Davita Black Rock Dialysis

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 44675 Based on facility staffing review, interview and review of facility policy the facility failed to ensure the treatment floor had a charge nurse that remained without an assignment. The finding included: Staffing schedules were reviewed for the period of 3/6/24 - 3/20/24. A sample review of the patient/staffing schedules identified the following: 1. On 3/7/24 the Clinical Coordinator was the charge nurse and was responsible for an assignment of six (6) patients on the first shift and three (3) patients on the second shift. 2. On 3/14/24 the charge nurse was responsible for an assignment of six (6) patients on the first shift and five (5) patients on second shift. 3. On 3/15/24 the Clinical Coordinator was the charge nurse and was responsible for an assignment of nine (9) patients on the first shift, nine (9) patients on second shift and six (6) patients on third shift. Review of the Connecticut Public Health Code Section 19-13-D dated 11/21/22 directed that in addition to the nurse manager, who shall not be counted in the dialysis unit’s staffing pattern. Interview with the FA 3/20/24 at 12:30 PM identified on 3/14/24 the Clinical Coordinator did not come in to work because he had already worked five days in a row. She identified on the days where the charge nurse had an assignment, she sent out a text to all the FA’s in the area looking for staff to pick up a shift but no one responded.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 44675 Based on observations, clinical record review, interview and review of facility policy for one (1) of three (3) patients reviewed for treatment initiation, (Patient #28), the facility failed to ensure the supplies used for the patient’s access remained with clean prior to use, and failed to properly clean a dialysis station. The finding included: a. Patient #28 had diagnoses that included end stage renal disease. Patient 28 #’s physician orders included hemodialysis treatment three times a week for three hours and thirty minutes with a right forearm Arteriovenous Fistula (AVF) connection between an artery and a vein that is accessed for hemodialysis treatments), 2.0 K 2.5 Ca dialysate, an estimated dry weight (EDW) of 79.5 kilograms and blood flow rate of 400. Observation conducted on 3/20/24 at 10:12 AM identified Staff Person #2 was preparing for Patient #28’s cannulation of his/her hemodialysis access. At 10:13 AM Staff Person #2 was observed tearing off medical tape into pieces and taping directly onto Patient #2 chairside table with no clean barrier between the chairside table and the tape. b. Observations while disinfecting Station #9 on 3/20/24 at 9:55 AM Staff Person #2 failed to clean the top of the IV pole, Hansen connectors and tubing, outside surface of the right and left chair arms, television and television arm, and counter behind the dialysis treatment chair. c. Observations while disinfecting Station #8 on 3/20/24 at 10:00 AM, Staff Person #3 failed to clean the cage on the side of the dialysis machine holding the television remote, outside surface of the right and left chair arms, television and television arm, and counter behind the dialysis treatment chair. Interview with the Clinical Coordinator on 3/20/24 at 2:00 identified it would be appropriate for the tape to have a barrier between the chairside table. Review of the Infection Control for Dialysis Facilities policy directed the dialysis station to be cleaned and disinfected at the end of each treatment.”

“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: 47491 Based on observations and review of facility policy, the facility failed to perform hand hygiene between tasks which created the potential of exposing patients and staff to contaminated medical equipment, infectious substances, and the transmission of infectious diseases. The findings included: a) Staff Person # 2 on 3/20/24 at 9:35 AM failed to perform hand hygiene after removing gloves following the insertion of needles to retrieve a syringe from the utility cart. b) Staff Person # 2 on 3/20/24 at 9:45 AM failed to perform hand hygiene after removing his/her gloves after disconnecting the lines from Patient #30’s central venous catheter (and proceeded to take Patient #30’s temperature and enter data into the computer with bare hands) and between glove changes prior to applying caps to the exposed limbs of Patient #30’s central venous catheter. Furthermore, Staff Person #2 failed to perform hand hygiene while disinfecting the dialysis station in between glove changes after disposing of items left on station #9’s side table, wiping down the wall box, cleaning the dialysis machine and getting additional cleaning cloths from the utility cart, and when disposing of used cleaning cloths. c) Staff Person #3 failed to offer Patient #29 at 9:55 AM hand sanitizer after holding his/her sites following treatment and removing his/her glove. Patient #29 proceeded to get weighed and left the facility without performing hand hygiene. Review of the Infection Control for Dialysis Facilities policy directs hand hygiene prior to gloving and immediately after glove removal.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 44675 Based on observations, clinical record review, interview and review of facility policy the facility failed to ensure the hemodialysis station was disinfected thoroughly per facility policy. The finding included: a) Observations conducted on 3/19/24 at 10:00 AM identified Staff Person #1 was disinfecting the dialysis station after a hemodialysis treatment. Staff Person #1 failed to clean the drain lines from the hemodialysis machine to the wallbox. Review of the infection control for dialysis facilities policy directed the wall box, drain, and water supply lines are considered part of the dialysis delivery system and should be clean with 1:100 bleach as part of the routine station disinfection between each patient treatment.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 47491 Based on observations and review facility policy, the facility failed to use aseptic technique when preparing intravenous medications. The findings included: Staff Person #4 was observed filling heparin syringes on 3/20/24 at 10:15 AM and failed to wash his/her hands prior to drawing heparin and failed to disinfect the septum of the heparin bottle prior to inserting the needle into the bottle for each heparin draw. Review of the Medication Policy directed an aseptic environment and technique is to be used when preparing medications and careful attention to hand washing is to be performed at this time. Review of the Anticoagulation Policy directed aseptic technique must be used for disinfection of the stopper prior to any entry of the vial.”

“PE-LSC-SPRINKLERS CFR(s): 494.60(e)(2) (2) Notwithstanding paragraph (d)(1) of this section, dialysis facilities participating in Medicare as of October 14, 2008 that require sprinkler systems are those housed in multi-story buildings construction Types II(000), III(200), or V(000), as defined in the Life Safety Code, section 21.1.6.1, which were constructed after January 1, 2008, and those housed in high rise buildings over 75 feet in height, which were constructed after January 1, 2008. This Standard is not met as evidenced by: 32738 Based on observation during document review on 03/18/24 at 10:30 AM while accompanied by the Regional Bio-Medical Technician the facility failed to maintain its sprinkler system. The findings include the following: a. Documentation was not provided to indicate that the wet and dry fire sprinkler systems had been inspected every 5 (five) years, as required by NFPA 25, “Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems”; i.e. no documentation of Fire Department connection hydrotesting being completed. b. Documentation was not provided to indicate that the fire pump for the facility sprinkler system has not been flow tested (at least annually) and churn tested monthly, as required by NFPA 25, “Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems”.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 44675 Based on clinical record review, interview and review of facility policy for one (1) of three (3) Patients reviewed for prescription compliance,(Patient #5), the facility failed to address an irregular finding pre, intra and post treatment per facility policy. The finding included: Patient #5 was admitted to the facility with diagnoses that included end stage renal disease and atrial fibrillation (irregular heartbeat). Patient #5’s physician orders included hemodialysis treatment three times a week for three hours and fifteen minutes, 2.0 K 2.5 Ca dialysate, estimated dry weight (EDW) of 82.5 kg and blood flow rate of 450. Review of Patient #5’s flowsheets identified the following: 1. On 1/22/24 Patient #5’s pre-treatment pulse at 2:42 PM was 119 Beats Per Mimute (BPM) standing and 107 BPM sitting (a normal pulse rate is between 60 - 100 BPM). Treatment was initiated at 2:54 PM by a patient care technician (PCT). The nursing assessment was conducted at 2:59 PM (after treatment was initiated with an abnormal finding) and although the heart rate was documented as 119 BPM, she identified Patient #5’s heart rate was of regular rate and rhythm. Patient #5’s post treatment pulse at 4:55 PM was 115 BPM standing and 101 BPM sitting. Patient #5’s post assessment identified Patient #5 was tachycardic (pulse greater than 100 BPM) but failed to identify what interventions were put into place and if the physician was notified. 2. On 1/25/24 Patient #5’s pre treatment pulse at 5:33 AM was 120 BPM standing and 111 BPM sitting. Treatment was initiated at 5:46 AM by a patient care technician (PCT) and the nursing assessment was conducted at 5:55 AM (after treatment was initiated with an abnormal finding). Patient #5’s post treatment pulse at 9:16 AM was 106 BPM standing and 104 BPM sitting. Patient #5’s post assessment was completed at 9:21 AM and identified Patient #5 was tachycardic but failed to identify what interventions were put into place and if the physician was notified. 3. On 1/27/24 Patient #5’s pre treatment pulse at 5:29 AM was 115 BPM standing and 111 BPM sitting. The nursing assessment was conducted at 6:12 AM and identified Patient #5’s heart rate was tachycardic. Patient #5’s post treatment pulse at 9:25 AM was 117 BPM standing and 100 BPM sitting. Patient #5’s post assessment identified Patient #5 was tachycardic but failed to identify what interventions were put into place and if the physician was notified. 4. On 1/30/24 Patient #5’s pre treatment pulse at 5:42 AM was 127 BPM standing and 117 BPM sitting. The nursing assessment was conducted at 5:57 AM and identified Patient #5’s heart rate was tachycardic. Patient #5’s post treatment pulse at 9:36 AM was 107 BPM standing and 114 BPM sitting. Patient #5’s post assessment identified Patient #5 was tachycardic but failed to identify what interventions were put into place and if the physician was notified. 5. On 2/1/24 Patient #5’s pre treatment pulse at 5:34 AM was 130 BPM standing and 121 BPM sitting. The nursing assessment was conducted at 5:43 AM and although the heart rate was documented as 130 BPM, she identified Patient #5’s heart rate was of regular rate and rhythm. Patient #5’s post treatment pulse at 9:14 AM was 71 BPM standing and 121 BPM sitting. Patient #5’s post assessment identified Patient #5’s heart rate was of regular rate and rhythm although the heart rate was documented as 121 BPM. 6. On 2/3/24 Patient #5’s pre treatment pulse at 5:38 AM was 127 BPM standing and 122 BPM sitting. The nursing assessment was conducted at 5:55 AM and identified Patient #5’s heart rate was tachycardic. Patient #5’s post treatment pulse at 9:16 AM was 127 BPM standing and 112 BPM sitting. Patient #5’s post assessment identified Patient #5 was tachycardic but failed to identify what interventions were put into place and if the physician was notified. 7. On 2/5/24 Patient #5’s pre treatment pulse at 2:41 PM was 122 BPM standing and 102 BPM sitting. The nursing assessment was conducted at 2:58 PM and although the heart rate was documented as 122 BPM, she identified Patient #5’s heart rate was of regular rate and rhythm. Patient #5’s post treatment pulse at 4:51 PM was 113 BPM standing and 110 BPM sitting. Patient #5’s post assessment identified Patient #5 was tachycardic but failed to identify what interventions were put into place and if the physician was notified. 8. On 2/6/24 Patient #5’s pre treatment pulse at 5:37 AM was 136 BPM standing and 126 BPM sitting. The nursing assessment was conducted at 5:49 AM and identified Patient #5’s heart rate was tachycardic. Patient #5’s post treatment pulse at 9:20 AM was 114 BPM standing and 97 BPM sitting. Patient #5’s post assessment identified Patient #5 was tachycardic but failed to identify what interventions were put into place and if the physician was notified. 9. On 2/8/24 Patient #5’s pre treatment pulse at 5:37 AM was 114 BPM standing and 113 BPM sitting. The nursing assessment was conducted at 5:40 AM and identified Patient #5’s heart rate was tachycardic. Patient #5’s post treatment pulse at 9:13 AM was 120 BPM standing and 111 BPM sitting. Patient #5’s post assessment identified Patient #5 was tachycardic but failed to identify what interventions were put into place and if the physician was notified. 10. On 2/10/24 Patient #5’s pre treatment pulse at 5:42 AM was 120 BPM standing and 119 BPM sitting. Treatment was initiated at 5:48 AM by a patient care technician (PCT) and Patient #5’s pulse was documented as 114 BPM. Patient #5’s treatment pulses signed off by the PCT were 112 BPM at 6:01 AM and 113 BPM at 6:32 AM. The nursing assessment was conducted at 6:49 AM (after treatment was initiated with an abnormal finding). Patient #5’s post treatment pulse at 9:23 AM was 111 BPM standing and 112 BPM sitting. Patient #5’s post assessment identified Patient #5 was tachycardic but failed to identify what interventions were put into place and if the physician was notified. Review of the hospital discharge summary dated 2/12/24 - 3/1/24 identified Patient #5 had a history of heart failure, atrial fibrillation and end stage renal disease. It identified Patient #5 finished his/her dialysis session on 2/12/24 with subsequent tachycardia and was sent to the emergency department by dialysis staff. On arrival to the emergency department, Patient #5’s pulse was 143 BPM and received Cardizem push for his/her heart rate in the 140’s. Interview with the Clinical Coordinator on 3/20/24 at 1:00 PM identified the technician needs to alert the nurse of an abnormal pulse rate prior to treatment initiation and the nurse needs to assess the patient prior to treatment initiation. Post treatment the nurse needs to assess the patient and alert the charge nurse if the patient remains with an abnormal pulse. The charge nurse is then to contact the physician on how to proceed and if the patient refuses, an against medical advice form needs to be completed. Review of the pre-intra-post treatment data collection, monitoring and nursing assessment policy directed during pre treatment data collection/assessment, any abnormal findings or findings outside of any patient specific ordered parameters discovered during the pre-treatment collection will be documented and immediately reported to the licensed nurse and the licensed nurse will assess the patient prior to the initiation of dialysis. It further directed the licensed nurse will round on patients without reported abnormal findings and complete the nursing assessment within one hour of treatment initiation. It identified the licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary and the physician will be notified of any concerns that may preclude the initiation of dialysis. If an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse and the licensed nurse will use their clinical judgement to determine if any clinical interventions or notification of the physician is necessary prior to discharge from the facility. It identified an abnormal finding of heart or pulse rate pre/intra/post is greater than 100 BPM and/or an irregular heart beat.”

“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: 44675 Based on clinical record review, interview and review of facility policy for two (2) of three (3) Patients (Patient #5 and #7), reviewed for anemia, the facility failed draw hemoglobin and hemacue per physician’s orders and address a significant drop in hemoglobin levels over one week with the physician. The finding included: 1. Patient #5 was admitted to the facility with diagnoses that included end stage renal disease and atrial fibrillation (AFIB). Patient #5’s physician orders included hemodialysis treatment three times a week for three hours and fifteen minutes, 2.0 K 2.5 Ca dialysate, estimated dry weight (EDW) of 82.5 kg and blood flow rate of 450. The annual stable plan of care dated 8/14/23 identified Patient #5’s hemoglobin goal was over 10 and that the team would continue to monitor the patient, check blood work and administer Mircera per protocol. Review of Patient #5’s hemoglobin labs identified on 12/14/23 Patient #5’s hemoglobin was 11.4 (expected value goal for chronic kidney patients is 10-12) and on 12/28/23 was 9.2 (decrease of 2.2 points in two weeks). A physician’s order dated 12/26/24 directed Mircera 75 mcg one time push for anemia. A physician’s order dated 1/3/24 directed Mircera 75 mcg every two weeks for anemia. Review of Patient #5’s lab results identified Patient #5’s hemoglobin on 1/11/24 was 7.5. Nursing note dated 1/16/24 at 11:22 AM identified Patient #5’s hemoglobin remained on a downward trend. Patient #5 reported having a urinary stent replaced three weeks ago with urinary bleeding for one to two weeks post procedure. The APRN increased Mircera to 100 mcg every two weeks and hemacue (measures hemoglobin in real time) to be checked at every treatment. A physician’s order dated 1/16/24 directed Mircera 100 mcg every two weeks for anemia. Review of Patient #5’s lab results identified on 1/18/24 Patient #5’s occult blood (stool sample) was negative for blood in his/her stool and Patient #5’s hemoglobin was 7.6. An APRN note dated 1/23/24 identified Patient #5’s hemoglobin was trending up, Mircera dose was increased and to draw a weekly hemoglobin. Review of Patient #5’s lab results identified Patient #5’s hemoglobin on 1/18/24 was 7.6 and on 1/25/24 was 7.4. An APRN note dated 1/30/24 identified for Patient #5’s anemia, to draw a weekly hemoglobin and hemacue every treatment. Review of Patient #5’s nursing notes and treatment flowsheets failed to identify a hemacue was measured on Patient #5’s treatment days of 1/25/24, 1/27/24 and 1/30/24. Review of Patient #5’s hemoglobin lab orders identified on 2/6/24 there was an order for a hemoglobin lab once a week and the order was discontinued on 2/7/24 by the electronic system. On 2/7/24 there was an order for a hemoglobin lab once a week and was discontinued on 2/8/24 by the electronic system. On 2/8/24 there was an order for hemoglobin two times a month. Review of Patient #5’s lab results identified Patient #5’s hemoglobin was not drawn weekly per the APRN direction on 1/23/24 and therefore Patient #5 did not have his/her hemoglobin measured on 1/1/24 and 2/8/24. Further review of Patient #5’s lab results identified Patient #5 had no hemoglobin results for the month of February 2024. Review of Patient #5’s nursing notes and treatment flowsheets failed to identify a hemacue was measured on Patient #5’s treatment days of 2/3/24, 2/6/24, 2/10/24 and 2/12/24. Patient #5 was hospitalized from 2/12/24 - 3/1/24 (unrelated to anemia). Review of Patient #5’s lab results identified Patient #5’s hemoglobin on 3/7/24 was 8.3 and on 3/14/14 was 8.8. Review of Patient #5’s nursing notes and treatment flowsheets failed to identify a hemacue was measured on Patient #5’s treatment days of 3/2/24, 3/7/24, 3/9/24 and 3/16/24. Interview with the Clinical Manager on 3/20/24 at 12:30 PM identified there is no policy and/or procedure related to hemacue. She identified the hemacue would be measured per the physician and as directed in their progress notes. Interview with the Clinical Coordinator on 3/20/24 at 1:30 PM identified there is currently not a way to place an order for patient hemacues in the electronic record. He identified the process is that if a patient needs a hemacue drawn, a post it note is placed on the machine and/or verbalized to the staff member. It was identified he was unaware Patient #5 did not have hemoglobin(s) results in February and identified the electronic record system canceled the lab order. 2. Patient #6 was admitted to the facility with diagnoses that included end stage renal disease. Patient #6’s physician orders included hemodialysis treatment three times a week for three hours and fifteen minutes, 2.0 K 2.5 Ca dialysate and an estimated dry weight (EDW) of 67.0 kg. Review of Patient #6’s lab results identified Patient #6’s hemoglobin on 12/15/23 was 13.8 and on 12/29/24 was 8.4 (a 5.4 decrease in two weeks). The Centralized Anemia Manager (CAM) note dated 1/2/24 identified Patient #5 had a hemoglobin decrease of 5.4 points, Mircera was restarted at 75 mcg every four weeks and could receive the dose in one week. It further identified the CAM sent notification to the facility and would call in the morning. Review of Patient #6’s progress notes failed to identify if the facility staff were aware of Patient #6’s hemoglobin decrease of 5.4 points and if the physician was notified of Patient #6’s hemoglobin decrease. Interview with the Clinical Coordinator on 3/20/24 at 1:16 PM identified for the large decrease in Patient #6’s hemoglobin, a hemacue (measures hemoglobin in real time) should have been done, and if the hemacue remained low the APRN should have been called.”

“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: 32738 Based on facility documentation, clinical record review, and interviews for 18 patients reviewed for medication administration, (Patient # 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 26, and 27) the facility failed to ensure that medications were labeled and prepared timely in accordance with facility policy. The findings include: 1. a. Patient #10 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer cinacalcet 30 milligrams at each hemodialysis treatment. b. Patient #11 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.75 micrograms at each hemodialysis treatment. c. Patient #12 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.75 micrograms at each hemodialysis treatment. d. Patient #13 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 2.5 micrograms at each hemodialysis treatment. e. Patient #14 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.25 micrograms at each hemodialysis treatment. f. Patient #15 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.25 micrograms at each hemodialysis treatment. g. Patient #16 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 1.0 micrograms at each hemodialysis treatment. h. Patient #17 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.75 micrograms at each hemodialysis treatment. i. Patient #18 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.25 micrograms at each hemodialysis treatment. j. Patient #19 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer cinacacet 30 milligrams at each hemodialysis treatment. k. Patient #20 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.50 micrograms at each hemodialysis treatment. Observations on 3/18/24 at 10:05 AM during the flash tour of the medication room identified Patient #10 through Patient #20’s aforementioned medications stacked in medication cups without the initials of who had poured the medications. 2. a. Patient #21 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer cinacalcet 125 milligrams at each hemodialysis treatment. b. Patient #22 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer cinacalcet 60 micrograms at each hemodialysis treatment. c. Patient #23 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.25 micrograms at each hemodialysis treatment. d. Patient #24 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 125 micrograms at each hemodialysis treatment. e. Patient #25 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 1.0 microgram at each hemodialysis treatment. f. Patient #26 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.25 micrograms at each hemodialysis treatment. g. Patient #27 had a diagnosis of end stage renal disease and required hemodialysis three (3) times weekly. Physicians orders dated 3/1/24 directed to administer calcitriol 0.25 micrograms at each hemodialysis treatment. Observations on 3/18/24 at 10:05 AM during the flash tour of the medication room identified Patient #20 through Patient #27’s aforementioned medications were stacked in medication cups without the initials of who had poured the medications, further the aforementioned patients treatment times were for the third shift and the time of the observation was the beginning of second shift. Interview with the charge nurse on 3/18/24 at 10:15 AM identified that the medications should be labeled with the initials of who poured the medications and medications should only be poured for the current shift of patients. Review of the medication administration policy identified that when a medication is poured the nurse must initial the label and medications should only be poured for the current shift. .”