Davita Pdi Rocky Hill

“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: 44675 Based on observations, facility documentation, facility policy and interviews, reviewed for hand hygiene, the facility failed to ensure patients who their removed gloves after holding their hemodialysis access were offered hand hygiene per facility policy. The findings include: a. Observations conducted 4/8/25 at 10:31 AM identified Patient #16 was observed with a glove on his/her right hand from holding his/her left hemodialysis access after hemodialysis treatment. At 10:35 AM Staff Member #3 taped up Patient #16’s access and the patient removed his/her gloves. Patient #16 proceeded to the scale with his/her belongings without being offered hand hygiene. b. Observation on 4/8/25 at 2:24 PM, Patient #15 was observed holding his/her hemodialysis access site with his/her gloved right hand. Patient #15 had his/her glove removed by staff at 2:49 PM, was not provided with hand sanitizer after removing the glove, was transferred to his/her wheelchair by two (2) staff members, brought to the scale, and was assisted outside of the clinic into the lobby area without performing hand hygiene before leaving the clinic floor. c. Observations conducted 4/9/25 at 9:50 AM identified Patient #17 was observed with a glove on his/her right hand from holding his/her left hemodialysis access after hemodialysis treatment. At 10:02 AM Staff Member #6 taped up Patient #17’s access and the patient removed his/her gloves without being offered hand hygiene. Patient #17 then went to the charge nurse station with his/her belongings to speak with the charge nurse, then the scale, then exited without being offered hand hygiene. Interview with the Facility Administrator on 4/8/25 at 3:25 PM identified patient were to be offered hand sanitizer after holding their access sites following treatment and before being discharged from the clinic floor. Review of the infection control for dialysis facilities policy directed patients and caregivers will be encouraged to perform hand hygiene after treatment before leaving the treatment area. 47491”

“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, facility documentation and interviews, the facility failed to appropriately clean and disinfect the dialysis station after a hemodialysis treatment. The findings included: Observations conducted on 4/9/25 at 10:43 AM identified during disinfection of the hemodialysis station after a patient treatment, Staff Person #6 failed to disinfect the top of the IV pole, the basket on the right side of the machine and the blood pressure cuff inside of the basket. Review of the infection control for dialysis facilities policy identified surfaces to disinfect include but are not limited to all surfaces in contact with the patient or their belongings and frequently contacted by healthcare personnel.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) out of six (6) hemodialysis patients reviewed for vaccinations (Patient #8), the facility failed to offer the Hepatitis B vaccination for a patient who became susceptible to the Hepatitis B virus in accordance with facility policy. The findings include the following: Patient #8 was admitted to the facility 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 left central venous catheter (CVC). Review of Patient #8’s energix (Hepatitis B vaccination) administration report identified Patient #8 last received a booster dose of energix on 11/13/20. Review of Patient #8’s hepatitis B antibodies dated 11/7/23 identified Patient #8’s hepatitis B antibodies were 25 (>10 indicates immunity from the hepatitis B virus). Review of Patient #8’s hepatitis B antibodies dated 9/12/24 identified Patient #8’s hepatitis B antibodies were 8 (<10 indicates susceptibility of the hepatitis B virus). Review of Patient #8’s medical record failed to identify if a booster dose was offered and/or administered. Interview with the Clinical Coordinator on 4/9/25 at 1:45 PM identified Patient #8 was medically conserved, and she reached out to the conservator several times to discuss the vaccine for Patient #8 but did not reach the conservator. However, she identified she did not document the attempts. Review of the hepatitis B surveillance, vaccination, infection control measures and isolation guidance directed on annual retesting of immune patients due to vaccination, for a hepatitis B antibody less than ten (10), with a nephrologist order, administer a booster dose of vaccine. There is no limit of annual boosters although future doses should be discontinued if at any time the patient fails to respond with a hepatitis B antibody greater than or equal to ten (10).”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 38422 Based on observation and interviews, the facility failed to ensure that a egress corrider was free from obstruction and failed to ensure that fire department connections were maintained. On 04/04/25 the surveyor while accompanied by the Bio Med Technicians, observed that the rear egress corridor was not free of obstructions as required by section #’s 21.2.1 and 7.1.10.1 of the “Life Safety Code”; i.e. The rear egress hallway had equipment stored in it and was not ready for full instant use. On 04/04/25 during document review, the surveyor, while accompanied by the Bio Med Technicians, observed that the Fire Department Connection and its piping were rusted and corroded. The facility failed to ensure that the Fire Department Connection was in good condition being maintained, as required by NFPA 25, “Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems” and as part of the facilities’ preventative maintenance program, i.e. facility failed to repair/replace Fire Department Connection parts that were identified as faulty on several sprinkler inspections dating back to August 2024. There was no plan in place to do repairs at the time of this survey.”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) of three (3) hemodialysis patients reviewed for grievances (Patient #13), the facility failed to ensure staff treated a patient with respect and dignity. The findings include the following: Patient #13 was admitted to the clinic on 11/12/24 with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a right forearm arteriovenous Fistula (AVF). Review of the grievance document dated 8/26/24 at 8:30 AM identified a teammate was verbally aggressive to Patient #13. Staff Member #5 spoke loudly to Patient #13 (referring to a diagnosis that Patient #13 had), “man don’t talk to me”. Staff Member #5 was immediately suspended pending the investigation and then terminated. Review of Staff Member #1’s statement identified she was in Patient #13’s section on 8/24/24. She identified she observed Staff Member #5 roll her eyes and stick her middle finger up at Patient #13. For a while Patient #13 was quiet and started to close his/her eyes when Staff Member #5 said “F*** that bast**d, his/her (name of disease) infected a**, he/she can suck my d*ck”. Review of Staff Member #2’s statement identified she observed Staff Member #5 sticking her middle finger at Patient #13. She heard Staff Member #5 say “this mother***er can suck my d*ck”. She identified she reported it to the FA as soon as she was able to. Although attempted, an interview with Staff Member #2 was not obtained. Interview with Staff Member #3 on 4/9/25 at 2:30 PM identified on 8/24/24 she was in a different pod on the treatment floor (across the room) when she heard Staff Member #5 swearing at Patient #13 and that Patient #13 had a certain disease loud enough for the rest of the treatment floor to hear. She identified she witnessed Staff Member #5 flip her middle finger up at Patient #13. She identified Staff Member #5 told her that Patient #13 needs to be careful because she had access to his/her information and could show up at his/her house. She identified she notified the Charge Nurse and FA. Although attempted, an interview with Staff Member #1 was not obtained. Interview with the FA on 4/9/25 at 2:00 PM identified on 8/24/24 she was notified Staff Member #5 flipped her finger at Patient #13 who then got irate and asked to be taken off the machine. Staff Member #5 was witnessed Staff Member #5 swearing and disclosing the Patients #13’s diagnosis. She identified Staff Member #5 was removed from the facility pending investigation and was terminated. She identified staff are trained on how to interact with difficult patients and that Staff Member #5 should not have responded in that way. Review of the patient’s rights policy directed patients have the right to be treated with respect, dignity, and recognition of individuality, choices, strengths, abilities cultural values, religious beliefs and personal needs and sensitivity to psychological needs. Patients have the right to be free from abuse, neglect, exploitation, coercion, manipulation, sexual abuse, sexual assault, seclusion or restraint.”

“PR-PRIVACY & CONFIDENTIALITY-RECORDS CFR(s): 494.70(a)(4) The patient has the right to- (4) Privacy and confidentiality in personal medical records; This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) of three (3) hemodialysis patients reviewed for grievances (Patient #13), the facility failed to ensure staff maintained protected patient medical information confidential. The findings include the following: Patient #13 was admitted to the clinic on 11/12/24 with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a right forearm arteriovenous Fistula (AVF). Review of the grievance document dated 8/26/24 at 8:30 AM identified a teammate was verbally aggressive to Patient #13. Staff Member #5 spoke loudly to Patient #13 (referring to a diagnosis that Patient #13 had), “man don’t talk to me”. Staff Member #5 was immediately suspended pending the investigation and then terminated. Review of Staff Member #1’s statement identified she was in Patient #13’s section on 8/24/24. She identified she observed Staff Member #5 roll her eyes and stick her middle finger up at Patient #13. For a while Patient #13 was quiet and started to close his/her eyes when Staff Member #5 said “F*** that bast**d, his/her (name of disease) infected a**, he/she can suck my d*ck”. Review of Staff Member #2’s statement identified she observed Staff Member #5 sticking her middle finger at Patient #13. She heard Staff Member #5 say “this mother***er can suck my d*ck”. She identified she reported it to the FA as soon as she was able to. Although attempted, an interview with Staff Member #2 was not obtained. Interview with Staff Member #3 on 4/9/25 at 2:30 PM identified on 8/24/24 she was in a different pod on the treatment floor (across the room) when she heard Staff Member #5 swearing at Patient #13 and that Patient #13 had a certain disease loud enough for the rest of the treatment floor to hear. She identified she witnessed Staff Member #5 flip her middle finger up at Patient #13. She identified Staff Member #5 told her that Patient #13 needs to be careful because she had access to his/her information and could show up at his/her house. She identified she notified the Charge Nurse and FA. Although attempted, an interview with Staff Member #1 was not obtained. Interview with the FA on 4/9/25 at 2:00 PM identified on 8/24/24 she was notified Staff Member #5 flipped her finger at Patient #13 who then got irate and asked to be taken off the machine. Staff Member #5 was witnessed Staff Member #5 swearing and disclosing the Patients #13’s diagnosis to others on the treatment floor. She identified Staff Member #5 was removed from the facility pending investigation and was terminated. She identified staff are trained on how to interact with difficult patients and that Staff Member #5 should not have responded in that way. Review of the patient’s rights policy directed patients have the right to privacy and confidentiality in all aspects of treatment. Patients have the right to be free from abuse, neglect, exploitation, coercion, manipulation, sexual abuse, sexual assault, seclusion or restraint.”

“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 three (3) of seven (7) patients (Patient #6, #9, and #11) reviewed for hemodialysis prescriptions, the facility failed to administer the hemodialysis treatment in accordance with physician’s orders. The findings included: 1. Patient #9 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for two (2) hours per treatment, using a 1.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 400, and dialysate flow rate (DFR) of 800 while using a central venous catheter. Review of Patient #9’s treatment records identified the following: a) On 1/3/25, Patient #9’s treatment was administered at a DFR of 500 from 10:45 AM to 11:31 AM without documentation identifying the reason the ordered DFR of 800 was not achieved. b) On 2/21/25, Patient #9’s treatment was administered at a DFR of 600 for the entire treatment without documentation identifying the reason the ordered DFR of 800 was not achieved. c) On 3/8/25, Patient #9’s treatment was administered at a DFR of 500 for the entire treatment without documentation identifying the reason the ordered DFR of 800 was not achieved. 2. Patient #11 had diagnoses that included end stage renal disease. Physician’s orders directed hemodialysis three (3)times weekly for four (4) hours and thirty (30) minutes per treatment, using a 2.0 potassium/3.0 calcium bath, a blood flow rate (BFR) of 450, and dialysate flow rate (DFR) of 600 while using an arteriovenous fistula. Review of Patient #11’s treatment sheets identified the following: a) On 10/25/24, Patient #11’s treatment was administered at a DFR of 500 the entire treatment without documentation identifying the reason the ordered DFR of 600 was not achieved. b) On 11/14/24, Patient #11’s treatment was administered at a DFR of 500 from 10:01 AM to 11:30 AM without documentation identifying the reason the ordered DFR of 600 was not achieved. c) On 11/15/24, Patient #11’s treatment was administered at a DFR of 500 the entire treatment without documentation identifying the reason the ordered DFR of 600 was not achieved. 3. Patient #6 had diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3)times weekly for three (3) hours with a left upper arteriovenous fistula (AVF), blood flow rate (BFR) of 450 and dialysate flow rate (DFR) of 500. A sample review of Patient #6’s treatment flowsheet records identified the following: a. On 3/5/25 Patient #6’s treatment was initiated at 6:14 AM with a BFR of 400 with no rationale as to why the prescribed BFR of 450 was not met. b. On 3/26/25 Patient #6’s treatment was initiated at 6:02 AM with a BFR of 400 with no rationale as to why the prescribed BFR of 450 was not met. c. On 3/28/25 Patient #6’s treatment was initiated at 6:04 AM with a BFR of 450 and at 7:01 AM the BFR was decreased to 400 for the rest of the treatment with no rationale as to why the prescribed BFR of 450 was not met. d. On 3/31/25 Patient #6’s treatment was initiated at 6:05 AM with a BFR of 400 with no rationale as to why the prescribed BFR of 450 was not met. Interview with the Facility Administrator on 4/8/25 at 3:20 PM identified if a physician’s order can not be attained, the reason why should be documented in the vitals line of the patient’s electronic medical record. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed that if the dialysis prescription is not being met (including the dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed.”

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for three (3) of six (6) hemodialysis patients reviewed for Social Work documentation (Patients #6, #10 and #12), the facility failed to ensure patients were seen by the social worker at a minimum of quarterly in accordance with facility policy. The findings included the following: 1. Patient #6 was admitted to the facility with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours with a left upper arteriovenous fistula (AVF). A quarterly progress social worker note dated 3/22/24 identified the social worker called Patient #6 via the phone for a monthly follow up. A quarterly progress social worker note dated 11/25/24 identified the comprehensive assessment had fulfilled the need for a quarterly social worker note for that period. The comprehensive assessment was completed on 11/26/24. Review of Patient #6’s medical record identified no social worker notes between the timeframe of 3/22/24 - 11/25/24 (total of eight months). 2. Patient #10 was admitted to the facility with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours with a left central venous catheter (CVC). A quarterly progress social worker note dated 1/3/24 identified the social worker met with Patient #10 during treatment. A quarterly progress social worker note dated 1/20/25 identified the comprehensive assessment had fulfilled the need for a quarterly social worker note for that period. The comprehensive assessment was completed on 1/20/25. Review of Patient #10’s medical record identified no social worker notes between the timeframe of 1/3/24 - 1/20/25 (total of thirteen (13) months). 3. Patient #12 was admitted to the facility 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 central venous catheter (CVC). A quarterly progress social worker note dated 10/30/23 identified the comprehensive assessment had fulfilled the need for a quarterly social worker note for that period. The comprehensive assessment was completed on 10/30/23. A social worker note dated 7/16/24 identified Patient #12 was provided paperwork to apply for payment for his/her daughter to be his/her paid caregiver and appeared stable. Review of Patient #10’s medical record identified no social worker notes between the timeframe of 10/30/23 - 7/16/24 (total of nine (9) months). A quarterly progress social worker note dated 1/21/25 identified the comprehensive assessment had fulfilled the need for a quarterly social worker note for that period. The comprehensive assessment was completed on 1/27/25. Review of Patient #12’s medical record identified no social worker notes between the timeframe of 7/16/24 - 1/21/25 (total of six (6) months), and no quarterly social worker notes between the timeframe of 10/30/23 - 1/21/25 (total of fifteen (15) months). Interview with the Social Worker on 4/8/25 at 2:40 PM identified she was hired as the Social Worker in September of 2024 and had training for approximately two months. She identified there was no Social Worker in the facility since March of 2024 (a social worker was hired in the summer but quite after six weeks). She identified the company had Social Worker help with the home program but in-center hemodialysis fell behind. Interview with the FA on 4/9/25 at 2:00 PM identified the facility was without a Social Worker since March of 2024. She identified a Social Worker was hired in June of 2024 but quit after six weeks. She identified the company was aware the facility was without a Social Worker and could not find a Social Worker to cover because of being short staffed of Social Workers. Review of the social worker I job description identified one of the essential duties and responsibilities of the social worker is to identify, assess and document psychosocial evaluations quarterly and annually and evaluate and monitor ongoing psychosocial issues and patient goals. Review of the social worker intervention and documentation requirements policy directed social worker progress notes are completed quarterly or more frequently as needed.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) out of six (6) hemodialysis patients reviewed for hospitalization (Patient #4), the facility failed to complete an unstable assessment after a prolonged hospitalization in accordance with facility policy. The findings include the following: Patient #4 was admitted to the facility on 5/24/24 with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours and fifteen (15) minutes with a right central venous catheter (CVC). Review of Patient #4’s hospitalization record identified Patient #4 was hospitalized from 6/26/24 - 8/2/24 due to a left leg amputation (37 days). The clinical record failed to identify a stability assessment was completed upon return to the facility from the prolonged hospitalization. Interview with the Manger of Clinical Services on 4/8/25 at 1:20 PM identified Patient #4 should have had a stability assessment completed upon return to the clinic from their hospitalization per facility policy. Review of the interdisciplinary team patient assessment and plan of care policy directed an initial plan of care will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted at least monthly for unstable patients including patients with extended or frequent hospitalizations. Unstable patients are to have comprehensive assessments monthly until the patient is determined by the interdisciplinary team to be stable.”

“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: 44675 Based on a review of clinical records, interview, and policy review for one (1) out of six (6) hemodialysis patients reviewed for adequacy (Patient #10), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with the physician orders. The findings include the following: Patient #10 had diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours with a left central venous catheter, blood flow rate (BFR) of 400 and dialysate flow rate (DFR) of 800. Review of the care plan dated 1/20/25 identified Patient #10 had a goal to maintain adequacy goal (1.2). A sample review of Patient #10’s treatment flowsheet records identified the following: a. On 3/21/25 Patient #10’s treatment was initiated at 6:05 AM with a DFR of 600 with no rationale as to why the prescribed DFR of 800 was not met. b. On 3/26/25 Patient #10’s treatment was initiated at 6:00 AM with a DFR of 800 and at 7:01 AM was decreased to 600 for the remainder of the treatment with no rationale as to why the prescribed DFR of 800 was not met. c. On 3/31/25 Patient #10’s treatment was initiated at 6:05 AM with a DFR of 600 with no rationale as to why the prescribed DFR of 800 was not met. d. On 4/4/25 Patient #10’s treatment was initiated at 6:02 AM with a DFR of 600 with no rationale as to why the prescribed DFR of 800 was not met. Review of Patient #10’s labs dated 4/2/25 identified Patient #10’s kt/v (adequacy of dialysis treatment) was 1.09 (adequate dialysis is greater than or equal to 1.2). Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed that if the dialysis prescription is not being met (including the dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) out of six (6) hemodialysis patients reviewed for psychosocial behaviors (Patient #8), the facility failed to update the psychosocial care plan to address the patient’s psychosocial needs in accordance with facility policy. The findings include the following: Patient #8 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 a left central venous catheter (CVC). A comprehensive assessment dated 1/23/25 identified Patient #8’s psychosocial goal was to meet and maintain optimal mental and/or functional status with the intervention to provide psychosocial counseling as indicated. The social worker comment identified the patient was unable to complete the assessment due to cognitive issues. The social worker reached out to the Skilled Nursing Facility (SNF) social worker but was unable to make contact. A callback was requested to discuss the case. Due to limited information, a comprehensive assessment could not be completed. A RN noted dated 1/23/25 identified Patient #8 was agitated during treatment, afraid to die and screaming disturbing other patients. The Social Worker was notified on importance to assist with an aid for Patient #8. A SW note dated 1/23/25 identified she contracted Patient #8’s nursing home and spoke with the nursing home social worker. She explained Patient #8 become agitated during treatment and would benefit from a supportive presence to keep him/her calm. The social worker stated she would bring it up during the morning meeting. A RN note dated 1/25/25 identified Patient #8 arrived to treatment very agitated and yelled the entire treatment. Patient #8 tried to slide off of his/her chair. A RN note dated 2/11/25 identified Patient #8 was agitated throughout the treatment. Patient #8 was screaming for staff and when the staff got to him/her, he/she wanted staff to sit with him/her. The RN explained why staff can not sit with him/her and Patient #8 screamed more, hit the chair and tried to pull his/her CVC lines. Patient #8 could not comprehend the risks of pulling of the CVC or blood lines. The RN notified the Social Worker to follow up with the nursing home to send a sitter with Patient #8 so he/she can receive a safe treatment. A SW note dated 2/11/25 identified she followed up with the social worker at Patient #8’s nursing home. She identified Patient #8 experiences agitation during treatment and the need for support staff to sit with Patient #8. The social worker at the nursing home identified they can not send a sitter due to staffing. The Social Worker spoke to the nurse and stated she would consult the APRN to explore ways to make Patient #8 more comfortable, possibly administering medication before treatment. The Social Worker expressed concern about Patient #8’s risk of self-harm during treatment. The Social Worker identified the FA would be in contact to discuss the matter further. However, review of Patient #8’s progress notes failed to address if the nursing home was followed up by dialysis staff for interventions to help Patient #8 be more comfortable during treatments. A comprehensive assessment dated 3/13/25 identified Patient #8’s psychosocial goal was to meet and maintain optimal mental and/or functional status with the intervention to provide psychosocial counseling as indicated. The social worker comment identified the patient was unable to complete the assessment due to cognitive issues. The social worker reached out to the SNF social worker but was unable to make contact. A callback was requested to discuss the case. Due to limited information, a comprehensive assessment could not be completed. Review of Patient #8’s psychosocial care plans on 1/3/25 and 3/13/25 identified the same information was present in both care plans that did not contain patient specific interventions to address Patient #8’s psychosocial needs. The care plan completed on 3/13/25 was not updated with new interventions for Patient #8’s psychosocial needs. Interview with Staff Member #7 and #8 on 4/7/25 at 1:45 PM identified Patient #8’s cognition has decreased, and he/she is blind. It was identified that Patient #8 is usually okay during the first hour of treatment and sleeps, then will wake up and start yelling. Patient #8 will sometimes pull at his/her CVC blood lines or try to get out of the chair during treatment. Patient #8 needs to know someone is there with him/her. Interview with the Social Worker on 4/8/25 at 2:40 PM identified due to Patient #8’s behaviors, she has attempted to have the nursing home send a sitter with Patient #8 but the nursing home was not able too due to staffing issues. She identified she reached out to Patient #8’s conservator to see if they would hire a private aid but the conservator identified there are no funds to do so. Interview with the FA on 4/9/25 at 2:00 PM identified the facility had attempted different strategies to assist with Patient #8’s concerns during treatment such as requesting an aid from the nursing home and giving Patient #8 headphones during treatment. However, there are no specific interventions in Patient #8’s plan of care. Review of the social worker job description identified one of the essential duties and responsibilities of the social worker is to identify and develop the treatment and psychosocial goals for an initial plan of care and updates the plan of care as outlined by the clinic’s governing body for stable and unstable patients. Review of the interdisciplinary team patient assessment and plan of care policy the interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs with measurable and expected outcomes and estimated timetables to achieve the outcomes. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care. If the expected outcome is not achieved, the interdisciplinary team (or individual IDT member) will adjust the patient’s plan of care to achieve the specified goal.”

“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 a review of clinical records, interview, and policy review for one (1) out of three (3) hemodialysis patients reviewed for treatment compliance (Patient #4), the facility failed to ensure against medical device (AMA) forms were completed and physician notified per facility policy and for (1) Patient (Patient #11) reviewed for cardiac arrest the facility failed to sequester and obtain dialysate samples in accordance with facility policy following a cardiac arrest. The findings include the following: 1. Patient #4 was admitted to the facility with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three times weekly for four (4) hours and fifteen (15) minutes with a right Central Venous Catheter (CVC). A sample review of Patient #6’s treatment flowsheet records identified the following: a. On 3/14/25 Patient #6 had four (4) hours and five (5) minutes of treatment (10 minutes short) with no documentation as to why Patient #6’s prescribed treatment time was not met. The medical record failed to identify an against medical advice (AMA) form was completed. b. On 3/17/25 Patient #6 had three (3) hours and forty-seven (47) minutes of treatment (38 minutes short) with no documentation as to why Patient #6’s prescribed treatment time was not met and if the physician was notified. The medical record failed to identify an against medical advice (AMA) form was completed. c. On 3/31/25 Patient #6 had three (3) hours and twenty-eight (28) minutes of treatment (57 minutes short) with no documentation as to why Patient #6’s prescribed treatment time was not met and if the physician was notified. The medical record failed to identify an against medical advice (AMA) form was completed. Review of the against medical advice policy directed that the AMA form will be used for patients who refuse to complete the prescribed treatment. It further directed the charge nurse will review and have the patient sign the AMA form. It directed if shortened/early termination of treatment time exceeds 30 minutes or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any). The AMA form will be maintained in the patients medical records. 2. Patient #11 had diagnoses that included end stage renal disease. Physician’s order directed to hemodialysis treatments three (3) times weekly for four (4) hours and thirty (30) minutes per treatment, with a 450-milliliter blood flow rate, 600-milliliter dialysate flow rate, use of a 2.0 potassium/3.0 calcium bath, and upper right arm arteriovenous fistula. Review of the 11/15/24 treatment sheet identified Patient #11’s treatment was initiated at 10:31 AM and that he/she had become unresponsive at 10:58 AM. Staff had given 200 milliliters of normal saline, administered oxygen, and initiated CPR (cardiopulmonary resuscitation) until paramedics arrived and took over. Patient #11 regained a pulse while at the facility, was transported to the hospital, placed on comfort measures only, and expired 11/23/24. Interview with the Facility Administrator (FA) on 4/8/25 at 3:00 PM identified the facility failed to sequester the dialysis machine Patient #11 was receiving treatment on the day he/she suffered a cardiac arrest. The FA further identified that, following a cardiac arrest, the machine and all attachments were to be sequestered for testing and culturing to ensure the cause of the patient’s cardiac arrest was not due to the dialysis machine/equipment and that the machine was not to be reintroduced to the treatment floor until deemed safe for use. The FA indicated he/she was unsure why the machine was not sequestered and that “ball was dropped”. Interview with the Biomed Technician (BT) on 4/9/25 at 1:17 PM identified he/she was not aware that a cardiac arrest had occurred in the clinic on 11/15/24 or that the machine needed to be sequestered for additional testing. The BT indicated when a machine was sequestered following a cardiac arrest, it was tested to ensure the machine was working properly, which included verifying the machine was calibrated correctly, its conductivity and temperature were within acceptable limits, and that it was safe for future use. The BT further identified the dialyzer should have also been cultured at that time to identify if any endotoxins or chemicals were present when the event occurred as well as performing any other tests/cultures listed on the sequestering machine checklist. Review of the Preventative Maintenance Sheet for machine #13 (the machine Patient #11 was being treated on the day of his/her cardiac arrest) was not pulled for maintenance or checked for safety until March 11, 2025 (three (3) months and twenty-four (24) days following the cardiac arrest) and had passed all testing. Review of the Sequestering - Teammate Guidance in the Event of Unexpected Clinical Outcomes directed the procedure of sequestering equipment and product following a serious safety event, which included removing the dialysis delivery systems with the disposable components from the treatment area, collecting samples for a full dialysate electrolyte panel, dialysate environmental samples including bacterial and endotoxins, and chemical tests on the dialysate solution. 47491”