Fmc of Western Hartford

“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, facility documentation, facility policy and interviews, the facility failed to provide a clean and sanitary environment. The findings include: Flash tour observations conducted of the facility treatment floor on 8/22/24 between 9:30 AM - 10:30 AM identified the following: 1. The isolation room had an opening in the wall with drywall exposed behind the hemodialysis chair. 2. The front wall perpendicular to Station #18’s lower trim and mid wall had openings in the wall with drywall exposed. 3. At 10:18 AM Staff Person #2 was observed transferring a patient in the Hoyer lift with assistance from the Clinical Manager. PCT #2 placed the Hoyer pad on top of the Hoyer lift and failed to disinfect the hoyer lift after use. The Hoyer lift was subsequently used for another patient. Review of the cleaning and disinfecting of the dialysis station policy directed dialysis equipment is used by multiple patients during a treatment day and it is critical that those items are thoroughly cleaned and disinfected between uses.”

“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, the facility failed to perform hand hygiene after patient care. The findings include: Observation conducted on 8/22/24 at 10:20 AM identified Staff Person # 2 was observed wearing gloves while performing patient care at Station #5 (removing needles etc). Staff Person #2 assisted the patient to the scale, removed the mounted hand sanitizer on the wall to spray into the patient’s hands without the benefit of removing h/her gloves and performing hand hygiene before touching a clean item. Staff Person #2 then walked to the exit door and pushed the handicap button with the same gloves on without the benefit of removing his gloves and performing hand hygiene before touching a communal button. Review of the hand hygiene policy directed hands are to be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water before and after direct contact with patients.”

“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 a facility tour performed on 8/22/24 and observations made on 8/26/24, the facility failed to label and prepare heparin syringes in accordance with policy. The findings included: a. Observation on 8/22/24 at 10:00 AM identified three (3) sets of heparin locks (syringes filled with heparin to prevent clotting in central venous catheter limbs post treatment) were drawn at 9:12 AM by Staff Person #3 for three (3) patients with treatment termination times of 3:13 PM, 2:42 PM, and 3:30 PM. Interview with Staff Person #3 on 8/22/24 at 10:10 PM identified heparin syringes should not be prepared greater than 4 hours from the time of administration and indicated the syringes were prepared over four hours prior to use. b. Observation on 8/26/24 at 10:13 PM identified two syringes filled with heparin were labeled with the patient’s name and date, however, both syringes were missing the preparer’s initials and time the syringes were filled. Interview with Staff Person #4 on 8/26/23 at 10:30 AM identified facility policy directed to time and initial each drawn syringe at the time of preparation. Interview with the Clinical Manager on 8/26/24 at 10:13 AM identified each medication was to note time and initials of drawer on the label at the time the medication was preparation. Review of facility policy directed medications may be pre-drawn up to 4 hours prior to administration.”

“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 a review of clinical records, interview, and policy review for one (1) of five (5) hemodialysis patients reviewed for treatment assessments (Patient #4), the facility failed to ensure the patient was assessed by the registered nurse during treatment, and assessed by the registered nurse when abnormal findings were identified in accordance with facility policy. The findings include the following: Patient #4 had a diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and fifteen (15) minutes with a left upper arteriovenous fistula (AVF), fifteen (15) -gauge needs, a dialysate flow rate (DFR) of 500 and blood flow rate (BFR) of 450. A review of Patient #4’s treatment flowsheets identified the following: a. On 12/12/23 the flowsheet failed to identify a registered nurse assessment was completed for Patient #4 including fluid assessment and auscultation of lung and heart sounds. b. On 12/19/23 Patient #4’s pre-treatment vitals taking by a Patient Care Technician (PCT) at 12:15 PM were temperature of 100.7 (temperature last treatment on 12/26/23 was 97.0), respiratory rate of 22 breaths per minute (normal range is 12-20 breaths per minute), pulse 113 beats per minute (normal range is 80-100 beats per minute) and blood pressure sitting 173/102 (normal range is 120/80). The PCT started Patient #4’s treatment at 12:20 PM without documentation that the registered nurse was notified of Patient #4’s abnormal vitals and assessment prior to treatment initiation. The nursing assessment was documented at 12:40 PM identifying Patient #4 had hypertension on arrival, elevated temperature and tachycardic (high heart rate). At 1:00 PM Patient #4’s pulse was 137 beats per minute with no documentation that the RN was notified and assessment of Patient #4. At 1:30 PM Patient #4’s pulse was 106 beats per minute with no documentation that the RN was notified and assessment of Patient #4. Patient #4 completed treatment at 2:55 PM and Patient #4’s temperature at 3:05 PM was 99.0. The flowsheet failed to identify a nursing assessment was conducted post treatment and/or interventions post treatment for Patient #4’s abnormal temperature. c. On 12/28/23 the flowsheet failed to identify a registered nurse assessment was completed for Patient #4 including fluid assessment and auscultation of lung and heart sounds. Interview with the Clinical Manager on 8/26/24 at 1:28 PM identified nursing assessments should be competed pre and post treatment. She identified if a patient has abnormal vital signs pretreatment, the patient needs to be assessed by the RN and the RN is to notify the physician for orders. She identified if a patient has abnormal vital signs post treatment, the patient needs to be assessed by the RN and the RN is to notify the physician. Review of the patient assessment and monitoring assessment directed, in part, if the PCT/LPN note any changes or abnormal findings in the patient’s condition the registered nurse must assess the patient. The RN will notify the patient’s physician of any abnormal findings, if necessary, based on clinical judgement for additional instruction. The RN will assess/re-assess any findings addressed pre or during treatment as needed. The policy directed during treatment to report to the nurse patients whose heart rates have dropped below 60 or risen above 100. The policy directed post treatment to ensure vital signs (blood pressure, pulse, respirations and temperature) and overall condition are stable for discharge. The RN will assess/re-assess post treatment as indicated.”

“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: 44675 Based on a review of clinical records, interview, and policy review for six (6) out of eleven (11) hemodialysis patients reviewed for prescription adherence (Patient #4, #5, #6, #7, #8 and #9), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with the physician orders. The findings include the following: 1. Patient #4 was admitted to the facility with diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and fifteen (15) minutes with a left upper arteriovenous fistula (AVF), fifteen (15)-gauge needs, a dialysate flow rate (DFR) of 500 and blood flow rate (BFR) of 450. A review of Patient #4’s treatment flowsheets identified the following: a. On 12/2, 12/6, 12/7, 12/9, and 12/14/23 the entirety of the treatment Patient #4’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met. b. On 12/12/23 Patient #4’s treatment was initiated at 11:51 AM with a BFR of 400. At 12:37 PM Patient #4’s BFR was decreased to 350 with no rationale as to why the prescribed BFR of 450 was not met. Review of the nursing notes on the aforementioned dates failed to identify documentation of why Patient #4’s hemodialysis prescribed BFR was not achieved. 2. Patient #5 was admitted to the facility with diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with a right upper arteriovenous fistula (AVF), fifteen (15)-gauge needs, a dialysate flow rate (DFR) of 800 and blood flow rate (BFR) of 500. A review of Patient #5’s treatment flowsheets identified the following: a. On 8/1, 8/3, 8/15, and 8/17/24 the entirety of the treatment Patient #5’s BFR was 450 with no rationale as to why the prescribed BFR of 500 was not met. b. On 8/6, 8/10, and 8/13/24 the entirety of the treatment Patient #5’s BFR was 400 with no rationale as to why the prescribed BFR of 500 was not met. Review of the nursing notes failed to identify documentation of why Patient #5’s hemodialysis prescribed BFR was not achieved. 3. Patient #6 had diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours and fifteen (15) minutes with a tunneled central venous catheter (CVC) in the right thigh, a dialysate flow rate (DFR) of 800 and blood flow rate (BFR) of 450. A review of Patient #6’s treatment flowsheets identified the following: a. On 8/21/24, Patient #6 began treatment at 11:49 AM with a BFR of 450. At 12:38 PM, Patient #6’s BFR was decreased to 300, decreased again at 1:05 PM to 250, increased to 350 at 2:38 PM, and increased to 400 at 3:30 PM without notation of why the ordered BFR of 450 was not met. Further, Patient #6 had begun treatment with a DFR of 800 at 11:49 AM. At 1:25 PM, Patient #6’s DFR was decreased to 600, decreased to 500 at 2:38 PM and stayed at 500 for the remainder of his/her treatment without notation of why the ordered DFR of 800 was not met. b. On 8/19/24, Patient #6 began treatment at 12:08 PM with a BFR of 400. At 1:06 PM, Patient #6’s BFR was decreased to 350, decreased to 300 at 2:05 PM, and remained at 300 for the rest of the treatment without notation of why the ordered BFR of 450 was not met. d. On 8/16/23, Patient #6 began treatment at 12:37 PM at a BFR of 400. At 2:00 PM, Patient #6’s BFR was decreased to 350 and remained at 350 for the rest of the treatment without notation of why the ordered BFR of 450 was not met. e. On 8/14/24, Patient #6 began treatment at 12:11 PM at a BFR of 350. Patient #6’s BFR remained at 350 for the rest of his/her treatment without notation of why the ordered BFR of 450 was not met. f. On 8/12/24, 8/9/24, and 8/5/24, Patient #6’s treatments began at a BFR of 400 and remained at 400 for the duration of his/her treatment without notation of why the ordered BFR of 450 was not met. Review of the nursing notes failed to identify documentation of why Patient #5’s hemodialysis prescribed BFR was not achieved. 4. Patient #7 had diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and twenty (20) minutes with an arteriovenous fistula in the right upper arm, a dialysate flow rate (DFR) of 800 and blood flow rate (BFR) of 450. a. On 8/21/24, Patient #7 began treatment at 4:58 PM at a BFR of 400. At 7:32 PM, Patient #7’s BFR was decreased to 350 and remained at 350 for the rest of his/her treatment without notation of why the ordered BFR of 450 was not met. b. On 8/16/24, Patient #7 began treatment at 5:21 PM at a BFR of 400 and remained at a BFR of 400 for the duration of his/her treatment without notation of why the ordered BFR of 450 was not met. c. On 8/7/24, Patient #7 began treatment at 5:14 PM at a BFR of 500 and remained at a BFR of 500 for the duration of his/her treatment without notation of why the ordered BFR of 450 was not maintained. Review of the nursing notes failed to identify documentation of why Patient #5’s hemodialysis prescribed BFR was not achieved. 5. Patient #8 had diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours with a left forearm fistula, a dialysate flow rate (DFR) of 800 and blood flow rate (BFR) of 450. a. On 8/21/24, Patient #8 began treatment at 7:22 PM at a BFR of 450. At 7:37 PM, the BFR was increased to 500 and remained at 500 for the duration of his/her treatment without notation of why the ordered BFR of 450 was not maintained. b. On 8/19/24, Patient #8 began treatment at 7:18 PM at a BFR of 400 and remained at a BFR of 400 for the duration of his/her treatment without notation of why the ordered BFR of 450 was not maintained. c. On 8/12/24, Patient #8 began treatment at 5:42 PM at a BFR of 450. At 6:31 PM, the BFR was decreased to 400. At 7:32 PM, the BFR was decreased to 350 and remained at a BFR of 350 for the remainder of the treatment without notation of why the ordered BFR of 450 was not met. Review of the nursing notes failed to identify documentation of why Patient #5’s hemodialysis prescribed BFR was not achieved. 6. Patient #9 was admitted to the facility with diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with a right upper arteriovenous fistula (AVF), fifteen(15) gauge needles with a dialysate flow rate (DFR) of 800 and blood flow rate (BFR) of 500. A review of Patient #9’s treatment flowsheets identified the following: a. On 7/29, 8/5, 8/10, 8/17/24 the entirety of the treatment Patient #5’s BFR was 450 with no rationale as to why the prescribed BFR of 500 was not met. b. On 8/16/24 the entirety of the treatment Patient #5’s BFR was 400 with no rationale as to why the prescribed BFR of 500 was not met. Review of the nursing notes failed to identify documentation of why Patient #4’s hemodialysis prescribed BFR was not achieved. Interview with the Clinical Manager on 8/26/24 at 1:19 PM identified BFR’s and DFR’s should be maintained per physician’s orders. If there is an issue with achieving the prescribed BFR and/or a change in the DFR, it should be documented in a progress notes. Review of the patient assessment and monitoring assessment directed, in part, during treatment to document machine parameters and safety checks every 30 minutes or more often as needed. The policy directed to check that the prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow.”

“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 a review of clinical records, interview, and policy review for two (2) of eleven (11) hemodialysis patients reviewed for fluid management, (Patient # 6 and # 8), the facility failed to report an abnormal blood pressure in accordance to facility policy. The findings included the following: Patient #6 had end stage renal disease and required hemodialysis treatments three (3) times weekly for four (4) hours and fifteen (15) minutes, run at a 450 blood flow rate (BFR) and 800 dialysate flow rate (DFR). Review of Patient #6’s treatment sheets identified the following: a. On 7/22/24, a pre-treatment sitting blood pressure of 194/114. b. On 8/2/24, a post treatment sitting blood pressure of 185/110. c. On 8/19/24, a pre-treatment sitting blood pressure of 191/122, a pre-treatment standing blood pressure of 204/121, and a post treatment sitting blood pressure of 177/114, a post treatment standing blood pressure of 182/119. d. On 8/21/24, a post treatment sitting blood pressure of 193/107. Further review of Patient #6’s 7/22/24, 8/2/24, 8/19/24, and 8/21/24 treatment sheets failed to indicate a registered nurse and/or physician was notified of Patient #6’s elevated blood pressures. 2. Patient #8 had end stage renal disease and required hemodialysis treatments three (3) times weekly for three (3) hours, run at a 450 blood flow rate (BFR) and 800 dialysate flow rate (DFR). Review of Patient #8’s treatment sheets identified the following: a. On 8/2/24, a post treatment sitting blood pressure of 191/82 and a post treatment standing blood pressure of 215/102. b. On 8/10/24, a post treatment sitting blood pressure of 190/83. c. On 8/12/24, a pre-treatment sitting blood pressure of 192/87. d. On 8/21/24, a pre-treatment sitting blood pressure of 193/92, a pre-treatment standing blood pressure of 203/86, and a post treatment standing blood pressure of 217/97. Further review of Patient #8’s 8/2/24, 8/10/24, 8/12/24, and 8/21/24 treatment sheets failed to indicate a registered nurse and/or physician was notified of Patient #8’s elevated blood pressures. Interview with the Clinic Manager on 8/26/24 at 1:19 PM identified the physician should be notified when a patient’s sitting or standing blood pressures are elevated or depressed prior to the initiation of treatment and at the discontinuation of treatment. The Clinic Manager further indicated the registered nurse should assess the patient and document his/her findings and that non-nursing staff are expected to inform nurse’s when they see elevated or low blood pressures. Review of the Patient Assessment and Monitoring policy directed to inform the nurse of systolic blood pressures greater than 180 or less than 100, and diastolic blood pressures greater than 100.”

“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, interview, and review of facility documentation for one (1) of two (2) patients (Patient #7), reviewed for anemia, the facility failed to administer the proper dose of an erythropoetin stimulating agent (ESA) medication per facility protocol. The findings included: Patient #7 had end stage renal disease, a right upper arm arteriovenous fistula, and required hemodialysis three (3) times weekly for three (3) hours and twenty (20) minutes at a blood flow rate (BFR) of 450, dialysate flow rate (DFR) of 800. Review of Patient #7’s hemoglobin level dated 6/19/24 identified a result of 9.8. A physician’s order dated 6/19/24 directed 200 micrograms (mcg) of Micera (a medication which stimulates red blood cell production) every two (2) weeks. Review of Patient #7’s hemoglobin level dated 7/3/24 identified a result of 9.0 (0.8 less than the previous result). A physician’s order dated 7/8/24 directed for 150 mcg of Micera (50 mcg less that the previous order) every two weeks. Review of Patient #7’s hemoglobin lab dated 7/10/24 identified a result of 8.1 (0.9 less than the previous result). Review of the Anemia Algorhythm for Micera Intervenous Administration and interview with the Clinic Manager on 8/26/24 at 8:40 AM identified Patient #7 should have been maintained on his/her 200 mcg dose of Micera with the drop in hemoglobin from 9.8 to 9.0 instead of a decrease in his/her dose of Micera (from 200 mcg to 150 mcg) and that a reticulocyte hemoglobin (a blood test that measures the percentage of immature red blood cells) should have been ordered during the month of July 2024 to best determine the appropriate dose of Micera for Patient #7. Review of Patient #7’s labs identified a reticulocyte count was not ordered until August 2024. The Clinical Manager further indicated on 8/26/24 at 8:50 AM that he/she was unable to provide a reason why the reticulocyte hemoglobin lab was not ordered timely as the corporate anemia manager was responsible for overseeing clinical anemia management and for placing the lab order.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) of five (5) hemodialysis patients reviewed for albumin (Patient #9), the facility failed to ensure the patient had an albumin drawn monthly per physician’s orders. The findings include the following: 1. Patient #9 was admitted to the facility with diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes with an arteriovenous fistula (AVF). Patient #9’s physician lab orders directed a monthly albumin level. An albumin level dated 5/7/24 identified Patient #9’s albumin was 3.1 (normal range 3.5 -5.0). Review of Patient #9’s medical record failed to identify an albumin for June 2024. A Registered Dietician note dated 7/11/24 identified there was no June albumin. Ongoing education was provided on increased protein in the diet as albumin was typically low for Patient #9. Review of Patient #9’s medical record identified Patient #9 received treatments in June on 6/3/24, 6/5/24, 6/7/24, 6/20/24, 6/12/24, 6/14/24, 6/17/24, 6/19/24, 6/21/24, 6/24/24, 6/26/24 and 6/28/24. Review of the nursing progress notes failed to identify why an albumin lab was not drawn for the month of June 2024. Albumin lab dated 7/26/24 identified Patient #9’s albumin was 3.1. Interview with the Dietician on 8/26/24 at 12:24 PM identified albumins are drawn monthly. She identified she noted in her progress notes that Patient #9’s June 2024 albumin was missed but did not know why.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 47491 Based on clinical record review, facility documentation, policy review and interview, for two (2) patients reviewed for peritoneal dialysis, (Patient #1 and #2), the facility failed to ensure that peritoneal dialysis treatment sheets were monitored to ensure the dialysate orders were followed in accordance with physician’s orders. Patient #1 had end stage renal disease, required daily peritoneal dialysis treatments, and had a peritoneal dialysis catheter in his/her lower abdomen. Patient #2 had end stage renal disease, required daily peritoneal dialysis treatments, and had a peritoneal dialysis catheter in his/her lower abdomen. Review of both Patient #1 and Patient #2’s daily treatment records identified both patients were compliant with their daily treatments, however failed to identify both patients were following their fluid guidelines (which specified the concentration of dialysate solution to use with treatments based on weight and/or blood pressure). Interview with Staff Person #6 on 8/22/24 at 12:55 AM identified patients were expected to follow fluid guidelines when performing home dialysis treatments. Staff Person #6 further indicated patients are educated by the physician and nurse when they fail to follow their fluid guidelines, however Staff Person #6 was unable to provide the documentation to substantiate education was consistently provided as fluid guidelines were not followed on several occasions. Review of the Review and Documentation of Home Therapies Patient Health Data policy directed the home therapies nurse to perform a comprehensive monthly review of all treatment data, to discuss this data review with the patient at monthly clinic, and to address and document concerns accordingly.”

“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) of three (3) hemodialysis patients reviewed for treatment compliance (Patient #5), the facility failed to complete Against Medical Advice (AMA) forms in accordance with facility policy, and failed to ensure expired medications were disposed of. The findings include the following: 1. Patient #5 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes. A review of Patient #5’s hemodialysis flowsheets identified the following: a. On 8/1/24 Patient #5 had three (3) hours and seven (7) minutes of treatment (23 minutes short of prescribed treatment) with no documentation as to why Patient #5’s prescribed treatment time was not met. b. On 8/6/24 Patient #5 had two (2) hours and nine (9) minutes of treatment (1 hour and 21 minutes short of prescribed treatment time) with no documentation as to why Patient #5’s prescribed treatment time was not met and if the physician was notified. c. On 8/10/24 Patient #5 had two (2) hours and eighteen (18) minutes of treatment (1 hour and 12 minutes short of prescribed treatment time) with no documentation as to why Patient #5’s prescribed treatment time was not met and if the physician was notified. d. On 8/13/24 Patient #5 had three (3) hours and seven (7) minutes of treatment (23 minutes short of prescribed treatment time) with no documentation as to why Patient #5’s prescribed treatment time was not met. e. On 8/20/24 Patient #5 had three (3) hours and eighteen (1) 8 minutes of treatment (12 minutes short of prescribed treatment time) with no documentation as to why Patient #5’s prescribed treatment time was not met. Review of Resident #5’s medical record failed to identify AMA forms for 8/1/24, 8/6/24, 8/10/24, 8/13/24 and 8/20/24. Interview with the Clinical Manager on 8/26/24 at 1:28 PM identified if a patient wants to come off of treatment early, the patient should be encouraged to stay. If a patient terminates treatment early, regardless of how early, an AMA form should be completed. Review of the early termination or arriving late for treatment policy directed treatment duration and frequent if prescribed by a patient’s physician and the facility expects that all patients will adhere to their prescribed treatment time and schedule. If a patient requests to leave treatment early the RN will evaluate the patient and discuss with the patient their reasons for requesting to terminate earlier than prescribed. The RN who evaluates the patient must document the rationale for early termination and reinforce the consequences of not receiving the entire prescribed treatment, The RN is responsible to notify the physician and document on the AMA form. The policy directed AMA’s are signed with each early termination event and filed in the patients medical record. 2) Observation on 8/22/24 at 9:45 AM identified an opened, expired (dated 7/18/24) vial of tuberculosis vaccine in the medication refrigerator. Interview with the Clinic Manager on 8/22/24 at 10:17 AM identified multi-use, opened medication vials should not be kept in the medication refrigerator or in circulation thirty (30) days past the date it was opened. Review of the Medication Preparation and Administration policy directed to discard any open multi dose vials twenty-eight (28) days after opening.”