Fmc St. Raphael Dialysis Center - New Haven

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 44675 Based on observations, policy review, and interviews, the facility failed to clean and disinfect non-disposable equipment brought in the hemodialysis station and clean and disinfect the dialysis station and after a hemodialysis treatment per facility policy. The findings included: i. Observation conducted on 6/25/25 at 10:15 AM of Staff Person #3 performing Station #22’s disinfection identified that the staff person failed to clean and disinfect the left and right side of the machine, and placed the disinfected the primer bucket on the left side of the machine that had not been disinfected. Further, Staff Person #3 failed to disinfect the drain lines coming out of the machine to the wallbox. ii. Observation conducted on 6/25/25 at 10:20 AM of Staff Person #5 performing Station #19’s disinfection identified the failure to clean and disinfect the bottom half of the machine and the drain lines coming out of the machine to the wallbox. iii. Observation conducted on 6/25/25 at 10:43 AM of Staff Person #2 had completed Patient #13’s nursing assessment using the stethoscope (lung sounds etc.), then placed the stethoscope around her neck and left station #13 without the benefit of disinfecting the stethoscope. She then proceeded to Station #19 and used the same stethoscope (not disinfected from the previous patient) to complete Patient #14’s nursing assessment. Review of the cleaning and disinfecting the dialysis station policy directed after use, any non-disposable equipment and supplies brought into the dialysis station (ex. stethoscope) must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station. It further directed to externally disinfect the dialysis machine with 1:100 bleach solutions after each dialysis treatment. It directed to use a cloth wetted with 1:100 bleach solution or EPA approved disinfectant wit clean and disinfect the dialysis station (chair, tables, machine, IV pole, hand sanitizer dispenser and holder, chaise wall).”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 44675 Based on observation, review of clinical records, interview, and policy review for one (1) of two (2) hemodialysis patients reviewed for Central Venous Catheter (CVC) care (Patient #13), the facility failed to perform catheter care per facility protocol. The findings include the following: Patient #13 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with a right CVC and heparin bolus of 3000 units IV push every treatment. Observation was conducted on 6/25/25 at 10:27 AM of Patient #13’s CVC care and treatment initiation by Staff Person #3 identified the application a chucks pad (disposable pad) onto the patient, then the old CVC exit site dressing was removed, and Staff Person #3 proceeded to clean the CVC exit site with a chlorhexidine swab (an antiseptic) without the benefit of performing hand hygiene and changing gloves. Staff Person #3 then removed her gloves and put on a new pair of gloves without performing hand hygiene. Staff Person #3 then removed the gauze wrapping around Patient #13’s CVC limbs and proceeded to only clean the hub (opening of the CVC limb) of the arterial limb without cleaning the entire limb (from the exit site down to the hub). Staff Person #3 then proceeded to place the uncapped CVC limb on the chuck pad (while the arterial hub was open) and then lifted the limb to place the syringe on the arterial limb to aspirate. At 10:31 AM Staff Person #3 only cleaned the hub of the venous limb without cleaning the entire limb. Upon completion of catheter care Staff Person #3 removed her gloves however, did not perform hand hygiene. Review of the hand hygiene policy directed to decontaminate hands using alcohol-based hand rub or washing hands with antimicrobial soap and water immediately after removing gloves. Review of the changing the catheter dressing procedure directed to perform hand hygiene, don clean gloves, inspect and remove the old dressing. Discard the dressing, remove gloves and perform hand hygiene. To clean the site, perform hand hygiene and don clean gloves. Review of the initiation of treatment using a central venous catheter (CVC) and optiflux single use ebeam dialyzer directed prior to initiation perform hand hygiene and don full PPE and place an under pad under the access limbs to protect the work area and patient’s clothing. When preparing the catheter, put mask a mask on the patient, doff gloves, perform hand hygiene then don new gloves. Use a sterile alcohol pad and scrub the sides (threads) and end of the hub thoroughly with friction. Do not place uncapped catheter limbs on under pad to prevent contamination.”

“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: 47491 Based on review of clinical records, interview, and review of facility policy and documentation for four (4) of five (5) patients (Patient #1, #3, #5, and #7) reviewed for hemodialysis prescription, the facility failed to administer the patient’s dialysis treatment in accordance with physician’s orders. The findings included: 1. Patient #1 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for four (4) hours and fifteen (15) minutes per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, and an autoflow dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #1’s treatment records identified the following: On 5/27/25, 5/29/25, and 6/5/25 Patient #1’s treatment was administered at a BFR of 400 through the entire treatment without documentation identifying the reason the ordered BFR of 450 was not achieved. 2. Patient #3 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for three (3) hours per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, an autoflow 1.5 dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #3’s treatment records identified the following: On 6/10 and 6/21/25 Patient #3’s treatment was administered at a BFR of 400 through the entire treatment without documentation identifying the reason the ordered BFR of 450 was not achieved. 3. Patient #5 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for three (4) hours per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, an autoflow 1.5 dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #5’s treatment records identified the following: On 6/11/25 and 6/13/25 Patient #5’s treatment was administered at a BFR of 250 through the entire treatment without documentation identifying the reason the ordered BFR of 450 was not achieved. 4. Patient #7 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for three (4) hours per treatment, using a 2.0 potassium/3.0 calcium bath, a blood flow rate (BFR) of 450, an autoflow 1.5 dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #7’s treatment records identified the following: On 5/30, 6/6, 6/13, and 6/23/25 Patient #7’s treatment was administered at a BFR of 400 through the entire treatment without documentation identifying the reason the ordered BFR of 450 was not achieved. Interview with the Facility Administrator on 6/25/25 at 4:12 PM identified the standard of practice was for staff to document why the blood flow rate (BFR) was not achieved, to document interventions used to achieve the prescribed BFR, or to obtain a new order from the provider for an adjusted BFR and to follow up for further assessment with the access center. Review of the Patient Assessment and Monitoring policy directed to check that the prescribed blood flow rate is being achieved or to document, in the medical record, if unable to meet the prescribed blood flow rate.”

“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: 44675 Based on clinical records, facility policy and interviews for one (1) of five (5) patients (Patient #7), the facility failed to notify the registered nurse (RN) of a patient’s elevated blood pressures and not meeting target weight. The finding included: 1. Patient #7 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for three (4) hours per treatment, using a 2.0 potassium/3.0 calcium bath, a blood flow rate (BFR) of 450, an autoflow 1.5 dialysate flow rate (DFR) while using a central venous catheter (CVC) with an estimated dry weight of 85 kilograms. a. Review of Patient #7’s 5/30/25 treatment record identified the following: -A blood pressure reading of 184/89 at 8:03 AM without a blood pressure recheck or documentation the nurse was notified of the elevated blood pressure. -A blood pressure reading of 181/179 at 8:30 AM without a recheck or documentation the nurse had assessed the patient when signing off on the vitals. -A blood pressure reading of 187/94 at 11:02 AM without a blood pressure recheck or documentation the nurse was notified of the elevated blood pressure. -A blood pressure reading of 180/89 at 11:34 AM without a blood pressure recheck or documentation the nurse was notified of the elevated blood pressure. -A post treatment sitting blood pressure of 186/96 without documentation the patient was assessed for his/her elevated blood pressure. Review of Patient #7’s on 6/11/25 treatment record identified the following: -A blood pressure reading of 194/101 at 10:05 AM and recheck reading of 185/118 at 10:09 AM by a registered nurse without identifying an assessment was performed. -A blood pressure reading of 188/100 at 11:09 AM without a blood pressure recheck or documentation the nurse was notified of the elevated blood pressure. -A blood pressure reading of 197/120 at 11:32 AM without a blood pressure recheck or documentation the nurse was notified of the elevated blood pressure. -A blood pressure reading of 195/114 at 12:07 PM checked by a registered nurse without identifying an assessment was performed. Review of Patient #7’s on 6/13/25 treatment record identified the following: A blood pressure reading of 202/97 at 9:07 AM without a blood pressure recheck or documentation the nurse was notified of the elevated blood pressure. A blood pressure reading of 200/111 at 9:49 AM without a blood pressure recheck or documentation the nurse was notified of the elevated blood pressure. A blood pressure reading of 184/109 at 10:09 AM without a blood pressure recheck or documentation the nurse was notified of the elevated blood pressure. Interview with the Facility Administrator on 6/25/25 at 4:21 PM identified abnormal blood pressures should be brought to the attention of the registered nurse and/or charge nurse for further assessment and/or intervention. Review of the Hypertension policy identified staff to recognize, report, and immediately address systolic blood pressures greater than 180 mm/Hg and/or diastolic blood pressures greater than 100 mm/Hg. b. A Review of the treatment record dated 6/23/25 identified Patient #7 had a pre-dialysis weight of 92.6 kilograms (7.6 kilograms over his/her estimated dry weight of 85 kilograms) and presented with shortness of breath. Staff Person #5 identified the charge nurse (Staff Person #2) was notified of the patient’s dialysis goal and noted Patient #7’s breathing improved after treatment, however, did not indicate Staff Person #2 was informed Patient #7 was still 4.6 kilograms over his/her estimated dry weight at the end of treatment. Interview with Staff Person #2 (charge nurse 6/23/25) on 6/25/25 at 12:40 PM identified he/she didn’t recall being informed that Patient #7 was 4.6 kilograms over his/her dry weight following treatment on 6/23/25 and that had he/she known, he/she would have contacted the provider for an extra treatment order and written a note in the electronic medical record. Staff Person #2 further indicated as a note was not entered in Patient #7’s clinical record on 6/23/25, Staff Person #2 could only surmise that he/she was not informed. Review of the Recommended Volume and Hypertension Evaluation and Management Algorithm directs, if a patient’s pre-weight is greater than the estimated dry weight, to discuss the treatment plan with the provider to increase the treatment time, schedule an extra treatment, and/or obtain a separate order for the target weight removal.”

“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: 44675 Based on clinical records, facility policy and interviews for three (3) of five (5) patients (Patient #1, 3, and 4,)reviewed for intradialytic vital signs, the facility failed to ensure vital signs and machine parameters were completed timely during the treatment per facility policy, for two (2) of five (5) patients (Patient #1 and #5) the facility failed to ensure that an Against Medical Advice (AMA) form was completed in accordance with facility policy, for two (2) of (5) patients (Patient #3 and #7), the facility failed to obtain post treatment standing blood pressures for ambulatory patients, and for one (1) of four (4) patients (Patient #6), reviewed for assessments, the facility failed to ensure abnormal vital signs were addressed with nurse during treatment and ensure an abnormal vital sign was addressed with the charge nurse and/or physician post treatment per facility policy, The findings included: 1. Patient #4 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours and thirty (30) minutes with left upper arteriovenous fistula (AVF) and 450 blood flow rate (BFR). A sample review of Patient #4’s hemodialysis flowsheets identified the following: i. On 5/14/25 at 11:00 AM Patient #4 had a vital sign and machine check. The next vital signs and machine check was completed at 12:00 PM (one hour later). The flowsheet failed to identify a check was completed in between. ii. On 6/13/25 at 11:36 AM Patient #4 had a vital sign and machine check. Patient #4’s blood pressure was 96/74 (normal value 120/80) and the comment section identified Patient #4’s blood pressure was low, and oxygen was applied. The next vital sign and machine check was completed at 1:06 PM (approximately one and a half hours later). The flowsheet failed to identify that vital sign checks were completed in between. iii. On 6/4/25 at 11:36 AM Patient #4 had a vital sign and machine check. Patient #4 had a vital sign check at 12:00 PM but it failed to identify the machine parameters. The next machine check was completed at 12:34 PM (one hour later). The flowsheet failed to identify a machine check was completed in between. iv. On 6/2/25 at 12:03 PM Patient #4 had a vital sign and machine check. Patient #4 had a vital sign check at 12:30 PM but it failed to identify the machine parameters. The next machine check was completed at 1:03 PM (one hour later). The flowsheet failed to identify a machine check was completed in between. Patient #4 had a vital sign check at 1:30 PM. The next vital sign check was completed at 2:26 PM (one hour later). The flowsheet failed to identify a vital sign check was completed in between. v. On 5/28/25 at 10:02 AM Patient #4 had a vital sign and machine check. Patient #4 had a machine check at 10:32 PM but it failed to identify Patient #4’s vital signs. The next vital sign check was completed at 11:05 AM (one hour later). The flowsheet failed to identify a check was completed in between. 2. Patient #1 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three times weekly for four (4) hours and fifteen (15) minutes per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, and an autoflow dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #1’s treatment records identified the following: i. On 5/29/25, a blood pressure reading of 148/67 was identified at 10:03 AM. The next blood pressure reading of 165/91 was identified at 11:02 AM, fifty-nine (59) minutes following the previous reading. ii. On 6/5/25, a blood pressure reading of 123/73 was identified at 10:33 AM. The next blood pressure reading of 143/83 was identified at 11:34 AM, one (1) hour and one (1) minute following the previous reading. iii. On 6/7/25, blood pressure readings were captured at 7:52 AM, 8:00 AM, and 8:30 AM, however the vitals line of the electronic medical record failed to identify the blood flow rate (BFR), dialysate flow rate (DFR), arterial and venous pressures, ultrafiltration rate and total fluid removed at each thirty (30) minute interval, until 9:04 AM. iv. On 6/12/25, a blood pressure reading of 150/81 was identified at 10:03 AM. The next blood pressure reading of 107/86 was identified at 11:08 AM, one (1) hour and five (5) minutes following the previous reading. 3. Patient #3 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for three (3) hours per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, an autoflow 1.5 dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #3’s treatment records identified the following: i. On 6/3/25, a blood pressure reading of 91/43 was identified at 12:05 PM. The next blood pressure reading of 108/46 was identified at 1:04 PM, fifty-nine (59) minutes following the previous reading. ii. On 6/12/25, a blood pressure reading of 153/76 was identified at 11:35 AM. The next blood pressure reading of 142/78 was identified at 1:05 PM, one (1) hour and thirty (30) minutes following the previous reading. iii. On 6/17/25, a blood pressure reading of 131/63 was identified at 1:05 PM. The next blood pressure reading of 130/64 was identified at 2:02 PM, fifty-seven (57) minutes following the previous reading. Interview with the Charge Nurse on 6/25/25 at 10:00 AM identified during treatment machine checks and patient blood pressure and pulse checks should be completed every 30 minutes, but no greater than 45 minutes. Review of the patient assessment and monitoring policy directed during treatment to obtain blood pressure, pulse, machine parameters and safety checks every 30 minutes or more as needed but not to exceed 45 minutes. 4. Patient #1 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3) times weekly for four (4) hours and fifteen (15) minutes per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, and an autoflow 1.5 dialysate flow rate while using a central venous catheter (CVC). Review of Patient #1’s treatment sheets identified the following: i. On 5/27/25, Patient #1 received three (3) hours and twenty-eight (28) minutes of treatment (terminated treatment forty-seven (47) minutes early). Review of Patient #1’s medical record failed to identify an AMA form was reviewed and completed. ii. On 6/7/25 Patient #1 received three (3) hours and forty-one (41) minutes of treatment (terminated treatment thirty-four (34) minutes early). Review of Patient #1’s medical record failed to identify an AMA form was reviewed and completed. iii. On 6/12/25, Patient #1 received three (3) hours and fifty-five (55) minutes of treatment (terminated treatment twenty (20) minutes early). Review of Patient #1’s medical record failed to identify an AMA form was reviewed and completed. 5. Patient #5 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for four (4) hours per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, and an autoflow 1.5 dialysate flow rate while using a central venous catheter (CVC). Review of Patient #5’s treatment sheets identified the following: i. On 5/21/25, Patient #5 received two (2) hours and thirty-two (32) minutes of treatment (terminated treatment eighty-eight (88) minutes early). Review of Patient #5’s medical record failed to identify an AMA form was reviewed and completed. ii. On 5/23/25, Patient #5 received two (2) hours and forty-two (42) minutes of treatment (terminated treatment seventy-eight (78) minutes early). Review of Patient #5’s medical record failed to identify an AMA form was reviewed and completed. iii. On 5/26/25, Patient #5 received three (3) hours and twenty-nine (29) minutes of treatment (terminated treatment thirty-one (31) minutes early). Review of Patient #5’s medical record failed to identify an AMA form was reviewed and completed. iv. On 5/30/25, Patient #5 received three (3) hours and thirty-two (32) minutes of treatment (terminated treatment twenty-eight (28) minutes early). Review of Patient #5’s medical record failed to identify an AMA form was reviewed and completed. v. On 6/4/25, Patient #5 received three (3) hours and twenty (20) minutes of treatment (terminated treatment forty (40) minutes early). Review of Patient #5’s medical record failed to identify an AMA form was reviewed and completed. vi. On 6/11/25, Patient #5 received three (3) hours and thirty-six (six) minutes of treatment (terminated treatment twenty-four (24) minutes early). Review of Patient #5’s medical record failed to identify an AMA form was reviewed and completed. vii. On 6/13/25, Patient #5 received three (3) hours and seven (7) minutes of treatment (terminated treatment fifty-three (53) minutes early). Review of Patient #5’s medical record failed to identify an AMA form was reviewed and completed. viii. On 6/18/25, Patient #5 received three (3) hours and thirty-seven (37) minutes of treatment (terminated treatment twenty-three (23) minutes early). Review of Patient #5’s medical record failed to identify an AMA form was reviewed and completed. ix. On 6/23/25, Patient #5 received three (3) hours and forty-six (46) minutes of treatment (terminated treatment fourteen (14) minutes early). Review of Patient #5’s medical record failed to identify an AMA form was reviewed and completed. Interview with the Clinical Operations Director on 6/25/25 at 4:24 PM identified treatments shortened by fifteen (15) minutes or more require the completion of an AMA form and if the patient refuses to sign the AMA form, a staff member and witness were to sign the form. Review of the Early Termination or Arriving Late for Treatment policy directed Against Medical Advice (AMA) forms were to be signed with each early termination event and filed in the patient’s medical record. 6. Patient #1 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three times weekly for four (4) hours and fifteen (15) minutes per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, and an autoflow dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #1’s treatment records identified the following: i. On 5/29/25, a blood pressure reading of 148/67 was identified at 10:03 AM. The next blood pressure reading of 165/91 was identified at 11:02 AM, fifty-nine (59) minutes following the previous reading. ii. On 6/5/25, a blood pressure reading of 123/73 was identified at 10:33 AM. The next blood pressure reading of 143/83 was identified at 11:34 AM, one (1) hour and one (1) minute following the previous reading. iii. On 6/7/25, blood pressure readings were captured at 7:52 AM, 8:00 AM, and 8:30 AM, however the vitals line of the electronic medical record failed to identify the blood flow rate (BFR), dialysate flow rate (DFR), arterial and venous pressures, ultrafiltration rate and total fluid removed at each thirty (30) minute interval, until 9:04 AM. iv. On 6/12/25, a blood pressure reading of 150/81 was identified at 10:03 AM. The next blood pressure reading of 107/86 was identified at 11:08 AM, one (1) hour and five (5) minutes following the previous reading. 5. Patient #3 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for three (3) hours per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, an autoflow 1.5 dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #3’s treatment records identified the following: i. On 6/3/25, a blood pressure reading of 91/43 was identified at 12:05 PM. The next blood pressure reading of 108/46 was identified at 1:04 PM, fifty-nine (59) minutes following the previous reading. ii. On 6/12/25, a blood pressure reading of 153/76 was identified at 11:35 AM. The next blood pressure reading of 142/78 was identified at 1:05 PM, one (1) hour and thirty (30) minutes following the previous reading. iii. On 6/17/25, a blood pressure reading of 131/63 was identified at 1:05 PM. The next blood pressure reading of 130/64 was identified at 2:02 PM, fifty-seven (57) minutes following the previous reading. 6. Patient #5 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for three (4) hours per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, an autoflow 1.5 dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #5’s treatment records identified the following: i. On 5/28/25, a blood pressure reading of 136/86 was identified at 12:47 PM. The next blood pressure reading of 173/101 was identified at 2:05 PM, one (1) hour and eighteen (18) minutes following the previous reading. ii. On 6/13/25, a blood pressure reading of 156/85 was identified at 1:33 PM. The next blood pressure reading of 157/80 was identified at 2:35 PM, one (1) hour and two (2) minutes following the previous reading. iii. On 6/18/25, a blood pressure reading of 155/108 was identified at 3:32 PM. The next blood pressure reading of 178/94 was identified at 4:20 PM, forty-eight (48) minutes following the previous reading. iv. On 6/23/25, a blood pressure reading of 164/88 was identified at 3:34 PM. Treatment was terminated at 4:22 PM, forty-eight (48) minutes following the previous blood pressure without any additional blood pressures recorded. Interview with the Director of Operations on 6/25/25 at 4:13 PM identified the vitals were to be taken every thirty (30) minutes while a patient was receiving treatment, and not to exceed forty-five (45) minutes. Review of the Patient Assessment and Monitoring policy directed blood pressure, pulse rate, machine parameters, and safety checks were to be obtained every thirty (30) minutes or more as needed, but not to exceed forty-five (45) minutes or per state regulation. 7. Patient #3 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for three (3) hours per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, an autoflow 1.5 dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #3’s treatment records dated 5/7/25, 5/27/25, 5/31/25, 6/3/25, 6/5/25, and 6/10/25 failed to identify a post treatment standing blood pressure was administered for an ambulatory patient. 8. Patient #7 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three times weekly for three (4) hours per treatment, using a 2.0 potassium/3.0 calcium bath, a blood flow rate (BFR) of 450, an autoflow 1.5 dialysate flow rate (DFR) while using a central venous catheter (CVC). Review of Patient #7’s treatment records dated 5/28/25, 6/6/25, 6/11/25, 6/13/25, 6/16/25, 6/19/25, 6/20/25, and 6/23/25 failed to identify a post treatment standing blood pressure was administered for an ambulatory patient. Interview with Staff Person #1 on 6/25/25 at 4:15 PM identified both sitting and standing blood pressures pre and post treatment were to be administered for ambulatory patients. Review of the Patient Assessment and Monitoring policy directed to obtain post-treatment vital signs to ensure the patient’s vital signs and overall condition were stable for discharge. 9. Patient #6 had diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with left upper arteriovenous fistula (AVF) and 400 blood flow rate (BFR). Review of Patient #6’s hemodialysis orders did not identify physician “special orders” and/or patient specific parameters during treatment. A review of Patient #6’s hemodialysis treatment flowsheets identified the following: i. On 6/23/25 at 6:24 AM identified Patient #6’s pre-treatment nursing assessment identified a regular pulse. At 7:00 AM Patient #6’s pulse dropped to 55 BPM (normal heart rate is 60 - 100 BPM), was documented by the PCT, however, failed to identify if the Register Nurse (RN) was notified. At 7:33 AM his/her heart rate was 55 BPM and at 8:04 AM it was 57 BPM, was documented by the PCT and failed to identify if the RN was notified. At 8:07 and 8:37 AM Patient #6’s heart rate was 57 BPM and it was documented by the RN. However, the RN failed to document that Patient #6’s abnormal heart rate was addressed. At 9:53 AM Patient #6’s post-treatment heart rate was 48 BPM and failed to identify if Patient #6’s abnormal heart rate was addressed and/if the change nurse and physician were notified. The post treatment nursing assessment timed at 5:33 PM did not address Patient #6’s abnormal pulse and/if the physician was notified. ii. On 6/18/25 at 6:41 AM identified Patient #6’s pre-treatment nursing assessment identified Patient #6’s pulse was regular. At 8:01 AM Patient #6’s heart rate dropped to 46 BPM, was documented by the PCT and failed to identify if the RN was notified. At 8:35 AM his/her heart rate was 68 BPM, at 9:02 AM the pulse decreased to 41 BPM and was documented by the PCT and failed to identify if the RN was notified. iii. On 6/11/25 at 6:27 AM identified Patient #6’s pre-treatment nursing assessment identified Patient #6’s pulse was regular. At 9:30 AM Patient #6’s heart rate dropped to 43 BPM, was documented by the PCT and failed to identify if the RN was notified. At 9:54 AM his/her heart rate was 42 BPM, was documented by the PCT and failed to identify if the RN was notified. At 9:56 AM Patient #6’s post treatment heart rate was 41 BPM and failed to identify if Patient #6’s abnormal heart rate was addressed and/if the change nurse and physician were notified. The post-treatment nursing assessment timed at 9:56 AM did not address Patient #6’s abnormal vital sign and/if the physician was notified. iv. On 6/4/25 at 6:24 AM identified Patient #6’s pre-treatment nursing assessment identified Patient #6’s pulse was regular. At 9:53 AM Patient #6’s heart rate dropped to 40 BPM, was documented by the PCT and failed to identify if the RN was notified. At 9:57 AM Patient #6’s post treatment heart rate was 46 BPM and failed to identify if Patient #6’s abnormal heart rate was address and/if the charge nurse and physician were notified. The post-treatment nursing assessment timed at 5:32 PM did not address Patient #6’s abnormal vital sign and/if the physician was notified. v. On 6/2/25 at 6:36 AM identified Patient #6’s pre-treatment nursing assessment identified Patient #6’s pulse was regular. At 8:16 AM Patient #6’s heart rate dropped to 43 BPM, was documented by the RN but failed to identify if the abnormal pulse was addressed. At 8:48 AM Patient #6’s heart rate was 40 BPM, at 9:01 was 38 BPM, at 9:35 was 42, at 9:59 AM was 44 BPM and was documented by the PCT and failed to identify if the RN was notified. At 10:03 AM Patient #6’s post treatment heart rate was 46 BPM and failed to identify if Patient #6’s abnormal heart rate was address and/if the charge nurse and physician were notified. The post-treatment nursing assessment timed at 10:23 AM did not address Patient #6’s abnormal vital sign and/if the physician was notified. Interview and record review with the Charge Nurse on 6/25/25 at 10:00 AM identified that a patient must have a physician special order to run a treatment with a vital sign different than what the policy directs. If the patient does not have physician special orders for vital signs during treatment different than what the policy states or patient specific parameters, the staff are to follow the policy. She identified Patient #6 did not have parameters or special orders to run treatment with a pulse less than 60 BPM. She identified during treatment checks, the PCT is to notify the nurse with an abnormal vital sign and the RN is then to assess the patient. She identified the RN must notify the Charge Nurse who would notify the physician for a heart rate <60 BPM prior to discharge from the clinic. Review of the patient assessment and monitoring policy directed during treatment to record the patient’s pulse and report to the nurse patients whose heart rates have dropped below 60, risen above 100 or become irregular. Review of the nursing supervision and delegation policy directed that the staff member who collects information pre, post and during treatment will document their findings. Any observed changes or abnormal findings in the patient’s condition must be reported to the registered nurse who will assess the patient. Registered nurses who are not the nurse in charge must report abnormal findings and interventions to the nurse in charge. Prior to discharge the registered nurse must review the treatment record for slow/fast/irregular heart rate and heart rate <60 or >100 addressed by the registered nurse with documentation present. A patient should be referred to the charge nurse for a heart rate that is of new onset and is below 60 BPM.”