During an interview on 09/03/24 at 8:30 AM, the Area Team Lead (ATL) 9 confirmed after reviewing the policy, staff should not palpate the insertion site without recleaning. Review of the facility’s policy titled, “Access Assessment and Cannulation,” dated 05/06/24, revealed, “. . . Perform skin antisepsis on one site at a time, allow to dry and them [sic] cannulate. Do not touch cannulation sites after skin disinfection. Note: This method minimizes the risk of contaminating the second site while cannulating the first site . . .””

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 22198 Based on observations, interviews, and policy review, the facility failed to ensure the dialysis stations were cleaned per policy and ensure that oxygen (O2) concentrators stored in the dialysis stations were cleaned as a part of the dialysis station to ensure a sanitary environment. This has the potential to negatively affect all 44 in center patients receiving dialysis at this facility. Findings include: 1. During an observation on 09/02/24 at 9:35 AM, Patient Care Technician (PCT) 11 was cleaning dialysis Station 7 and missed cleaning the O2 concentrator stored in the dialysis station, failed to empty and clean the prime waste bucket, the exterior the dialysis machine side, and the red biohazardous sharps container attached to the side of the dialysis machine. During an interview on 09/02/24 at 9:40 AM, PCT11 confirmed he/she had finished cleaning the dialysis station but forgot to empty and clean the prime waste bucket, or the exterior the dialysis machine side and the red biohazardous sharps container attached to the side of the dialysis machine. PCT11 confirmed that the O2 concentrators were stored in the dialysis station because the facility did not have a lot of space but was not aware it needed to be cleaned as a part of the dialysis station whether it was used or not. 2. During an observation on 09/02/24 at 10:01 AM at Station 5, the oxygen tubing was disconnected from the O2 concentrator. However, PCT10 failed to clean the O2 concentrator while the cleaning of the dialysis station after the patient left. During an interview on 09/02/24 at 10:53 AM, PCT10 stated he/she was not aware that the O2 concentrator stored in the dialysis station should be cleaned as a part of the dialysis station whether it is used or not. During an interview on 09/02/24 at 3:00 PM, Area Team Lead (ATL) 9 stated that the O2 concentrators previously were stored in another area and was not aware that they were now being kept in the dialysis stations. Review of the facility’s policy titled, “Cleaning and Disinfecting the Dialysis Station,” dated 09/05/23, revealed, “Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment, patient training, and/or patient clinic visits.””

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 22198 Based on observations, interviews, and review of the Quality Assessment Performance Improvement (QAPI) meeting minutes, the facility failed to maintain and fix physical environment concerns identified and brought forward in two of two dialysis area (water room and the dialysis treatment floor) by the Biomedical Technician (BMT) II as far back as 2020. The failure to maintain and fix the physical environment places 44 incenter dialysis patients and all staff at risk for equipment failure, potentially hazardous environment, and safety issues. Findings include: During an observation of the Water Treatment Room on 09/02/24 at 9:20 AM, revealed standing water was observed along the wall and door threshold entering the dialysis water room from the dialysis treatment floor. There was standing water under the wooden pallets in the middle of the dialysis water room floor as well as under the pallets and next to the water testing area. The cement floor in the dialysis water room was pitted and areas were discolored, and the paint on the floor was also peeling. During an interview on 09/02/24 at 9:20 AM Registered Nurse (RN) 6 confirmed there was standing water in the dialysis water room and stated he/she was uncertain what caused the standing water along the door threshold or under the wooden pallets with dialysis storage. During an observation of the Water Treatment Room on 09/02/24 at 9:25 AM, standing water was observed along the wall and door threshold entering from the dialysis treatment floor. Standing water was observe under the wooden pallets with dialysis storage and next to the water testing area. During an interview on 09/02/24 at 9:25 AM Patient Care Technician (PCT) 10 confirmed there was standing water in the Water Treatment Room and stated he/she was uncertain what caused the standing water along the door threshold but thought the water on the floor by the wooden pallets filled with dialysis storage might be from the dialysis testing station overflow. During an observation in the Water Treatment Room on 09/03/24 at 4:06 PM with BioMedical Technician (BMT)II-7 and BMT I-3 there was more water standing on the Water Treatment Room floor between the carbon filter tanks, the brine tank and the door that lead to the dialysis treatment floor. During an interview on 09/03/24 at 4:06 PM, BMT II-7 stated that they (BMT I and BMT II) had removed as much of the standing water in the Water Treatment Room floor as, but the floor was not pitched correctly and not conducive for draining water and overflow water to drain properly. BMT II stated that a work order, dated 2020, was submitted to have the floor redone to improve the drainage, but it was too costly, so the request was denied. During further observations in the Water Treatment Room on 09/03/24 at 4:06 PM, the back flow preventer was rusted and the stands that keep water room equipment off the floor were rusted, and the door jamb and threshold were also rusted. During an interview on 09/03/24 at 4:06 PM when asked about the water along the wall leading and the door jamb and threshold that were rusted, BMT II-7 stated he/she was not sure where the water along the wall was coming from; stating it was potentially from leakage from a dialysis station wall box on the other side of the wall, but would not be able to say for sure until the wall was opened up. During continued interview on 09/03/24 at 4:06 PM, BMT II-7 and BMT I-3 confirmed that there were physical environment concerns related to the dialysis floor as follows: a. The drywall in the corner near the door dialysis Station 6 and the water room door was discolored, blistering, and bowing. b. The dialysis room floor had multiple tiles that were cracked and buckling. c. The sinks had calcification, and cabinets were discolored and in need of being replaced. d. The current patient scale (identified as a temporary scale) did not fit into the space assigned to the former scale and was a trip hazard. On 09/02/24 at 2:40 PM Patient (P) 2 was observed tripping, without falling or injury, while getting on the scale. e. There were gouges out of the dry wall behind the dialysis stations. Review of the monthly QAPI meeting minutes from the last 12 months (June 2023 through June 2024), revealed, there were 58 pages of Physical Environment concerns during the lookback period. Under the section titled “Physical Environment,” there were repeated issues brought from forward from 2020 to present as follows: “The DO [Director of Operation] and Area team lead [ATL] identified the following during visit in December: The DO and ATL identified that the outside wall panels were deteriorating, and some were caving in and missing baseboards. The CRIT construction manager was aware of this, and task was scheduled for completion in December. ... The walls in the water room that needs patching and painting, concrete floor deteriorating, rusting on base of drench shower and some baseboards. Waiting on contracting company for bid. [Name] will follow up. ... 01/21/20, the ATL, FA and ATOM [Area Technician Operation Manager] did a follow up walkthrough of the backroom to complete assessment of the area and plan on how to proceed with repairs. The plan includes wall patching and painting, fix deteriorating floor concrete, convert back storage room to biohazard room (will need door, light, and exhaust). The construction vendor was in the unit and ATOM is working with this vendor for painting, concrete floor ... 01/30/2020 Follow up with ATOM, FA, ATL during QAI [QAPI]. Rust in water room around doors and metal lift where water heater sits. [Name] to correct 01/30/20. Replace sinks in breakroom and treatment floor. Per [name] sinks available. Will check with contractor to get them replaced. Broken floor tiles. Baseboards in treatment floor need repaired. Contracting company was notified. [Name] will follow up. 02/21/20 Follow up with ATOM, FA, ATL during QAI The walls in the water room that needs patching and painting, concrete floor deteriorating, rusting on base of drench shower and some baseboards. Waiting on contracting company for bid. [Name] to follow up. ... There were entries dated from 06/28/21 to 07/24/24 as follows: “Floor scale is not measuring accurately for heavier patients and wheelchairs. Waiting on contact from vendor on possible replacement.” During an interview and review of the QAPI meeting minutes for “Physical Environment” on 09/03/24 at 4:06 PM with BMT II-7 and BMT I-3 indicated that the issues identified during this survey, had been identified in the 2020 audit after the 2019 storm repairs. BMT II-7 stated, the company sent in an auditor to conduct an audit on the facility after the roof was replaced after the storm in 2019 blew the roof off the dialysis facility displacing all their patients. BMT II-7 stated the company auditor identified the same things discussed above, however, there was discussion of getting a new building, so these concerns were not fixed. BMT II-7 stated that the exception was the patient scale that was order but being built and it was not certain the timeframe it would be completed. BMT II-7 confirmed it remained a trip hazard. During an interview on 09/04/24 at 12:00 PM BMT II-7 stated that a company came in on 12/01/21 and provided a report. Review of the report, dated 12/27/21, revealed ,”The clinic flooded in November 2021 due to a leak in the domestic copper pipe to the hot water heater. ln addition, the brine salt tank was overfilled three times about two and half months ago. In the past year, the safety shower in the Water Room had accidentally flooded the Water Room and Treatment Room. Treatment Room/ Water Room Door Area - Treatment Room Side Water damage was observed. West wall 2 1/2 ft [foot] in length and 2 ft tall North edge 1/2 ft in the length and 2 ft tall Paint on the wall bubbling on drywall. No mold was observed. No musty odors were detected. Water Room Water damage was observed around lower door frames. Small areas, a few inches in height, at the bottom of the frames No mold was observed. No musty odor was detected. Mold Spore Sampling The levels of mold surface samples collected do not indicate an unacceptable level mold growth activity at the time of the assessment. Air Sampling Air samples were collected and submitted to [Name of Laboratory], for laboratory analysis to determine concentrations of airborne mold spores. Samples were collected using a Zefon Bio-Pump or E-Lite pump using Air-O-Cell sampling cassettes with 15 liters per minute of airflow and a 10-minute sample duration. The air samples collected in the Treatment Room and the Water Room do not contain elevated levels of airborne mold at the time of sampling. The Water Room mold type distribution ratio indicated filtered outside air and did not indicate active mold activity within the room. The results from those rooms are within the normal range and do not pose a health concern. The air sample results confirm that the low levels of surface mold are not creating a health concern.” During an interview after reviewing the above report on 09/04/24 at 12:00 PM, BMT II-7 stated that an evaluation for spores, fungus, and mold was completed once, but there had not been another evaluation or inspection. BMT II-7 confirmed that the bubbling walls and standing water were not fixed and continue to be a problem.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 22198 Based on observations, interviews, and manufacturer’s instructions for use (IFU), the facility failed to follow the manufacturer’s recommendations for one vial of Tuberculin Purified Protein (skin test for exposure to TB) multi-dose vial. This failure to follow the manufacturers IFU puts all 44 incenter dialysis patients at risk for receiving unstable medical products. Findings include: On 09/02/24 at 12:10 PM an open vial of “Tuberculin Purified Protein Derivative” was observed in the medication refrigerator. The vial was not labeled with the date it was opened. During an interview on 09/02/24 at 12:10 PM Registered Nurse (RN) 6 confirmed that the Tuberculin Purified Protein had been opened and not dated but should have been labeled with the date opened. Review of the insert Manufacture’s IFU for “TUBERSOL Tuberculin Purified Protein Derivative” not dated revealed, “A vial of TUBERSOL which has been entered and in use for 30 days should be discarded.””

“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: 22198 Based on observation, interview, record review, and review of the facility’s policies, the facility failed to ensure that: 1. blood pressure (BP) concerns were managed per policy for two of five patients (Patient (P) 2 and P3) and 2. patient post dialysis treatment assessments were complete and accurate for two of five patients (P2 and P3) medical records were reviewed. This had the potential to affect all 44 in center dialysis patients. Findings include: 1. a. Review P2’s dialysis treatment sheets titled, “Treatment Sheet For Facility: BMA PARKER - JV,” and dated 08/21/24, revealed the following: 8:51 AM - At the start of P2’s treatment, P2’s BP was 159/104. 104 was above the predetermined high parameters (100) for diastolic blood pressure in the facility’s policy. There was no documentation Registered Nurse (RN) was notified. 9:05 AM - BP was 163/109. 9:24 AM - BP was 165/111. 9:41 AM - BP was 170/111. 10:01 AM - BP was 172/114. There was no documentation to show the RN was notified of the blood pressure readings that exceeded the facility’s paraments. 10:21 AM - It was recorded P2 was given Clonidine 0.1 milligrams (mg) related to high blood pressure readings. “Not relieved” was recorded under the response for the medication. There was no documentation to show the RN followed the facility’s policy to notify the physician or physician extender. 10:23 AM - BP was 174/116. 10:42 AM - BP was 189/128. This was above the predetermined high parameters for systolic/diastolic BPs (180/100) in the facility’s policy. There was no documentation that the RN was notified. 10:56 AM - It was recorded P2 was given Clonidine 0.1 milligrams (mg) related to high blood pressure readings. “Not relieved” was recorded under the response for the medication. There was no documentation to show the RN followed the facility’s policy to notify the physician or physician extender. 11:01 AM - BP was189/120. 11:26 AM - BP was189/118. The RN documented chair side but failed to address or document an assessment or intervention related to the elevated BPs. 11:40 AM - BP was 182/119. 12:03 PM - BP was 179/125. 12:16 PM - BP was 176/112. Review of P2’s the post treatment “Nursing Evaluation,” dated 08/21/24 at 1:09 PM revealed, “RN Evaluation - No unusual findings noted patient completed lx without complications, vss [vital signs stable], blood returned without event, denies complaints.” During an interview on 09/03/24 at 3:30 PM Area Team Lead (ATL) 9 confirmed that for P2 the RN did not follow the facility’s policy for assessing, addressing, and documenting hypertension. b. Review of P3’s dialysis treatment sheets titled “Treatment Sheet For Facility: BMA PARKER - JV,” dated 08/23/24 revealed the following: 7:21 AM - BP was 187/94, there was no documentation that the RN was notified. 7:46 AM - BP was 196/64, there was no documentation the RN was notified. There was no documentation that the RN was notified of the blood pressure readings that exceeded the parameters in the facility’s policy. Review of P3’s dialysis treatment sheets titled “Treatment Sheet For Facility: BMA PARKER - JV,” dated 08/26/24 revealed the following: 7:21 AM - BP was 170/71. There was no other BP reading documented until 8:24 AM, one hour and three minutes later. This was not within the 30 minute time frame required per policy. 10:23 AM - BP was 181/61. There was no documentation the RN was notified. Review of P3’s dialysis treatment sheets titled “Treatment Sheet For Facility: BMA PARKER - JV,” dated 09/02/24 revealed the following: 7:29 AM - BP was 203/84. 8:03 AM - BP was 187/83. 10:09 AM - BP was 189/68. There were no documentation to show any nursing assessments were completed to determine any necessary interventions for the elevated BPs on 09/02/24. During an interview on 09/04/24 at 10:45 PM, ATL9 confirmed that for P3, the RN did not follow the facility’s policy for assessing, addressing, and documenting hypertension. Review of the facility’s policy titled, “Hypertension,” dated 09/07/21 revealed, “. . . Staff will recognize, report, and immediately address systolic blood pressures greater than 180 mm/Hg and/or diastolic blood pressures greater than 100 mm/Hg. Notify the nurse in charge if a patient has a systolic blood pressure greater than 180 mm/Hg and/or diastolic blood pressure greater than 100 mm/Hg. The RN will assess the patient and determine if further nursing interventions are needed. If hypertension is related to hypervolemia, decrease EDW [estimated dry weight]: Follow Fluid Management algorithm or notify physician for possible estimated dry weight adjustment outside of algorithm parameters. If hypertension is not related to hypervolemia, notify the physician for additional orders/interventions. Document on patient’s treatment record . . .” 2. a. During an observation on 09/02/24 at 10:40 AM, P2 was observed vomiting at the start of the dialysis treatment. P2 continued to be nauseated and vomited throughout the dialysis treatment from 10:56 AM until 2:26 PM. During an interview on 09/02/24 at 10:50 AM, RN6 confirmed P2 came in and was habitually nauseated and vomiting throughout the entire treatment. RN6 revealed this had been going on for over two weeks. When asked about antiemetic (anti-nausea) medication for P2, RN6 stated he/she “would just throw it up.” Review of P2’s dialysis treatment flow sheet titled, “Treatment Sheet For Facility: BMA PARKER - JV,” dated 09/02/24, revealed P2’s treatment started at 10:56 AM and ended 2:26 PM. The pre-treatment “Nursing Evaluation” pre-treatment was incomplete. There was no documentation of P2’snausea or vomiting observed during this treatment. No antiemetic medication was offered during this treatment. The post treatment “Nursing Evaluation,” dated 09/02/24 at 4:46 PM, two hours after the treatment ended, recorded, “General Assessment-Gastrointestinal Associated Symptoms “Nausea, Vomiting;” however, in P2’s “Nursing Note,” it was recorded, “Pt [patient] completed tx [treatment] without complications . . .” Review of the facility’s “Standing Orders,” dated November 2023, and under the “Nausea/Vomiting” section of the standing orders, revealed, “Prochlorperazine (Compazine, an antiemetic) 5 mg PO [oral] q [every] 4 hrs [hours] . . .” During an interview, review of the observation, and record review of P2 on 09/02/24 at 10:30 AM, ATL9 stated that P2’s nausea and vomiting has been going on for a while but was uncertain of the time frame, as the medical records did not identify when the problem started. ATL9 confirmed that the nursing pre-assessment was missing for P2, and that the post-assessment and nursing note contained conflicting information and did not describe an accurate picture of P2’s nausea and vomiting throughout the treatment. ATL9 was asked why P2 did not receive antiemetics during this treatment. ATL9 stated P2 was nauseated and vomiting and probably would have thrown up the medication. ATL9 confirmed that the doctor could have been called for IV (intravenous) or sublingual antiemetic medication. b. Review of P3’s post treatment “Nursing Evaluations,” dated 08/23/24 and 08/26/24, revealed no nursing evaluation. The only documentation was identified as a nursing note. During an observation on 09/02/24 at 10:09 AM, the machines at Station [number] were alarming during P3’s treatment, indicating an elevated BP reading. The BP reading on the screen was 189/68. Patient Care Technician (PCT) 10 lowered P3’s legs. PCT10 did not approach the RN on duty to notify RN6 of the elevated BP or the intervention. At 10:25 AM, P3 complained of cramping. At 10:31 AM, P3 became rigid, and his/her arms were firmly contracted to his/her chest. PCT11 approached P3 and held his/her arms to prevent disconnection of blood lines and/or needles. PCT 10 and RN6 then came to the chair side and completed a sternal rub when P3 did not respond to verbal stimuli. When P3 was arousable, a blood sugar check was completed, and the results were 116. Review of P3’s dialysis treatment flow sheet titled, “Treatment Sheet For Facility: BMA PARKER - JV,” dated 09/02/24, revealed P3’s treatment started at 7:29 AM with an elevated BP of 203/84. At 10:09 AM - PCT 10 documented, “RN notified. Put pt’s feet down due to elevated BP.” It was recorded that the treatment was ended at 10:30 AM. At 10:34 AM, PCT10 documented, “Treatment Discontinued Without Problem; Additional saline given to patient due to delay in response.” At 10:40 AM, PCT10 documented, “Denies Complaints; Pt states had some cramping but relieved After additional saline was given.” At 2:58 PM (four hours and 28 minutes after the treatment ended), the RN documented, “. . . @ [at] approx. [approximately] 10:26 PCT reported to this RN that pt was not responding to [him/her], pt was lethargic and slow to respond, vs wnl [within normal limits], BS [blood sugar] 116, pt given addition fluids, awake and responsive at this time. Pt declined EMS [Emergency Medical Services]. MD notified . . .” At 2:59 PM (four hours and 29 minutes after the treatment ended), the RN documented, “. . . No Unusual findings noted. Patient completed tx without complications, vss [vital signs stable], blood returned without event, denies complaints . . .” Review of the medication given during this treatment under the header “Medication” revealed P3 had not been offered or given Clonidine during this treatment. There was no documentation to show the PCT adjusted the dialysis machine temperature. A review of the facility’s “Standing Orders,” dated November 2023, revealed, “If the BP is consistently > [greater than] 180 systolic or > 120 diastolic for 30 minutes, change the Machine Temperature setting to 37* [degrees] C [Celsius]. If the BP remains consistently >180 systolic or > 120 diastolic for 30 minutes after changing the machine temperature, give Clonidine 0.1mg [milligram] po. May repeat q 30 minutes x 2. If BP remains >180 systolic or >120 diastolic after 3 doses given, call MD/Physician extender . . .” During an interview, review of the observation on 09/02/24, and record review for P3 on 09/04/24 at 10:45 AM, ATL9 confirmed that P3 was not offered or given clonidine for the elevated BP per the standing order. ATL9 confirmed that PCT10’s reporting of P3’s hypertensive symptoms were not accurately documented as PCT10 documented the RN was notified at 10:09 AM and the RN6 documented notification at 10:26 AM, and the observation on 09/02/24 was that the RN was notified at 10:31 AM (based on the dialysis machine clock) when P3 became rigid and unresponsive. ATL confirmed that the “RN Evaluation” for the treatment of 09/02/24 at 2:59 PM indicated “No Unusual findings noted. Patient completed tx without complications” did not accurately describe P3’s conduction intra and post dialysis. ATL9 stated the expectation of the facility is that staff accurately document their findings. ATL9 confirmed that the RN failed to document the complete “Nursing Evaluation” for 08/23/24 and 08/26/24 and that did not follow facility protocol. Review of the facility’s policy titled, “Arizona State Specific - Patient Assessment Pre and Post HD [hemodialysis] Treatment,” dated 11/20/08 revealed, “Components of the Pre-Treatment RN Assessment . . . The patient is assessed pre dialysis in order to ensure that the patient is stable to undergo the dialysis treatment and to ensure a safe and appropriate dialysis. The RN will perform an assessment which includes review and evaluation of the data collection done by the PCT if applicable, prior to initiation of treatment. During the assessment, the nurse systematically collects, verifies, analyzes, and communicates data about a patient . . . Components of Post Treatment RN Assessment . . . The patient is assessed after a dialysis treatment to determine the patient’s response to the delivered hemodialysis prescription. All predialysis [sic], intradialysis [sic], and post dialysis assessment data should be compared and interpreted. The post treatment assessment may include but is not limited to . . . Patient report of well-being or complaint, continued presence, or absence of pretreatment [sic] complaints or symptoms, resolution of intradialytic complaints or symptoms.””

“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: 22198 Based on interview, record review, and review of facility policy, the facility failed to ensure the prescribed dialysis flow rate (DFR) was correctly entered for one of five dialysis patients (Patient (P) 1) and that staff identified the incorrect flow rate during safety checks. This had the potential to negatively affect all 44 dialysis patients. Findings include: Review of P1’s most current dialysis order, dated 08/09/24, revealed the Blood Flow Rate (BFR) was 600 with the DFR on Autoflow1.5 (900). During an observation on 09/02/24 from 10:10 AM until 12:44 PM, during P1’s entire treatment, the DFR was set at 400. During an interview on 09/03/24 at 3:30 PM, Area Team Lead (ATL) 9 confirmed that the DFR was ordered at an Autoflow rate of 1.5 of the 600 BFR, which would be 900. ATL stated that the dialysis machines will not allow the DFR to be run above 800, so the maximum P1 could have been run at was BFR 600/DFR 800. ATL confirmed that during the 30-minute safety checks between 10:10 AM and 12:44 PM, staff did not identify that P1’s prescription was entered incorrectly. Review of the facility’s policy titled, “Patient Assessment and Monitoring,” dated 05/01/23, revealed, “. . . Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations . . .” The safety check section titled, “Machine Parameters and Extracorporeal Circuit” recorded, “. . . Check dialysate flow rate setting is correct, and the prescribed flow is being delivered . . .””