Dci - Avon Dialysis Inc.

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 46618 Based on facility documentation and interview the facility failed to ensure that the staff were educated anually on the evacuation plan. The finding includes: On 09/16/25 at approximately 10:00 AM, the surveyor was not provided with documentation from the Facility Administrator to indicate that the facility had eviewed the evacuation plan at least annually with staff as required by the Emergency Preparedness Codes, §494.62(b)(2), Condition for Coverage for End-Stage Renal Disease (ESRD) Facilities; i.e. there is no documentation that staff has been trained on the Emergency Plan -either initially or at least annually.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 47491 Based on review of clinical records, observations, and review of facility documentation and policy for two (2) of eight (8) patients (Patient #11 and #12) during treatment initiation, the facility failed to properly wear gowns and face mask when cannulating the patients’ hemodialysis accesses. The findings included: 1. Patient #12 had diagnoses which included end stage renal disease. A physician’s order directed hemodialysis treatment three times weekly for our (4) hours at a blood flow rate of 450 and a dialysate rate of 600 while utilizing a right upper arm fistula (AVF). Observation on 9/17/25 at 6:15 AM identified Staff Person #6 cannulating (inserting needles) into Patient #12’s access without wearing a gown or protective eyewear. 2. Patient # 11 had diagnoses that included end stage renal disease, a physician’s order for hemodialysis three (3) times weekly for three (3) hours and thirty (30) minutes per treatment, at a blood flow rate of 450 and dialysate flow rate of 800 while utilizing a left upper arm arteriovenous fistula (AVF). Observation on 9/17/25 at 6:16 AM identified Staff Person #7 cannulating (inserting needles) into Patient #11’s left upper arm arteriovenous fistula without wearing a gown or protective eyewear. Interview with Staff Person #6 and Staff Person #7 at 7:29 AM on 9/17/25 identified staff should be wearing personal protective equipment (which consisted of a gown, gloves, face shield and mask) when cannulating patients and that it was unsafe to cannulate patients without wearing proper personal protective equipment due to the potential of blood splatter. Interview with the Nurse Manager at 9:28 AM on 9/17/25 identified staff are expected to wear a gown, gloves, mask or face shield when cannulating patients or whenever there was a potential exposure to blood. Review of the Cannulation, Taping, and Removal of Hemodialysis Fistula/Graft Needle policy directed staff to put on full personal protective equipment, which includes a gown, gloves, and face shield when there was a risk from splash from blood or body fluids. Review of the Universal Precautions policy directed staff to wear personal protective equipment appropriate to the anticipated potential occupational exposure and during the initiation and termination of dialysis treatment, manipulation of access, needles, or catheters, administration of medications through the extracorporal circuit or by subcutaneous injection, the reprocessing of dialyzers, and cleaning an disinfecting of patient care supplies and equipment.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 47491 Based on observations and inteview, the facility failed to ensure that the doors to the treatment floor were not propped open. The findings included: Observation at 6:12 AM on 9/17/25 identified the lobby door leading to the clinic floor was propped and left open using a wooden wedge. Interview with the Charge Nurse on 9/17/25 at 6:18 AM identified the lobby door leading to the clinic floor remained open to let first shift patients into the clinic, however should have been closed. Interview with the Nurse Manger on 9/17/25 at 7:40 AM identified the door connecting the lobby to the clinic floor should always remain closed, unless being used to enter or exit the clinic floor. The Nurse Manager further identified that when ht edoor was propped open anyone could enter the treatment floor. Although requested, the facility did not have a written policy regarding the fire door.”

“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 prescriptions, 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 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 treatment records identified the following: i. 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. ii. On 8/1/25, Patient #2’s treatment was initiated at a BFR of 300 from 12:03 AM 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. iii. On 8/8/25 Patient #2’s treatment was administered at a BFR of 300 for the entirety of the 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 documents and policy for one (1) of five (5) patients (Patient #4) reviewed for medication administration, the facility failed to administer blood pressure medication in accordance with physician’s orders to a patient with chronic hypotension. The findings included:. Patient #4 had diagnoses that included end stage renal disease, a physician’s order for hemodialysis treatment three (3) times weekly for three (3) hours and forty-five (45) minutes, at a blood flow rate of 400 and dialysate rate of 600 while using a central venous catheter (CVC). 1. A physician’s order directed administration of 10 milligrams (mg) of Midodrine (administered to treat low blood pressures) for systolic blood pressure less than 140 pre-treatment, a mid-treatment 10 mg dose of Midodrine for systolic blood pressures less than 100, and administration of 5 mg of Midodrine to be given at 10:00 AM. Review of Patient #4’s treatment records identified the following: i. A treatment record dated 8/18/25 failed to identify Patient #4 was administered his/her 10:00 AM dose of Midodrine. ii. A treatment record dated 8/20/25 identified Patient #4’s pre-treatment blood pressure was 107/55 at 6:27 AM and dialysis treatment was initiated at 6:32 AM. However, the treatment record identified Patient #4 was administered his/her pre-treatment dose of Midodrine at 8:14 AM, however, this was one hour and forty-two minutes after treatment initiation. iii. A treatment record dated 9/3/25 identified Patient #4’s pre-treatment blood pressure was 113/80 at 6:21 AM and dialysis treatment was initiated at 6:27 AM. However, the treatment record failed to identify Patient #4 had been administered his/her pre-treatment and 10:00 AM dose of Midodrine. iv. A treatment record dated 9/5/25 identified blood pressures of 91/55 at 9:57 AM, 93/64 at 10:01 AM, and 98/59 at 10:06 AM, however failed to identify the 10:00 AM dose of Midodrine was administered. Interview with the Nurse Manager at 8:46 AM on 9/17/25 identified the facility could administer pre-treatment medications up to one (1) hour following treatment initiation and that the 10-milligram pre-treatment dose of Midodrine on 8/20/25 at 8:14 AM was late. The Nurse Manager further identified the facility’s standard of practice was to follow physician’s orders. Review of the Medication Preparation Administration and Documentation policy directs to assess the right time and frequency of medication administration.”

“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 a review of clinical records, interview, and policy review for one (1) of four (4) hemodialysis patients reviewed for anemia (Patient #3), the facility failed to transcribe an increased in medication dosage for a patient with a decrease in hemoglobin. The findings include the following: 1. Patient #3 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three times weekly for three (3) hours and 30 minutes with a left upper arteriovenous fistula (AVF) and an estimated dry weight (EDW) of 110.5 kilograms (kg). Review of Patient #3’s labs identified on 7/9/25 Patient #3’s hemoglobin was 11.1 (expected lab range 10-12). A physician’s order 7/11/25 through 8/1/25 directed Mircera (increase red blood cell production) 30 micrograms (mcg) every two (2) weeks. Review of Patient #3’s labs identified on 7/30/25 Patient #3’s hemoglobin was 8.1 (3 point drop in the hemoglobin level). Review of medication administration report dated 7/30/35 identified Patient #3 received Mircera 30 mcg. A nursing note dated 8/1/25 identified Patient #3’s hemoglobin was 8.1, a significant drop from 11.1. The APRN was notified and ordered Mircera increase to 120 mcg every two (2) weeks. A physician’s order dated 8/2/25 - 8/28/25 directed Mircera 120 mcg every two (2) weeks. Review of Patient #3’s labs identified on 8/6/25 identified Patient #3’s hemoglobin was 7.7 A nursing note dated 8/8/25 identified Patient #3’s hemoglobin was 7.7. The physician was notified and increased Mircera to 120 mcg every week. An anemia care plan note dated 8/12/25 identified the physician increased Patient #3’s Mircera order to be administered weekly. Review of Patient #3’s labs identified on 8/13/25 identified Patient #3’s hemoglobin was 8.9. Review of Patient #3’s labs identified on 8/20/25 identified Patient #3’s hemoglobin was 9.6 Review of medication administration report dated 8/20/35 identified Patient #3 received Mircera 120 mcg (two week after dose on 8/4/25, the dose was changed to weekly on 8/8/25). Interview and record review with the Clinical Manager on 9/16/25 at 2:33 PM identified on 8/8/25 the RN wrote a note that Patient #3’s hemoglobin was 7.7 and the physician ordered 120 mcg Mircera weekly, however did not enter the order into the system. She identified the anemia protocol continued to change the Mircera dose based on the labs drawn. Review of the Corporate Mircera Management Protocol identified the goal is maintain a hemoglobin of 10 - 11 g/dl.”

“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 four (4) hemodialysis patients reviewed for prescriptions (Patient #5), the facility failed to ensure the patient’s hemodialysis treatment was in accordance with the physician orders. The findings include the following: 1. Patient #5 was admitted to the facility with diagnoses that included end stage renal disease. Review of the physician’s orders directed hemodialysis three times weekly for three (3) hours and forty-five (45) minutes with a right internal jugular central venous catheter (CVC) and a blood flow rate (BFR) of 450. Patient #5’s kt/v (measures adequacy of hemodialysis) on 7/21/25 was 1.2 (goal for adequate dialysis is 1.2). A sample review of Patient #5’s treatment flowsheets identified the following: i. On 8/18/25 Patient #5’s CVC was accessed successfully, however for the entirety of the treatment Patient #5’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met. ii. On 8/20/25 Patient #5’s CVC was accessed successfully, however for the entirety of the treatment Patient #75s BFR was 300 with no rationale as to why the prescribed BFR of 450 was not met. iii. On 8/25/25 Patient #5’s CVC was accessed successfully, however for the entirety of the treatment Patient #5’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met. iv. On 9/1/25 Patient #5’s CVC was accessed successfully, however for the entirety of the treatment Patient #5’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met. v. On 9/3/25 Patient #5’s CVC was accessed successfully, however for the entirety of the treatment Patient #5’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met. Patient #5’s kt/v on 9/3/25 was 1.17. vi. On 9/12/25 Patient #5’s CVC was accessed successfully, however for the entirety of the treatment Patient #5’s BFR was 400 with no rationale as to why the prescribed BFR of 450 was not met. Review of the clinical record failed to identify documentation of why Patient #5’s hemodialysis prescribed BFR was not achieved. Interview with the Clinical Manager on 9/16/25 at 2:18 PM identified the company goal for kt/v is 1.3. She identified Patient #5 was started on IDPN which could make the kt/v worse and his/her time was increased. Patient #5’s kt/v was 1.2 on 7/21/25 and therefore Patient #5’s BFR was increased to 450. She further identified if a BFR is not achieved, staff are to document the reason why. If the BFR is consistently not met, the physician is to be notified. Review of the Patient Assessments: During Dialysis (Chronic) policy directed during treatment to assess machine parameters every thirty (30) minutes, including blood and dialysate flow rate. Ensure that prescribed rates are being delivered as it affects dialyzer clearance.”

“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 observation, clinical records, interview, and policy review for one (1) out of seven (7) patients (Patient #11), the facility failed to ensure a patient receiving hemodialysis treatment had their hemodialysis access visible throughout treatment, and for one (1) out of four (4) hemodialysis patients reviewed for treatment initiation (Patient #10, #13, and #14), the facility failed to ensure the patient’s hemodialysis access was appropriately cleaned and disinfected before cannulation per facility policy, and for one (1) of four (4) patients (Patient #2), reviewed for treatment monitoring, the facility failed to ensure abnormal vital signs pre, during and post treatment, were addressed with the charge nurse and physician per facility policy. The findings included the following: 1. Patient # 11 had diagnoses that included end stage renal disease, a physician’s order for 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 450, dialysate flow rate of 800 while utilizing a left upper arm arteriovenous fistula (AVF). Observation of Patient #11 while receiving treatment on 9/17/25 identified the following: i. At 6:55 AM, Patient #11 was observed with a blanket covering his/her left upper arm fistula. ii. At 7:01 AM, Staff Person #6 was observed in Patient #11’s station verifying vitals and machine parameters on his/her dialysis machine, however failed to assess Patient #11’s access which remained covered. iii. At 7:15 AM, the surveyor summoned the charge nurse to Patient #11’s station and asked what type of access the patient had. The Charge Nurse proceeded to remove Patient #11’s blanket from his/her access arm to identify the type and location of his/her access. Interview with Charge Nurse on 9/17/25 at 7:18 AM identified Patient #11’s access site was covered by his/her blanket and should have been assessed when staff entered Patient #11’s station. The Charge Nurse further identified a covered access could delay staff’s response to a displaced or dislodged needle which could result in an infiltration or bleeding event. Interview with the Nurse Manager at 9:58 AM on 9/17/25 identified patient accesses were to remain uncovered at all times when receiving treatment. Interview with the Medical Director at 10:06 AM on 9/17/25 identified the policy was clear and that a patient’s hemodialysis access was to remain uncovered throughout dialysis treatment as unexpected bleeding could occur and lead to exsanguination or death. Review of the Line Separation policy directed the patient’s vascular access should always be visible while on treatment. 2. Patient #10 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 left upper arteriovenous fistula (AVF), 15-gauge needles and blood flow rate (BFR) of 400. i. Observation conducted on 9/16/25 at 11:30 AM identified Staff Person #5 performing treatment initiation for Patient #10 at Station #10. Staff Person #5 used a total of two (2) alcohol pads per cannulation site prior to cannulation. Staff Person failed to use a total of three (3) alcohol pads per cannulation site per facility policy. 3. Patient #13 had diagnoses that included end stage renal disease, a physician’s order for hemodialysis three (3) times weekly for four (4) hours and thirty (30) minutes, using a right forearm fistula. i. Observation on 9/17/25 at 6:26 AM identified Patient #13 being prepared for treatment initiation. Staff Person #7 utilized an alcohol prep pad and wiped the entire length of the access, vertically, twice, utilized a new alcohol prep pad and wiped the arterial cannulation site once from left to right and inserted the arterial needle. Staff Person #7 than palpated Patient #13’s access prior to cannulating with the second (venous) needle, however failed to clean the cannulation site after touching it. 4. Patient #14 had diagnoses that included end stage renal disease, a physician’s order for hemodialysis three (3) times weekly for four (4) hours a, using a left upper arm graft. Observation on 9/17/25 at 6:37 AM identified Patient #14 being prepared for treatment initiation. Staff Person #6 utilized the same alcohol prep pad three separate times, cleaned the patient’s access in a vertical motion, and then inserted the arterial needle. Interview with the Staff Educator on 9/17/25 at 9:47 AM identified the access should be cleansed with three (3) separate alcohol prep pads in a circular, in to out motion, with no specified dry or contact time. Review of the Cannulation, Taping, and Removal of Hemodialysis Fistula/Graft Needle directed staff to cleanse the venipuncture area of the access using three (3) alcohol prep pads per site, using a circular motion from in to out, and to insert the needles while the alcohol was still wet. The policy further directed once the site had been cleaned, the area must not be re-contaminated by the patient or by staff touching the area. If the site were to become contaminated, then re-disinfect. 5. Patient #2 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 forty-five (45) minutes with a right internal jugular catheter (CVC) and 450 blood flow rate (BFR). Review of Patient #2’s hemodialysis orders did not identify physician “special orders” and/or patient specific parameters during treatment. A sample review of Patient #2’s hemodialysis treatment flowsheets identified the following: a. On 8/18/25 Patient #2’s pre-treatment pulse was 56 Beats Per Minute (BPM) (normal heart rate is 60 -100 BPM) and treatment started at 11:03 AM with a pulse of 52 BPM by the LPN. Patient #2’s pulse remained below 60 BPM during treatment with a range of 46 BPM - 56 BPM. Patient #2’s post-treatment pulse was 56 PBM. Review of the flowsheet failed to identify if Patient #2’s abnormal heart rate was addressed with the change nurse and if physician were notified. The post treatment nursing assessment timed at 2:35 PM did not address Patient #2’s abnormal vital signs and/if the physician was notified. Review of the nursing notes failed to identify if Patient #2’s abnormal vital sign was addressed with the physician. b. On 8/22/25 Patient #2’s pre-treatment pulse was 55 BPM and treatment started at 11:03 AM with a pulse of 53 BPM by the LPN. Patient #2’s pulse remained below 60 BPM during treatment with a range of 48 BPM - 54 BPM. Patient #2’s post-treatment pulse was 51 PBM. Review of the flowsheet failed to identify if Patient #2’s abnormal heart rate was addressed with the change nurse and if physician were notified. The post treatment nursing assessment timed at 2:42 PM did not address Patient #2’s abnormal vital signs and/if the physician was notified. Review of the nursing notes failed to identify if Patient #2’s abnormal vital sign was addressed with the physician. c. On 8/29/25 Patient #2’s pre-treatment pulse was 63 BPM treatment started at 11:17 AM with a pulse of 60 BPM. At 11:59 AM Patient #2’s pulse decreased to 57 BPM, at 12:29 PM was 52 BPM, at 1:00 PM was 48 BPM, at 1:09 PM was 51 BPM and remained in the 50’s for the remainder of the treatment. Review of the flowsheet failed to identify Patient #2’s abnormal pulses were addressed. Patient #2’s post-treatment pulse was 58 PBM. Review of the flowsheet failed to identify if Patient #2’s abnormal heart rate was addressed with the change nurse and if physician were notified. The post treatment nursing assessment timed at 2:50 PM did not address Patient #2’s abnormal vital signs and/if the physician was notified. Review of the nursing notes failed to identify if Patient #2’s abnormal vital sign was addressed with the physician. d. On 9/5/25 Patient #2’s pre-treatment pulse was 59 BPM and treatment started at 11:12 AM with a pulse of 59 BPM by the LPN. Patient #2’s pulse remained below 60 BPM during treatment with a range of 48 BPM - 54 BPM. Patient #2’s post-treatment pulse was 51 PBM. Review of the flowsheet failed to identify if Patient #2’s abnormal heart rate was addressed with the change nurse and if physician were notified. The post treatment nursing assessment timed at 2:42PM did not address Patient #2’s abnormal vital signs and/if the physician was notified. Review of the nursing notes failed to identify if Patient #2’s abnormal vital sign was addressed with the physician. Interview and policy review with the Clinical Educator on 9/17/25 at 10:50 AM identified for a pulse less than 60 BPM, the Patient Care Tehnician/Licensed Practical Nurse is to notify the Registered Nurse (RN) and the RN is to notify the Charge Nurse (CN). Further, for a pulse less than 50 BPM, the CN is to notify the Physician (MD). Interview with the Clinical Manager on 8/17/25 at 1:30 PM identified Patient #2 did not have patient specific special physician orders to be dialyzed with a pulse less than the policy identifies (less than 60 BPM). Therefore, the facility is expected to follow the guidance of the patient assessment policy. Review of the Patient Assessments: Pre-Dialysis and Post-Dialysis policy directed to assess the patient’s vital signs pre-treatment, including pulse rate. Notify the CN of a rate greater than 120 BPM or less than 60 BPM. Review of the DCI Staff Parameter Reporting Guidelines directed the acceptable range for heart rate is 60 - 100 BPM regular or known previous irregular. The PCT/LPN should report to the RN and the RN should report to the CN if the heart rate is less than 60 BPM or greater than 120 BPM or a new onset of irregular. The CN should report to the physician if the heart rate is less than 50 BPM or greater than 120 BPM or a new onset of an irregular rhythm”