Community Dialysis Center

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 51593 Based on interview and record review, the facility failed to ensure staff followed policy and procedures for one of three sampled patients (Patient 1), when Dialysis Technician (DT - a healthcare worker who operates the machines that filter waste and fluid from the blood for patients with kidney failure) 1 and Registered Nurse (RN) 3 did not verify Patient 1’s heparin (medication that stops your blood from clotting) order prior to administration and Patient 1 did not receive medication according to physician orders. This failure resulted in Patient 1 receiving heparin 5000 units instead of the ordered heparin 500 units and had the potential to result in Patient 1 experiencing severe, uncontrolled bleeding that could have led to hospitalization or death. Findings: During a review of Patient 1’s “Outpatient Hemodialysis Treatment Summary”, dated 12/5/25, the “Outpatient Hemodialysis Treatment Summary” indicated, “Hemodialysis (a medical treatment that acts as an artificial kidney [organ that filters waste and extra fluid from the blood], filtering waste products and extra fluid from the blood when the kidneys aren’t working well) outpatient (a patient who receives medical treatment without being admitted to a hospital) ... Frequency: Monday, Wednesday, Friday ... Visit Diagnoses: Primary: end stage renal disease (ESRD - the final, permanent stage of kidney failure where the kidneys can no longer function enough to be kept alive, requiring either hemodialysis or a kidney transplant to survive) on dialysis ...” During a review of Patient 1’s “Therapy Plan Information”, dated 12/30/25, the “Therapy Plan Information” indicated, “Plan Order Summary: All Current Orders: heparin ... 500 Units in total volume 0.5 mL (milliliters - unit of measurement) syringe ... 500 Units, hemodialysis port (an access point created in a patient’s body to allow large amounts of blood to be safely removed) injection, ONCE ...” During an interview on 12/19/25 at 9:27 a.m. with the Assistant Nurse Manager (ANM), the ANM stated Dialysis Technician (DT) 1 was working with Patient 1 on 12/5/25. The ANM stated that the label on Patient 1’s heparin syringe (a tool with a tube, plunger, and needle used to push liquids in our pull them out of the body) indicated heparin 500 unit bolus (a single, large dose of medication or fluid given over a short period of time to quickly raise its concentration in the body) was to be administered to Patient 1 at the start of his hemodialysis treatment. The ANM stated DT 1 prepared heparin 5000 units in the syringe and did not follow or verify the physician order for heparin 500 units prior to administering to Patient 1. The ANM stated DT 1 administered heparin 5000 units to Patient 1. During a concurrent interview and record review on 12/19/25 at 9:48 a.m. with Registered Nurse (RN) 1, Patient 1’s “Progress Note”, dated 12/5/25, was reviewed. The progress note indicated, “[DT 1] ... accidentally gave patient heparin 5000 units bolus instead of ordered dose 500 units ... Electronically signed by [RN 2] at 12/5/25 ...” RN 1 stated the physician order was for heparin 500 units, not heparin 5000 units. RN 1 stated DT 1 should have verified Patient 1’s heparin dosage with his medication administration record (MAR), and the physician order prior to administration. RN 1 stated there was a risk for Patient 1 to experience excessive bleeding, leading to hospitalization. During an interview on 12/19/25 at 9:53 a.m. with the ANM, the ANM stated DT 1 verified Patient 1’s heparin dosage with RN 3 prior to administration. The ANM stated RN 3 placed his initials on the label of Patient 1’s heparin syringe indicating that the dosage was correct. The ANM stated RN 3 told DT 1 that “the medication was good to give”. The ANM stated DT 1 then administered heparin 5000 units to Patient 1. The ANM stated Patient 1’s physician order for heparin was not verified or followed by DT 1 or RN 3 prior to administration. The ANM stated she expected DT 1 and RN 3 to verify the volume of heparin in the syringe and compare the label on the syringe to Patient 1’s MAR and physician order prior to administration. The ANM stated there was a potential for Patient 1 to experience excessive bleeding, which could be life-threatening. During an interview on 12/19/25 at 10:00 a.m. with the Executive Director of Nursing (EDN), the EDN stated heparin is considered a “high-risk medication ... because it can cause bleeding if too much is given.” The EDN stated DT 1 and RN 3 should have followed the Five Rights of Medication Administration (a safety checklist used by healthcare professionals to prevent medication errors which include verifying: the right patient, the right medication, the right dose, the right route, the right time). The EDN stated DT 1 and RN 3 should have verified Patient 1’s heparin dosage with his MAR and physician order prior to administration. During an interview on 12/19/25 at 10:20 a.m. with RN 2, RN 2 stated she was “ ... in charge of caring for [Patient 1] on 12/5/25.” RN 2 stated the facility practice was for the dialysis technician to prepare the heparin and then verify the dosage with the nurse prior to administration. RN 2 stated DT 1 verified Patient 1’s heparin dosage with RN 3. RN 2 stated DT 1 misread Patient 1’s heparin label as 5000 units instead of 500 units then prepared the syringe with 5000 units. RN 2 stated DT 1 and RN 3 should have verified Patient 1’s heparin dosage with the physician order prior to administration. RN 2 stated Patient 1 could have experienced excessive bleeding, which could lead to hospitalization. During an interview on 12/19/25 at 10:31 a.m. with RN 3, RN 3 stated after DT 1 prepared Patient 1’s heparin, DT 1 came to him to verify the dosage. RN 3 stated he placed his initials on the label of Patient 1’s heparin syringe indicating that “ ... whatever volume is drawn up in the syringe matches the label on the syringe.” RN 3 stated he did not verify Patient 1’s heparin dosage to his MAR or physician order prior to placing his initials on the label of Patient 1’s heparin syringe. RN 3 stated he should have verified Patient 1’s heparin order prior to placing his initials on the label of Patient 1’s heparin syringe to ensure the dosage was correct. During an interview on 12/31/25 at 9:51 a.m. with the Technical Supervisor (TS), the TS stated the facility practice was for the evening dialysis technician to hand write the patient heparin labels based on physician orders and place the label on the syringe. The TS stated the morning dialysis technicians look at the prepared heparin label and fill the syringe with heparin according to the label. During an interview on 12/30/25 at 2:17 p.m. with DT 1, DT 1 stated she was the morning dialysis technician on 12/5/25 DT 1 stated she prepared Patient 1’s heparin dosage by referring to the label on the syringe. DT 1 stated she thought she read heparin 5000 units on the label of Patient 1’s heparin syringe. DT 1 stated she verified Patient 1’s heparin dosage with RN 3 prior to administration. DT 1 stated RN 3 placed his initials on Patient 1’s heparin label, indicating that the dosage was correct. DT 1 stated she then administered heparin 5000 units to Patient 1. DT 1 stated that neither she nor RN 3 verified Patient 1’s heparin dosage with his MAR or physician order prior to administration. DT 1 stated the medication error could have been prevented if she or RN 3 had verified Patient 1’s heparin dosage with his MAR or physician order. DT 1 stated Patient 1 could have experienced excessive bleeding. During a concurrent interview and record review on 12/19/25 at 11:12 a.m. with the ANM and EDN, the facility’s policy and procedure (P&P) titled, “Medications - Orders, Administration, Storage, Documentation”, dated 6/30/25, was reviewed. The P&P indicated, “Policy: ... 17. It is the responsibility of the person administering the medication to verify the following ... d. The right dose ... Procedure: ... M. Each person administering medications or treatment is required to check the medication against the MAR, or original written order ... prior to medication administration.” The ANM stated the P&P applies to all staff who administer medications, which included DT 1 and RN 3. The ANM and EDN stated DT 1 and RN 3 did not follow the facility’s P&P. During a concurrent interview and record review on 12/19/25 at 11:12 a.m. with the ANM and EDN, the facility’s P&P titled, “Administration of Heparin - Dialysis”, dated 8/14/24, was reviewed. The P&P indicated, “Definitions: A. INDEPENDENT DOUBLE CHECK is a check of the factors below performed independently by a second qualified healthcare practitioner. This check should be performed alone and apart from each other ... For medications, the factors to be verified during the Independent Double Check may include ... 3. Right dose of drug ...” The ANM stated the Independent Double Check described in the P&P applied to DT 1 and RN 3. The ANM stated DT 1 and RN 3 should have verified Patient 1’s heparin dosage independently prior to administration. The ANM and EDN stated DT 1 and RN 3 did not follow the facility’s P&P. During a review of the facility’s P&P titled, “Medication Administration - Hemodialysis”, dated 9/22/22, the P&P indicated, “Definitions: B. Five Rights of Medication Administration ... 3. The right dose ... Procedure: A. Verify medication orders on the therapy plan as per nephrologist (kidney doctor) / APP (Advanced Practice Professional) order ... B. Follow the five rights of medication administration ...””