Fkc Smyrna

“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: 27438 Based on observation, interview, and a dialysis treatment floor inspection form review, it was determined the facility’s physical environment was not maintained to provide a comfortable treatment environment for patients and staff when three ceiling light panels were observed non-functioning on the treatment floor for one of three treatment days. The non-functioning lights hindered the facility’s ability to provide ceiling lighting for patient treatment and had the potential to negatively affect all 59 in-center hemodialysis patients on census. Findings include: Observation on 01/15/25 at 10:35 AM revealed the ceiling panel lights at Station #9, #11, and ceiling panel light above the treatment floor laboratory work area were not functioning. During an interview on 01/15/25 at 11:05 AM, the Facility Administrator verified the lights were not functioning by having the light wall switches for the unit turned off and on by staff. During an interview on 01/15/25 at 12:30 PM, the Area Technical Operations Manager verified the lights were not functioning and stated he/she had created a requisition to fix the lights. Review of the facility’s form provided by the Facility Administrator titled, “Physical Environmental Building Inspection/Building Interior Physical Environmental Inspection,” an undated computer form, failed to identify a question related to the observation of the treatment floor ceiling lighting.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 27438 Based on observations, interviews, policy, and manufacturer’s directions for use (DFU) review, the facility failed to follow the bloodline manufacturer’s DFU during dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing it through a filter) treatments by not monitoring and maintaining the arterial drip chamber (a pressure and air monitoring component of the dialysis bloodline tubing) fluid levels at 85- 95% full during treatment for one of three treatment days. Failure to follow the manufacturer’s DFU had the potential to negatively impact the safety and wellbeing of the 59 patients receiving in-center hemodialysis treatments at this facility. Findings include: 1. Observations on 01/13/25 between 10:20 AM and 10:42 AM revealed the arterial drip chamber fluid levels were less than 50% full in Stations 10 and 12. Patient Care Technician (PCT) 2 was observed interacting and documenting at Station 10 and 12, however failed to adjust the arterial drip chamber (level at 50%) to the manufacturer’s DFU of 85-95%. During an interview on 01/13/25 at 10:42 AM, PCT 2 verified the arterial chamber levels at the stations were low and stated staff are to observe the chamber levels during observations and adjust the level when observed low to 75%. PCT2 was unable to provide the manufacturer’s recommendation that arterial drip chamber fluid levels should be 85-95% full during treatment. 2. Observations on 01/13/25 between 10:20 AM and 11:00 AM revealed the arterial drip chamber fluid level was less than 50% full in Stations 8. During an interview on 01/13/25 at 11:00 AM, PCT 1 verified the arterial chamber level at station 8 was below 50% and stated staff are responsible to observe the chamber levels during treatment and adjust the level as needed. PCT1 was unable to provide the manufacturer’s recommendation that arterial drip chamber fluid levels should be 85-95% full during treatment. Review of the “COMBISET Blood Tubing Set with Access Flow Reversing Connector,” manufacturer’s DFU used at this facility indicated, “Dialysis Treatment precautions ...Maintain fluid level in pre-pump arterial chamber at 85 to 95% full.... Readjust levels as needed.””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 27438 Based on observation, interview, and policy review, the facility failed to ensure patient’s hemodialysis access site was uncovered and visible for one of three days of the survey. The dialysis access site (tubing/needle insertion sites and line connections) for all patients on treatment must always be visible to staff to ensure the lines and tubing/needles do not become dislodged or disconnected and could affect all 59 hemodialysis patients receiving treatment in the facility. Findings include: Observations on 01/15/25 between 10:45 AM and 11:05 AM revealed the Patient (P) 8 at Station 14 had his/her dialysis access site covered by a blanket. The Certified Clinical Hemodialysis Technician (CCHT) 3 was observed communicating with P8 but failed to uncover the access site during the 20-minute observation. During an interview on 01/15/25 at 11:05 AM, CCHT3 acknowledged that P8’s access was covered and should always be uncovered for safety purposes. Review of the facility’s policy titled, “Patient Assessment and Monitoring,” revision date 05/01/2023, indicated, “All patients must be under visual observation by clinical staff during treatment ...Observe connections are secure and visible ...ensure access remains uncovered throughout the treatment.””

“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: 27438 Based on record reviews, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for one of seven in-center patients (Patient (P)6). Failure to follow the medical providers dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for all 59 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P6’s “Treatment Sheet” forms, found in the electronic medical record (EMR), revealed three of six printed “Treatment Sheet” forms from 01/02/25 through 01/14/25, indicated the following: On 01/02/25, the staff failed to follow the dialysis prescription Blood Flow Rate (BFR) of 400 milliliters per minute (ml/min) when during the four-hour treatment the BFR remained at 350 ml/min. On 01/04/25, the staff failed to follow the dialysis prescription BFR of 400 ml/min when during the four-hour treatment the BFR remained at 350 ml/min. On 01/07/25, the staff failed to follow the dialysis prescription BFR of 400 ml/min when during the four-hour treatment the BFR remained at 350 ml/min. There was no documented rationale for the change to the prescribed BFR. During an interview on 01/14/25 at 2:00 PM, the Facility Administrator reviewed and verified the discrepancy between the prescription and machine generated “Treatment Sheet” forms for P6 and revealed that he/she expects staff to monitor and document the BFR findings every 30 minutes and all treatment prescriptions for patients to be followed or have documentation on why the prescription was not followed. Review of the facility’s policy titled, “Patient Assessment and Monitoring,” revised 05/01/2023, indicated, “During Treatment...Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations ...Check prescribed blood flow is being achieved, or reason is documented in the medical record if unable to meet prescribed blood flow.”

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 44880 Based on document review and staff interview it was determined that the facility failed to collaborate with local emergency preparedness agencies annually, with potential to impact all 60 patients who receive treatments at the facility. Findings include: The facility document titled, “Guidelines for Emergency Preparedness” dated 7/3/2023 stated, “...Annually per procedure, the facility will contact their local disaster management agency to ensure that the agency is aware of the dialysis facility’s presence in the community in the event of an emergency...” There was no evidence of annual contact to the local emergency preparedness agency to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This finding was confirmed with Employee #2 on 3/6/24 at 2:58 PM.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility 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. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 46255 Based on document review and staff interview it was determined that the facility failed to maintain emergency preparedness supplies with potential to impact 28 of 28 patients at the facility on 3/5/24. Findings include: The facility document titled, “Emergency Medications, Equipment and Supplies” dated 05/01/23 stated, “... An emergency evacuation box contains supplies primarily needed to emergently remove needles, cap catheters, and provide saline as needed for every licensed station once the patient is in a secure location. Refer to Emergency Evacuation Box Contents...The medications and supplies outlined in this policy must be maintained at the facility for emergency use...An itemized log must be kept indicating the contents...”. The facility document titled “FMC Smyrna, Emergency Box Contents”, dated 01/11/23 stated, “...1EA, Oxygen Mask...1EA, Stethoscope...10EA, Tongue Blade ...4, Epinephrine (Adrenalin) 1:1000 1mg/ml vial...”. A. During an environmental tour on 3/5/24 between 8:45 AM and 11:38 AM the following was observed: 1. Patient treatment area: -Emergency box/Crash cart listed items not all present, per emergency box content list. -Missing 1 Oxygen Mask (0 Oxygen Masks present on cart). -Missing 1 Stethoscope (0 Stethoscopes present on cart). -Missing 2 of 4 Epinephrine (Adrenalin) 1:1,000, 1mg/ml vial (2 vials present on cart). These findings were confirmed with Employee #19 on 3/5/24 at 11:12 AM.”

“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: 44880 Based on observation, document review, and staff interview, it was determined that the facility failed to provide a sanitary environment to minimize the transmission of infectious agents within the unit, with a potential to impact 28 of 28 patients at the facility on 3/5/24. Findings include: The facility document titled, “Storage of Supplies” dated 4/5/2021 stated, “...Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated...”. A. During an environmental tour on 3/5/24 between 8:45 AM and 11:38 AM the following was observed. 1. Patient treatment area -Observed 9 corrugated cardboard boxes on a plastic cart next to pod #2; the boxes label indicated the contents were Sodium Bicarbonate bags from Fresenius Medical Care. Reference number 08-4078-BB and multiple lot numbers including: 23NK01021, 23PK01003, 23NK01009. This finding was confirmed with Employee #7 on 3/5/24 at time of discovery.”

“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: 46255 Based on observation, policy review, and staff interview, it was determined that for 2 of 10 (Patient #s 7 and 8) patient care observations, staff failed to perform hand hygiene during patient care. Findings include: A. Facility policy titled “Hand Hygiene” dated 11/06/2023 stated, “...Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications...” B. Facility policy titled “Access Assessment and Cannulation” dated 7/5/2022 stated, “...Perform skin antisepsis...allow to dry and them [sic] cannulate. Do not touch cannulation sites after skin disinfection...” C. Facility policy titled “Medication Preparation and Administration” dated 2/06/2023 stated, “...Perform hand hygiene prior to...handling vials...and preparing or administering medications...” D. Patient #7 On 3/5/2024, between 10:24 AM and 10:40 AM, Employee # 10 was observed assessing the AV (arteriovenous) fistula of Patient #7 by inspecting, palpating, and auscultating the site. He/she then performed hand hygiene and donned gloves, applied skin antiseptic to cannulation sites, palpated the AV fistula again, then inserted and secured the first cannulation needle. Employee #10 then inspected the AV fistula and inserted and secured the second cannulation needle. During an interview on 3/5/2024 at 10:40 AM, Employee #10 confirmed after applying skin antisepsis to Patient #7’s cannulation sites, he/she palpated the AV fistula and did not remove gloves and perform hand hygiene before inserting the cannulation needles. E. Patient #8 a. On 3/5/2024, between 10:45 AM and 10:51 AM, Employee #4 was observed assessing the AV (arteriovenous) fistula of Patient #8 by inspecting, palpating, and auscultating the site. He/she then performed hand hygiene and donned gloves, applied skin antiseptic to cannulation sites, palpated the AV fistula again, then inserted and secured the first cannulation needle. Employee #4 then inspected the AV fistula and inserted and secured the second cannulation needle. During an interview on 3/5/2024 at 10:51 AM, Employee #4 confirmed after applying skin antisepsis to Patient #8’s cannulation sites, he/she palpated the AV fistula and did not remove gloves and perform hand hygiene before inserting the cannulation needles. b. On 3/5/2024, between 12:23 PM and 12:25 PM, Employee #13 was observed preparing IV (Intravenous) Venofer (iron injection) for Patient #8. Employee #13 was observed typing at the computer, then removing a single dose vial of IV Venofer, wiping the stopper with an alcohol wipe, withdrawing the medication into a sterile syringe, labeling the medication, donning gloves, taking the medication to the dialysis station, wiping the injection port with an alcohol wipe, injecting the medication and discarding the syringe into the Sharps container. During an interview on 3/5/2024 at 12:28 PM, Employee #13 confirmed that after typing on the computer, he/she failed to perform hand hygiene before preparing the IV medication. Employee #13 also confirmed that after withdrawing the medication from the vial into a sterile syringe and labeling the medication, he/she failed to perform hand hygiene before donning clean gloves.”

“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: 46255 Based on observation, document review, and staff interview, it was determined that the facility failed to maintain a safe, functional, and clean environment 28 of 28 patients at the facility on 3/5/24. Findings include: The facility document titled “General Cleanliness and Infection Control Guidelines” dated 2/7/2022, stated, “...Solutions will be stored and labeled per policy...”. The facility document titled “Compressed Gas Storage & Handling Program” dated 8/15/20221 stated, “...The following minimum guidelines concerning the use, storage, and transportation of compressed gases shall be observed in the facility...Clinic Management shall be responsible for maintaining a designed storage area...Container storage areas shall be prominently posted with the hazard class and the name of the gas(s) being stored...” The facility document titled “Expiration Dates Sterile Supplies” dated 7/4/2012 stated, “...Appropriately dispose of sterile items that have reached the expiration date...Expiration dates of sterile supplies contained in emergency boxes or code carts should be noted and logged as per facility protocol...” A. During an environmental tour on 3/5/24 between 8:45 AM and 11:38 AM the following was observed: 1. Janitor Supply Closet -Observed multiple containers without labels: -1 gallon jug containing a yellow liquid -2 spray bottles, approximately 16 oz capacity containing a blue liquid -1 spray bottle, approximately 32 oz capacity containing a yellow liquid This finding was confirmed with Employee #7 on 3/5/24 at time of discovery. 2. Water room -Observed 6 Oxygen tanks secured in a cart next to the door going from the Water Room to the Loading Area. There was no hazard label signage present on 3 out of 3 doors to the Water Room or in the area where the oxygen was being stored. -In an interview with Employee #7 on 3/5/24 at time of discovery, the employee stated that the containers were empty and the oxygen supply company refused to take the containers back. The employee reported not knowing what to do with the empty containers. This finding was confirmed with Employee #7 on 3/5/24 at time of discovery. 3. Patient treatment area, Crash Cart -2 Zoll CPR Stat-padz Adult Electrodes with Real CPR Help; reference #: 8900-0402, lot #:442014; expired 10/28/2022. -1 Con-Med Yankauer; reference #: 0034910, lot #: 201903014; expired 2/28/2024. These findings were confirmed with Employee #19 on 3/5/24 at 11:12 AM.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 44880 Based on observation, document review, and staff interview, it was determined that the facility failed to maintain the building for 28 of 28 patients at the facility on 3/5/24. Findings include: Facility unable to provide documentation such as policies, procedures, or contracts for how maintenance of the building is to be addressed. A. During an environmental tour on 3/5/24 between 8:45 AM and 11:38 AM the following was observed: 1. Patient treatment area -Observed a hole of approximately 3” in diameter in the wall above the cabinets over dirty sink #2 This finding was confirmed on 3/6/24 by Employee #3 at 2:58 PM.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 46255 Based on observation, document review, and staff interview, it was determined that the facility failed to maintain a safe and functional, environment for 60 of 60 patients at the facility. Findings include: The facility was unable to provide a procedure or policy for entering module information into semi-annual and annual preventive maintenance checks of hemodialysis machines. The facility was unable to provide a procedure or policy for maintaining access to emergency eye wash stations. A. During an environmental tour on 3/5/24 between 8:45 AM and 11:38 AM the following was observed: 1. Water room. -Observed eye wash station not easily accessible by staff in water treatment room; blocked by 2 patient privacy screens and a grey push cart. This finding was confirmed with Employee #7 on 3/5/24 at time of discovery. B. During document review on 3/5/24 between 11:33 AM and 3:00 PM the following was observed: 1. Annual and Semi-Annual Preventative Maintenance Records -Observed missing information from annual and semi-annual preventive maintenance documentation for 3 sampled Fresenius 2008T Hemodialysis machines (out of a total of 18 machines at the facility). This finding was confirmed on 3/6/24 by Employee #7 at 10:00 AM.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 46255 Based on medical record review, policy review and staff interview, it was determined that for 3 of 9 patients (Patient #’s 2, 3, and 6) in the medical record review sample, the facility failed to ensure that the dialysis prescription was being followed as ordered. Findings include: Facility policy titled “Unable to Achieve Prescribed Blood Flow Rate” dated 11/01/2021 stated, “...Achieving prescribed BFR [blood flow rate] is a critical parameter in achieving adequate treatment...Notify physician/extender if unable to achieve prescribed blood flow rate...Document in patient’s treatment record what action taken to address inadequate blood flow and if unable to resolve...” Facility policy titled “Patient Assessment and Monitoring” dated 5/01/2023 stated, “...Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow...Check dialysate flow rate setting is correct, and the prescribed flow is being delivered...” Facility policy titled “Nursing Supervision and Delegation” dated 11/06/2023 stated, “...The registered nurse must...review patient treatment prescription...to verify correct settings, and if dialysis prescription is being followed...” Patient # 2 Dialysis prescription: BFR (Blood Flow Rate) 450 mL/min (milliliters per minute) and DFR (dialysate flow rate) 800 mL/min. 2/24/2024 Treatment: 1:33 PM BFR 450 mL/min DFR 500 mL/min. 1:50 PM BFR 450 mL/min DFR 500 mL/min. 2:17 PM BFR 450 mL/min DFR 500 mL/min. 2:26 PM BFR 450 mL/min DFR 500 mL/min. 2:34 PM BFR 450 mL/min DFR 500 mL/min. 2:48 PM BFR 450 mL/min DFR 500 mL/min. 3:09 PM BFR 450 mL/min DFR 500 mL/min. No reason documented in the treatment record to explain why the BFR and DFR were not running at the prescribed flow rates. No evidence of physician notification. These findings were confirmed with Employee #3 on 3/6/2024 at 2:00PM. Patient #3 Dialysis prescription: BFR 400 mL/min and DFR 800 mL/min. 2/22/2024 Treatment: 9:44 AM: BFR 375 mL/min DFR 500 mL/min. Treatment initiated. 10:07 AM: BFR 375 mL/min DFR 500 mL/min. 10:37 AM: BFR 375 mL/min DFR 500 mL/min. 11:06 AM: BFR 375 mL/min DFR 500 mL/min. 11:21 AM: BFR 375 mL/min DFR 500 mL/min. 12:03 PM: BFR 375 mL/min DFR 500 mL/min. 12:18 PM: BFR 375 mL/min DFR 500 mL/min. 12:49 PM: BFR 375 mL/min DFR 500 mL/min. 1:05 PM: BFR 375 mL/min DFR 500 mL/min. 1:19 PM: BFR 375 mL/min DFR 500 mL/min. 1:34 PM: BFR 375 mL/min DFR 500 mL/min. 1:46 PM: BFR 375 mL/min DFR 500 mL/min. Treatment ended. No reason documented in the treatment record to explain why the BFR and DFR were not running at the prescribed flow rates. No evidence of physician notification. These findings were confirmed with Employee #3 on 3/6/2024 at 1:11 PM. Patient #3: 2/27/2024 Treatment: 9:58 AM: DFR 500 mL/min. Treatment initiated. 10:07 AM: DFR 500 mL/min. 10:07 AM: DFR 500 mL/min. 10:15 AM: DFR 500 mL/min. 10:51 AM: DFR 500 mL/min. 11:02 AM: DFR 500 mL/min. 11:16 AM: DFR 500 mL/min. 11:32 AM: DFR 500 mL/min. 12:07 PM: DFR 500 mL/min. 12:27 PM: DFR 500 mL/min. 12:36 PM: DFR 500 mL/min. 1:00 PM: DFR 500 mL/min. 1:28 PM: DFR 500 mL/min. 1:40 PM: DFR 500 mL/min. 2:06 PM: DFR 500 mL/min. Treatment ended. No reason documented in the treatment record to explain why the DFR was not running at the prescribed flow rate. No evidence of physician notification. These findings were confirmed with Employee #3 on 3/6/2024 at 12:46 PM. 2/23/2024 Patient #6 Dialysis prescription: BFR (Blood Flow Rate) 375 mL/min and DFR 800 mL/min. 6:01 AM BFR 375, DFR 500 6:18 AM BFR 375, DFR 500 6:38 AM BFR 375, DFR 500 6:59 AM BFR 375, DFR 500 7:08 AM BFR 375, DFR 800 Correct, but no reason given why it was 500. 7:08 AM BFR 375, DFR 500 Back to 500, with no reason given. 7:19 AM BFR 375, DFR 800 Correct, but no reason given why it was 500. 3/1/2024 05:39 AM BFR 300, DFR 800 No note justifying why BFR was not at 375. 06:05 AM BFR 300, DFR 800 06:05 AM BFR 300, DFR 800 No reason documented in the treatment record to explain why the BFR and DFR was not running at the prescribed flow rate. No evidence of physician notification. These findings were confirmed with Employee #3 on 3/6/2024 at 2:00PM.”