Fmc Shoreline Dialysis Center

“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: a. Observations conducted on 8/12/25 at 2:10 PM identified during disinfection of the hemodialysis station after a patient treatment, Staff Person #4 failed to clean and disinfect the crit line (monitors blood volume, blood levels, and oxygen saturation) attached to the machine and the drain lines coming from the machine to the wallbox. She further failed to clean and disinfect the chair step on the bottom of the hemodialysis chair. b. Observations conducted on 8/13/25 at 10:01 AM identified during disinfection of the hemodialysis station after a patient treatment, Staff Person #3 failed to clean and disinfect the drain lines coming from the machine to the wallbox. She further failed to clean and disinfect the chair step on the bottom of the hemodialysis chair. c. Observations conducted on 8/13/25 at 10:58 AM identified during disinfection of the hemodialysis station after a patient treatment, Staff Person #1 failed to clean and disinfect the drain lines coming from the machine to the wallbox and the chaise wall behind the chair. She further failed to clean and disinfect the television inside of the station. Review of the cleaning and disinfecting of the dialysis station policy directed to externally disinfect the dialysis machine with 1:100 bleach solution after each dialysis treatment. It directed to use a 1:100 bleach solution to clean the dialysis station (chair/bed, tables, machine, television, IV pole, BP cuff, hand sanitizer dispenser, chaise wall behind chair).”

“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 two (2) of four (4) patients, (Patient #8 and #9), observed during dialysis treatment termination, the facility failed to ensure staff changed gloves and performed hand hygiene prior to disconnecting the patient from their dialysis treatment, and for one (1) of two (2) hemodialysis patients (Patient #11) reviewed for catheter care, the facility failed to perform catheter care per facility protocol. The findings included: 1. Patient #8 had diagnoses that included End Stage Renal Disease (ESRD). Physician’s orders directed to hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes, using a 2.0 potassium/2.5 calcium dialysate, a blood flow rate of 400, and a dialysate flow rate of 800 while utilizing a central venous catheter (CVC). Observation made on 8/12/25 at 9:14 AM identified Patient #8 being prepared for treatment termination. Staff Person #2 was observed adjusting Patient #8’s blood pressure cuff prior to disconnecting his/her dialysis line from the arterial limb of his/her CVC and subsequently failed to change his/her gloves and perform hand hygiene prior to disconnecting the arterial line from the patient’s catheter, exposing the uncovered end of the catheter to potential contamination. Furthermore, Staff Person #2 again adjusted Patient #8’s blood pressure cuff prior to disconnecting his/her dialysis line from the venous limb of his/her CVC and failed to change his/her gloves and perform hand hygiene prior to disconnecting the venous line from the patient’s catheter, exposing the uncovered end of the catheter to potential contamination. Staff Person #2 continued with the termination of treatment process, applying syringes with normal saline to each catheter end to flush both limbs, attaching a new syringe to each limb to instill the heparin, and then covered the end of each open catheter limb with a cap, all while using the same gloves he/she was wearing when adjusting the blood pressure cuff. 2. Patient #9 had diagnoses that included ESRD. Physician’s orders directed to hemodialysis three (3) times weekly for four (4) hours, using a 2.0 potassium/2.5 calcium dialysate, a blood flow rate of 400, and a dialysate flow rate of 800 while utilizing a central venous catheter (CVC). Observation made on 8/12/25 at 10:34 AM identified Patient #9 being prepared for treatment termination. Staff Person #2 was observed adjusting Patient #9’s face mask as he/she prepared to disconnect the treatment lines from the patient’s CVC, however Staff Person #2 failed to change his/her gloves and perform hand hygiene prior to initiating the disconnection process. Staff Person #2 was observed disconnecting the lines from each CVC limb, attaching a syringe with normal saline to flush both limbs, attaching a new syringe to each limb to instill heparin, and then applying a cap to the opened catheter limb prior to applying a gauze wrap to contain the limbs of the catheter, all while using the same gloves he/she adjusted the patient’s mask. Interview with the Charge Nurse on 8/13/25 at 11:16 AM identified staff should be changing gloves and performing hand hygiene prior to initiating the disconnection process when their hands contact of a possible contaminant in order to prevent cross contamination prevent infection. Review of the Termination of Treatment Using A Central Venous Catheter policy directs staff to change gloves, perform hand hygiene, and apply new gloves after obtain the patient’s blood pressure during the disconnection process. 3. Patient #11 had diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours with a central venous catheter (CVC). Observation conducted on 8/13/25 at 10:58 AM identified Staff Member #5 performing treatment initiation at Station #4 with Patient #11. Patient #11 was observed with his/her mask below his/her nose during treatment discontinuation. Staff Member #5 exposed the hubs of the catheter while Patient #11’s mask was not covering his/her nose. Review of the discontinuation of treatment using a central venous catheter policy directed prior to discontinuation put a mask on the patient, doff (remove) gloves, perform hand hygiene and don new gloves.”

“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 one (1) of three (3) patients, (Patient #2), reviewed for hemodialysis prescription, the facility failed to administer the patient’s dialysis treatment in accordance with physician’s orders. The findings included: Patient #2 had diagnoses that included ESRD. Physician’s orders directed hemodialysis three (3) times weekly for four (4) hours, using a 2.0 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 (CVC). Review of Patient #2’s treatment records identified the following: a. On 7/23/25, Patient #2’s treatment was initiated at a BFR of 350 from 11:53 AM to 12:03 PM, then decreased to 325 from 12:03 PM to 12:31 PM, and decreased to 300 from 12:31 PM to 1:06 PM, and to 270 from 1:06 PM to 1:50 PM without documentation identifying the reason the ordered BFR of 400 was not achieved. b. On 8/1/25, Patient #2’s treatment was initiated at a BFR of 300 from 12:03 PM to 12:36 PM, then decreased to 250 from 12:36 PM to 1:03 PM, and increased to 300 from 1:03 PM to 4:02 PM without documentation identifying the reason the ordered BFR of 400 was not achieved. c. On 8/8/25, Patient #2’s treatment was administered at a BFR of 300 for the entirety of the four (4) hour treatment without documentation identifying the reason the ordered BFR of 400 was not achieved. Interview with the Charge Nurse on 8/13/25 at 10:55 AM identified staff should be documenting reason the prescribed BFR could not be attained in the electronic medical record, and that the nurse should be informed to ensure interventions were implemented and the physician updated if warranted. 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: 47491 Based on review of clinical records, interviews, and review of facility documentation for two (2) of three (3) patients (Patient #2 and #4) reviewed for intradialytic hypotension, the facility failed to address the patient’s low intradialytic blood pressures and/or administer blood pressure medication in accordance with physician’s orders. The finding includes: 1. Patient #2 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 400, dialysate flow rate (DFR) of 800, use of a central venous catheter (CVC), and an estimated dry weight (EDW) of 57.0 kilograms. A physician’s order dated 9/4/24 directed Midodrine HCl, 10 milligrams by mouth, as needed and may repeat two (2) times for systolic blood pressures below 110. Review of Patient #2’s 5/30/25 treatment sheet identified the following: a. A blood pressure of 101/68 at 12:04 PM, documentation failed to identify that 10 milligrams of midodrine was administered. b. A blood pressure of 101/68 at 12:32 PM, documentation failed to identify that 10 milligrams of midodrine was administered. c. A blood pressure of 84/66 was recorded at 1:06 PM, documentation failed to identify that 10 milligrams of midodrine was administered. d. A blood pressure of 106/70 at 1:19 PM, documentation failed to identify 10 milligrams of midodrine was administered. e. A blood pressure of 105/50 at 1:40 PM and administration of 10 milligrams of midodrine [one (1) hour and thirty-six (36) minutes following the recorded blood pressure of 101/68]. f. A blood pressure of 96/58 was recorded at 3:00 PM. Documentation failed to indicate that 10 milligrams of midodrine was administered. 2. Patient #4 had diagnoses that included ESRD. Physician’s orders directed hemodialysis three (3) times weekly for four (4) hours and thirty (30) minutes per treatment, using a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 400, dialysate flow rate (DFR) of 800 utilizing a Central Venous Catheter (CVC). Review of Patient #4’s treatment sheets identified the following: a. On 6/28/25, a blood pressure of 95/37 and 83/36 were recorded at 10:34 AM. Documentation failed to indicate an intervention was implemented or that a nursing assessment was performed. b. On 7/3/25, a blood pressure of 74/41 was recorded at 10:30 AM. The next blood pressure recorded was 86/51 at 10:47 AM. Documentation failed to indicate the patient’s blood pressure was reassessed or that an intervention was implemented. Interview with the Charge Nurse on 8/13/25 at 10:01 AM identified the patients’ blood pressures should have been reassessed when systolic blood pressure was less than 100, the nurse should have been informed of the patient’s low blood pressure reading so that he/she could assess the patient, and normal saline should have been administered to stabilize the patient. The Charge Nurse further indicated that an additional dose of midodrine should have been administered to Patient #2 as several systolic blood pressure readings fell below that 110 parameter established in the physician’s order (as long as the times of administration were at least one (1) hour apart). Review of the Hypotension policy directed staff to recheck the patient’s blood pressure, compare to the previous blood pressures, if the blood pressure is verified low, place the patient into a modified Trendelenberg (elevation of legs 30-45 degrees above the patient with hip flexion) position, reduce ultrafiltration to minimum 300 milliliters/hour, notify physician for additional orders, administer normal saline bolus of 100-200 milliliters as ordered, if blood pressure doesn’t respond to normal saline bolus to immediately contact the treating physician for orders, and monitor and document blood pressure every five (5) minutes until the patient returns to baseline or as ordered by the treating physician.”

“PA-ASSESS ANEMIA CFR(s): 494.80(a)(4) The patient’s comprehensive assessment must include, but is not limited to, the following: (4) Evaluation of factors associated with anemia, such as hematocrit, hemoglobin, iron stores, and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agent(s). This Standard is not met as evidenced by: 47491 Based on review of clinical records, interviews, and review of facility policy and documentation for one (1) of three (3) patients (Patient #2) reviewed for anemia, the facility failed to draw a patient’s hemoglobin following hospitalization in accordance with facility policy. The finding included: Patient #2 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 400, and dialysate flow rate (DFR) of 800 while using a central venous catheter (CVC). Review of Patient #2’s blood work dated 7/23/25 identified a hemoglobin result of 10.1. Review of the hospital discharge summary identified Patient #2 was hospitalized from 7/24/25 to 7/31/25. Review of facility documentation identified Patient #2 returned to the facility and was administered hemodialysis treatment on 8/1/25, 8/4/25, and 8/6/25. Review of Patient #2’s blood work dated 8/6/25 (five (5) days post hospitalization) identified Patient #2’s hemoglobin level had dropped to 8.6 g/dL (a 1.5 g/dL drop) from the previous hemoglobin lab draw dated 7/23/25. Interview with the Charge Nurse on 8/13/25 at 10:36 AM identified the facility’s standard of practice was to draw a patient’s hemoglobin level on their first treatment following a hospitalization and that the facility missed scheduling his/her lab draw on the first or second day he/she returned to the clinic (8/1/25 and 8/4/25). Review of the Micera Algorithm In Center 4.0 Quick Reference Guide directed to discontinue the patient’s current dose of Micera following hospitalization, draw a hemoglobin the first treatment back at the facility, select the Micera dose using the Maintenance Dose Chart, and administer the dose following the lab draw/dose administration schedule.”

“POC-OUTCOME NOT ACHIEVED-ADJUST POC CFR(s): 494.90(b)(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient’s current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section. This Standard is not met as evidenced by: 44675 Based on clinical records, facility policy and interviews for one (1) of three (3) patients (Patient #1), reviewed for care plans, the facility failed to adjust the patient’s plan of care to reflect newly diagnosed comorbidity resulting in an adjustment to anemia management per facility policy. 1. Patient #1 was admitted to the facility with diagnoses that included End Stage Renal Disease (ESRD). Review of the physician’s orders directed hemodialysis two (2) times weekly for four (4) hours with a left upper Arteriovenous Fistula (AVF). Review of the annual care plan dated 12/18/24 identified Patient #1 was stable. The area of focus for anemia management identified the goal for hemoglobin was 10-11 with interventions that included change in ESA (stimulate red blood cell production) dose and to monitor hemoglobin, ferritin and t-stat (iron levels). Review of Patient #1’s medication administration record identified Micera (ESA) was last administered on 4/30/25. The physician note dated 5/14/25 identified Patient #1 had a new diagnosis of rectosigmoid cancer and had a plan for a robotic resection. It identified Patient #1’s hemoglobin was below goal and ESA was contraindicated due to his/her comorbidity. The social worker note dated 5/23/25 identified she received a call from a referred hospital transplant unit that Patient #1 was deferred due to invasive cancer found during colonoscopy. Hemoglobin result dated 6/3/25 identified Patient #1’s hemoglobin was 6.5 (goal is greater than or equal to 10). A nursing note dated 6/6/25 identified Patient #1’s hemoglobin was 6.5, was not prescribed Mircera (ESA) due to malignancy, and had a transfusion on 6/5/25. The hospital discharge summary dated 6/20/25 - 6/25/25 identified Patient #1 had a right hemicolectomy (remove portion of intestine) due to carcinoma (cancer) of the colon. The social worker note dated 7/11/25 identified Patient #1 was scheduled to start chemotherapy every other week for six (6) months. A nursing note dated 7/25/25 identified for Patient #1 to have a transfusion for a hemoglobin less than seven (7). The interdisciplinary team failed to update the care plan with new goals and/or interventions after Patient #1’s new onset of a cancer diagnosis and management for anemia (due to erythropoietin stimulating agent now contraindicated). Interview with the Clinical Manager on 8/13/25 at 2:00 PM identified the facilities care plan electronic system did not trigger an unstable care plan assessment for Patient #1. She identified the care plan should be updated within thirty (30) days to reflect the new diagnosis. Review of the comprehensive interdisciplinary assessment and plan of care policy identified the components of the comprehensive interdisciplinary assessment include current health status including co-morbid conditions and evaluation of factors associated with anemia and potential treatment plan for anemia. It further directed unstable criteria as marked deterioration in health status, such as advance or metastatic cancer or other organ system disease which interferes with the patient’s ability to follow aspects of the treatment plan. It directed unstable patients must be assessed by the IDT monthly.”

“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 one (1) of seven (7) patient (Patient #7) receiving hemodialysis treatment the facility failed to ensure the hemodialysis access was visible at all times, for (1) of three (3) hemodialysis patients (Patient #1) reviewed for treatment compliance, the facility failed to ensure that Against Medical Advice (AMA) forms were completed in accordance with facility policy, for one (1) of three (3) hemodialysis patients (Patient #3) reviewed for treatments the facility failed to ensure the pre-treatment nursing assessment was completed timely per facility policy, for one (1) of three (3) patients (Patient #6) reviewed for treatments, the facility failed to perform a post treatment standing blood pressure for an ambulatory patient. The findings included:. 1. Patient # 7 had diagnoses that included End Stage Renal Disease (ESRD). A physician’s order directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes per treatment, utilizing a 2.0 potassium/ 2.5 calcium dialysate bath, at a blood flow rate of 400, and an autoflow 1.5 dialysate flow rate while utilizing a Central Venous Catheter (CVC). Observation of Patient #7 while receiving treatment on 8/12/25 identified the following: a. At 1:03 PM Patient #7’s CVC was covered completely by a pillow. b. At 1:05 PM Staff Person #1 at Patient #7’s dialysis station to check his/her vitals. Staff Person #1 adjusted Patient #7’s blood pressure cuff (on his/her right arm), however failed to addressed Patient #7’s covered access, At 1:06 PM, surveyor observed Staff Person #1 leaving Patient #7’s dialysis station to attend to another patient. Interview with Staff Person #1 on 8/12/125 at 1:09 PM identified Patient #7’s access site was still covered as Staff Person #1 removed his/her pillow that was laying on his/her chest to identify the location of the patient’s CVC. Staff Person #1 identified the patient’s access should never be covered, that when you enter a patient’s station for whatever need or reason, their access should always be checked to ensure it was visible. Staff Person #1 further identified hat he/she glanced over at Patient #7’s access to see if it was visible, but didn’t realize that it was covered. Interview with the Charge Nurse on 8/13/25 at 11:18 AM identified staff should be checking and assessing the patient each time they enter a patient’s station, which includes ensuring the access is visible. Interview with the Medical Director on 8/13/25 at 12:07 PM identified the hemodialysis access should always be visible throughout a patient’s treatment to ensure the patient is not bleeding and to prevent the patient from exsanguination (bleeding out). The Medical Director further identified that staff should be checking the patient’s access each time they enter the patient’s station. Review of the Patient Assessment and Monitoring policy directed staff to ensure the access remains uncovered throughout the patient’s treatment. 2. Patient #1 was admitted to the facility with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours with a left upper Arteriovenous Fistula (AVF). A review of Patient #1’s dialysis treatment sheets identified the following: a. On 7/4/25 Patient #1 received three (3) hours and fifty-one (51) minutes of treatment (9 minutes early). The flowsheet and nursing notes failed to identified why Patient #1’s treatment was terminated early and if the charge nurse and/or physician was notified. b. On 7/11/25 Patient #1 received three (3) hours and forty-nine (49) minutes of treatment (11 minutes early). The flowsheet and nursing notes failed to identified why Patient #1’s treatment was terminated early and if the charge nurse and/or physician was notified. c. On 7/16/25 Patient #1 received three (3) hours and forty (40) minutes of treatment (20 minutes early). The flowsheet and nursing notes failed to identified why Patient #1’s treatment was terminated early and if the charge nurse and/or physician was notified. Review of Patient #1’s medical record failed to identify an against medical advice (AMA) form was reviewed and completed. d. On 7/21/25 Patient #1 received three (3) hours and fifty-two (52) minutes of treatment (8 minutes early). The flowsheet and nursing notes failed to identified why Patient #1’s treatment was terminated early and if the charge nurse and/or physician was notified. Review of Patient #1’s medical record failed to identify an against medical advice (AMA) form was reviewed and completed. e. On 8/1/25 Patient #1 received three (3) hours and twenty-two (22) minutes of treatment (38 minutes early). The flowsheet and nursing notes failed to identified why Patient #1’s treatment was terminated early and if the charge nurse and/or physician was notified. f. On 8/6/25 Patient #1 received three (3) hours and forty-three (43) minutes of treatment (17 minutes early). The flowsheet and nursing notes failed to identified why Patient #1’s treatment was terminated early and if the charge nurse and/or physician was notified. Review of Patient #1’s medical record failed to identify an against medical advice (AMA) form was reviewed and completed. Interview with the Clinical Manager on 8/13/25 at 2:00 PM identified on Fridays, Patient #1 received chemotherapy and came to treatment after. She identified the facility cannot allow for his full treatment time due to the facility closing. She identified Patient #1 would not need to complete an AMA for the Fridays the facility is not able to accommodate him/her (7/4, 7/11 and 8/1). She identified for the other days the patient should have completed an AMA. Review of the early termination or arriving late for treatment policy directed for patients requesting early termination of a treatment in an outpatient facility will be referred to the supervising registered nurse. The RN will evaluate the patient and discuss with the patient their reasons for requesting to terminate their treatment earlier than prescribed. The RN who evaluates the patient must be document the rationale for early termination and reinforce the consequences of not receiving the entire prescribed treatment. The RN is responsible for notifying the provider, and to document on the AMA form. 3. Patient #3 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 sample review of Patient #3’s dialysis treatment sheets identified the following: a. On 7/9/25 Patient #3’s treatment was initiated at 10:21 AM and the nursing assessment was documented as completed at 12:31 PM (2 hours and 10 minutes after treatment initiation). b. On 7/25/25 Patient #3’s treatment was initiated at 10:13 AM and the nursing assessment was documented as completed at 2:48 PM (4 hours and 35 minutes after treatment initiation). c. On 8/6/25 Patient #3’s treatment was initiated at 10:40 AM and the nursing assessment was documented as completed at 12:30 PM (1 hour and 50 minutes after treatment initiation). d. On 8/8/25 Patient #3’s treatment was initiated at 10:21 AM and the nursing assessment was documented as completed at 12:31 PM (2 hours after treatment initiation). Interview with the Clinical Manager on 8/13/25 at 2:00 PM identified the medical record should reflect the accurate time the nursing assessment was completed. Review of the nursing supervision and delegation policy directed that the registered nurse must evaluate each patient preferably within an hour or according to state requirements. 3. Patient #6 had diagnoses that included ESRD. Physician’s orders directed hemodialysis three (3) times weekly for three (3) 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 7/10/25 and 7/24/25 identified the patient was ambulatory, however, failed to identify a post treatment standing blood pressure was administered for an ambulatory patient. Interview with the Clinical Manager on 8/13/25 at 2:40 PM identified ambulatory patients should be administered a post treatment standing blood pressure and if refused, staff should be documenting the declination. 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.”