Davita Douglas Dialysis

“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: 03383 Based on observations, a review of facility Policy and Procedure and Centers for Disease Control and Prevention (CDC) Recommendations, it was determined that the Infection Control Committee failed to ensure that one of one patient (P#12) observed who held pressure to his access site for hemostasis (stopping of the flow of blood) after dialysis; and one of one Licensed Practical Nurse (LPN HH) observed during initiation of dialysis treatment, performed hand hygiene (washed hands or used an alcohol-based hand sanitizer), after removal of contaminated gloves or removed contaminated gloves and performed hand hygiene prior to touching a clean area and prior to performing clean task. Failure to perform infection control techniques such as hand hygiene, increased the risk for cross contamination with the potential to expose 95 patients who were dialyzing at this facility. Findings were: During observation in the Patient Treatment Room on 1/24/24 and 1/25/24 between 7:30 a.m. and 11:30 a.m., the following was revealed: - On 1/24/24 at 11:14 a.m., P#12 who was seated at Station (S) 22 was observed applying pressure to his access site with a gloved hand. When hemostasis was obtained, P#12 removed his glove and left the treatment area without performing hand hygiene after the glove was removed. - On 1/25/24 at 7:38 a.m. LPN HH was observed initiating dialysis treatment on P#13 who was seated at S21. LPN HH cleansed the CVC ports, removed her gloves and without performing hand hygiene, donned a clean pair of gloves and attached the dialysis machine tubing to the CVC ports. - When finished, LPN HH touched the dialysis machine panel (dirty) and then touched the keyboard (clean) and entered data while she wore contaminated gloves. A review of Policy: 1-05-01 titled, “Infection Control For Dialysis Facilities” last revised in April 2023 stated: Hand Hygiene: 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene: b. Prior to gloving and immediately after removal of gloves, c. After contamination with blood or other infectious material, d. After patient and dialysis delivery system contact... g. Before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2. Patients and caregivers will be encouraged to: a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area... According to CDC recommendations, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during 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: 03383 Based on observation and a review of facility policy, it was determined that the Infection Control Committee failed to ensure that all Direct Patient Care Staff cleaned up blood spill and disinfected the area as soon as possible. This deficient practice had the potential for cross contamination and increased risk of infection and could affect 95 in-center patients who were dialyzing at this facility. Findings were: During observation in the Patient Treatment Room on 1/24/24 between 11:10 a.m. and 11:30 a.m., the following was revealed: - A drop of blood [approximately 15.2 cm (centimeters)] was observed on the floor located in front of Station 22 on 1/24/24 at 11:14 a.m. The blood remained on the floor and a pad was placed over the blood at 11:26 a.m. A review of Policy: 1-05-01 titled, “Infection Control For Dialysis Facilities” dated April 2023 stated: Disinfection Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials...”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 03383 Based on observation, staff interview, and a review of facility policies, it was determined that the Infection Control Committee failed to ensure that one of one physician (Medical Director) observed, used proper infection control techniques and/or used dedicated equipment in the isolation room to prevent cross contamination. Failure to perform infection control techniques increased the risk of cross contamination with the potential to expose all Hepatitis B surface Antigen susceptible patients, who were dialyzing at this facility. The facility census was 95. Findings were: During observation in the Patient Treatment Room on 1/25/24 between 5:30 a.m. and 7:38 a.m., the following was observed: The Medical Director (MD) was observed entering the Isolation Room where a Hepatitis B positive patient was receiving dialysis treatment. The MD donned a yellow gown over blue gown, donned gloves, and mask; however, brought his own personal stethoscope into the isolation room. MD used the stethoscope to listen to the patient’s lungs. The MD placed the stethoscope around his neck afterward without disinfecting the stethoscope with bleach solution per facility policy. MD exited the isolation room after removing gown and gloves; washed hands with soap and water at a sink located across from the isolation room, and left the Treatment Room without disinfecting his stethoscope. There was a stethoscope dedicated to Isolation Room but was not used by the MD. Surveyor discussed observations with the MD on 1/25/24 at approximately 8:05 a.m. The MD confirmed the above findings and stated that he likes to use his stethoscope because it picks up sounds better. A review of Policy: 1-05-01 titled, “Infection Control For Dialysis Facilities” dated April 2023 stated: Disinfection Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e., used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. Non-disposable items are to be disinfected after each patient use, prior to removal from the treatment area/station and if contaminated between uses. A review of Policy: 1-05-02 titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation” dated October 2023 stated: Equipment/Supplies a. Dedicated ancillary supplies such as blood pressure cuffs, clamps, tourniquets, stethoscope ...and non-disposable items will be used. b. Such supplies will be labelled “isolation” and will remain in the isolation room/area or station and will be disinfected after every patient use with 1:100 (one to one hundred) bleach solution.”

“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: 03383 Based on observation and staff interview, it was determined that the facility failed to ensure that two of nine patients (P#10 and P#11) observed, had their vascular access sites uncovered/visible to the staff throughout dialysis treatment, to ensure patient safety. This deficient practice could provide an opportunity for accidental needle dislodgement or a line disconnection to go undetected and could result in exsanguination (severe loss of blood). The facility census was 95. Findings were: During observation in the Patient Treatment Room on 1/25/24 between 7:20 a.m. and 7:40 a.m., the following was revealed: P#10 and P#11 who were seated at Stations 6 and 7 respectively, had their dialysis access sites covered completely with a blanket. Surveyor informed PCT JJ about the covered accesses at 7:36 a.m. on 1/25/24. PCT JJ uncovered access sites of P#10 and P#11, who were both asleep.”

“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: 03383 Based on a review of medical records, staff interviews, and a review of facility policy, it was determined that the facility failed to ensure that all Direct Patient Care Staff adhered to the patient’s plan of care and facility policy pertaining to patients’ dialysis prescriptions [BFR (blood flow rate), DFR (Dialysate Flow Rate), and length of treatment time] for seven of nine sampled patients (P#1, P#2, P#3, P#4, P#6, P#7, and P#8). Failure to implement the patients’ dialysis prescriptions could negatively affect the dose of dialysis delivered. The facility census was 95. Findings were: A review of P#1, P#2, P#3, P#4, P#6, P#7, and P#8’s treatment flowsheets dated 1/9/24 - 1/23/24 showed the following: P#1: - P#1’s dialysis prescriptions: Treatment time: 210 minutes [3 hours 30 minutes], EDW (Estimated Dry Weight): 82 kg (kilogram), BFR: 400 mL/min (milliliter per minute), DFR: 500 mL/min. On 1/9/24: - P#1’s BFR was set at 300 mL/min for the entire treatment. - PCT LL notified the Charge Nurse (CN) about inability to achieve BFR but did not indicate why BFR could not be achieved. - At 7:37 a.m., LPN HH verified that P#1’s prescription matched what was being delivered during the dialysis treatment when it did not match. - At 9:33 a.m., PCT OO discontinued dialysis treatment and did not document that the CN was notified of the reason why P#1’s treatment was discontinued early (P#1 received 122 minutes of dialysis treatment instead of 210 minutes). On 1/18/24: - P#1 dialyzed with a BFR of 350 mL/min from 9:43 a.m. to 11:32 p.m., and the BFR was decreased to 300 mL/min at 11:32 a.m. to 12:32 p.m. - P#1’s dialysis treatment was terminated 18 minutes earlier. - LPN GG verified at 9:43 a.m. that P#1’s prescription matched what was being delivered during the dialysis treatment when it did not match. On 1/20/24: - Treatment record showed dialysis treatment was initiated at 6:40 a.m. and discontinued at 9:28 a.m. - There was a lack of documented reason for the early termination of P#1’s dialysis treatment. P#2: P#2’s dialysis prescriptions: Treatment time: 180 minutes [3 hours], EDW: 75.5 kg, BFR: 450 mL/min, DFR: 500 mL/min. On 1/12/24: - P#2 dialyzed with a BFR of 400 mL/min during the entire treatment from 5:21 a.m. to 8:16 a.m. - Treatment record did not show why P#2 dialyzed with a BFR of 400 mL/min instead of 450 mL/min as ordered. - At 5:57 a.m., RN EE verified that the patient’s prescription matched what was being delivered during the dialysis treatment when it did not match. P#3: - P#3’s dialysis prescriptions: Treatment time: 195 minutes [3 hours and 15 minutes], EDW: 83 kg, BFR: 400 mL/min, DFR: 800 mL/min. On 1/18/24: - P#3’s treatment started at 9:31 a.m. and was discontinued at 12:53 p.m. - P#3’s BFR was set at 200 at the initiation of treatment at 9:31 a.m. until 10:04 a.m., when it was increased to 400 mL/min. - The DFR was at 500 mL/min during initiation of treatment at 9:31 a.m. until 10:04 a.m., when it was increased to 800 mL/min; then the DFR was decreased to 500 mL/min at 12:34 p.m. until treatment was terminated at 12:53 p.m. - The record did not show why BFR was set at 200 instead of 400 mL/min or why DFR was decreased to 500 mL/min. - P#3’s pre dialysis weight was 82 kg and the post dialysis weight was 82.8 kg. - There was a lack of documentation that addressed patient’s weight gain post dialysis. - LPN HH verified at 9:39 a.m. that the patient’s prescription matched what was being delivered during the dialysis treatment. On 1/22/24: - P#3’s treatment started at 9:29 a.m. and was discontinued at 12:45 p.m. - P#3 dialyzed with a DFR of 500 mL/min during the entire dialysis treatment. - RN CC verified at 9:57 a.m., that the patient’s prescription matched what was being delivered during the dialysis treatment. P#4: P#4’s dialysis prescriptions: Treatment time: 180 minutes [3 hours], EDW: 83 kg, BFR: 450 mL/min, DFR: 800 mL/min. On 1/13/24: - P#4’s treatment started at 10:31 a.m. and was discontinued at 1:17 p.m. - P#4 dialyzed with a BFR of 400 mL/min during the entire dialysis treatment. - The record did not show why BFR was set at 400 instead of 450 as ordered. - At 10:09 a.m., RN DD verified that the patient’s prescription matched what was being delivered during the dialysis treatment when it did not match. P#6: P#6’s dialysis prescriptions: - Treatment time: 180 minutes [3 hours], EDW: 82 kg, BFR: 450 mL/min, DFR: 800 mL/min. On 1/11/24: - P#6’s treatment started at 6:45 a.m. and was discontinued at 9:39 a.m. - Treatment record showed that the BFR was at 210 mL/min at the initiation of dialysis at 6:45 a.m. The BFR was increased to 400 mL/min at 7:02 a.m. until 9:39 a.m., when treatment was terminated. - There was a lack of documented reason for the BFR below 450 mL/min as ordered. - At 7:56 a.m., RN BB verified that patient’s prescription matched what was being delivered during dialysis treatment when it did not match. P#7: P#7’s dialysis prescriptions: - Treatment time: 210 minutes [3 hours 30 minutes], EDW: 79.5 kg, BFR: 400 mL/min, DFR: 800 mL/min. On 1/12/24: - P#6’s treatment started at 5:45 a.m. and was discontinued at 9:17 a.m. - P#6’s DFR was set at 500 mL/min during initiation of dialysis treatment at 5:45 a.m. until 7:30 a.m. - There was no documentation for the DFR of less than 800 mL/min as ordered. - At 5:56 a.m., RN EE verified that the patient’s prescription matched what was being delivered during dialysis treatment when it did not. P#8: P#8’s dialysis prescriptions: Treatment time: 195 minutes [3 hours and 15 minutes], EDW: 88 kg (kilogram), BFR: 400 mL/min, DFR: 800 mL/min. On 1/15/24: - P#8’s treatment started at 1:15 p.m. and was discontinued at 4:19 p.m. - P#8’s BFR was set at 200 mL/min during initiation at 1:15 p.m. to 2:01 p.m.; was increased to 230 mL/min from 2:31 p.m. to 13:32 p.m.; and was decreased to 200 mL/min from 3:32 p.m. to 4:19 p.m. - At 1:30 p.m., RN EE verified that the patient’s prescription matched what was being delivered during dialysis treatment when it did not match. - There was a lack of documented reason for dialyzing P#8 with a BFR of less than 400 mL/min, per the plan of care. -The above findings were discussed and reviewed with the Facility Administrator (FA) and Group Facility Administrator (GFA) on 1/26/24 between 8:30 a.m. and 10:40 a.m. The FA and GFA confirmed the above findings and did not produce the missing documentation. A review of Policy: 1-03-08 titled, “Pre-Intra-Post treatment Data Collection, Monitoring and Nursing Assessment” dated October 2023 stated: Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment... Prescription components include but are not necessarily limited to: Blood flow rate [BFR] and dialysate flow rate [DFR] ...”

“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: 03383 Based on a review of medical records, staff interviews and review of facility policies, it was determined that the medical director failed to ensure that all Direct Patient Care Staff adhered to facility policies pertaining to hypertension [elevated blood pressure (BP)] and hypotension (low BP), to ensure that seven of nine patients (P#1, P#2, P#3, P#4, P#7, P#8, and P#9) sampled, received medical care/interventions appropriate to the patient’s dialysis needs. This failure could negatively affect the health and safety of 95 patients who were dialyzing at this facility. Findings were: A review of P#1, P#2, P#3, P#4, P#5, P#7, P#8, and P#9’s treatment flowsheets dated 1/9/24 - 1/23/24 showed the following: P#1: On 1/9/24: - P#1’s BP was 92/62 mm Hg (millimeters of mercury) during initiation of dialysis treatment at 7:31 a.m. - At 8:33 a.m., P#1’s BP was 94/46 mm Hg. Patient Care Technician (PCT) LL documented BP low, repeat BP. - At 8:35 a.m., P#1’s BP was 90/62 mm Hg. PCT LL documented BP low, repeat BP. - At 8:36 a.m., P#1’s BP was 94/59 mm Hg. PCT LL documented BP low, pt (patient) states no complaints. - There was a lack of documented evidence that PCT LL notified a licensed nurse of the low BP readings. - At 9:03 a.m., P#1’s BP was 113/69 mm Hg. - At 9:30 a.m., P#1’s BP was 98/55 mm Hg. - At 9:33 a.m., P#1’s BP was 96/58 mm Hg. PCT OO discontinued P#1’s dialysis treatment after 122 minutes of dialysis. P#1’s presribed length of dialysis time was for 210 minutes. - There was a lack of documented evidence that a licensed nurse was notified of the above low BP readings and early termination of dialysis. - There was also no documentation of the reason for the early termination of P#1’s dialysis treatment. On 1/18/24: - At 12:01 p.m., during dialysis treatment, P#1’s BP was 125/79 mm Hg. - At 12:32 p.m., P#1’s BP dropped to 97/77 mm Hg. - There was a lack of documented evidence of any interventions done. - P#1’s dialysis was discontinued 18 minutes earlier with no documented reason for the early termination of treatment. - There was no documentation that the licensed nurse was notified of the drop in patient’s BP that was greater than 20 mm Hg or the early termination of dialysis treatment. P#2: On 1/15/24: - P#2’s BP was 180/125 during the initiation of dialysis treatment at 5:27 a.m. - At 5:32 a.m., P#2’s BP went up to 200/93 mm/Hg. - There was a lack of documented evidence that the licensed nurse was notified of the elevated BP readings. P#3: - P#3’s BP was 179/73 during initiation of dialysis treatment at 9:25 a.m. by Registered Nurse (RN) EE. - At 9:31 a.m., P#3’s BP was 187/82 mm Hg. RN CC documented patient monitored. - At 10:01 a.m., P#3’s BP was 180/78 mm Hg. RN CC documented patient monitored. - At 10:31 a.m., P#3’s BP was 190/74 mm Hg. RN CC documented patient awake and alert with no complaints at this time. - At 11:26 a.m., P#3’s BP was 199/77 mm Hg. RN CC documented treatment terminated. - P#3 dialyzed for 121 minutes instead of 195 minutes as prescribed. - There was a lack of documented evidence that RN CC administered Clonidine (medicine used to treat high BP) per facility standing order for elevated BP. - There was no documention that explained the reason for the early termination of P#3’s dialysis treatment. On 1/12/24: - P#3’s BP was 196/80 during initiation of dialysis treatment at 9:25 a.m. by RN FF. - At 9:31 a.m., P#3’s BP was 206/83 mm Hg. RN CC documented BP elevated, monitoring.. - At 10:01 a.m., P#3’s BP was 203/84 mm Hg. RN CC documented patient tolerating treatment well at this time, no complaints. - At 10:31 a.m., P#3’s BP was 185/83 mm Hg. RN CC documented patient tolerating treatment well at this time. - At 11:01 a.m., P#3’s BP was 196/86 mm Hg. RN CC documented patient tolerating treatment well at this time. BP elevated. - At 11:31 a.m., P#3’s BP was 172/87 mm Hg. RN CC documented no complaints at this time. - At 12:01 p.m., P#3’s BP was 185/72 mm Hg. RN CC documented patient appears to be tolerating treatment well at this time. - At 12:31 p.m., P#3’s BP was 171/62 mm Hg. RN CC documented patient awake and alert with no complaints at this time. - At 12:45 p.m., P#3’s BP was 208/88 mm Hg. RN CC documented treatment terminated. - There was a lack of documented evidence that RN CC administered Clonidine per facility standing order for elevated BP. P#4: On 1/16/24: - P#4’s EDW was 97 kg (kilogram). P#3’s pre dialysis weight was 103.5 kg and the post dialysis weight was 100.2 kg. - P#4’s BP was 179/102 mm Hg during initiation of dialysis treatment at 10:01 a.m. PCT NN documented will monitor BP; did not notify the RN. - At 10:32 a.m., P#4’s BP was 181/95 mm Hg. PCT NN documented BP elevated, will monitor BP. - At 11:02 a.m., P#4’s BP was 170/103 mm Hg. PCT NN documented BP elevated, will monitor BP. - At 11:32 a.m., P#4’s BP was 173/99 mm Hg. - At 12:02 p.m., P#4’s BP was 152/99 mm Hg. PCT NN documented BP elevated, will monitor BP. - At 12:28 p.m., P#4’s BP was 153/101 mm Hg. PCT NN documented BP elevated, UF (Ultra Filtration - removal of fluid) Goal adjusted. - At 12:32 p.m., P#4’s BP was 160/101 mm Hg. PCT NN documented BP elevated, will continue to monitor. - At 12:39 p.m., P#4’s BP was 161/107 mm Hg. - There was no documentation that the licensed nurse was notified of the elevated diastolic (bottom number) BP readings. - P#4’s post dialysis weight was 100.2 kg which was 3.2 over his EDW. There was a lack of documented interventions that addressed P#4’s excess fluids post dialysis. On 1/18/24: - P#4’s BP was 194/110 mm Hg during initiation of dialysis treatment at 9:46 a.m. PCT NN documented will monitor BP. There was a lack of documentary evidence that the RN was notified. - At 10:02 a.m., P#4’s BP was 181/95 mm Hg. PCT NN documented BP elevated, will monitor BP - At 10:32 a.m., P#4’s BP was 177/106 mm Hg. PCT NN documented BP elevated, will monitor BP. - At 11:02 a.m., P#4’s BP was 178/113 mm Hg. PCT NN documented BP elevated, will monitor BP. - At 11:32 a.m., P#4’s BP was 173/108 mm Hg. PCT NN documented BP elevated. - At 12:02 p.m., P#’4s BP was 173/108 mm Hg. PCT NN documented BP elevated. - At 12:31 p.m., P#4’s BP was 187/102 mm Hg. PCT NN documented BP elevated. Patient complained of cramping, UF turned off, will monitor BP. - At 12:32 p.m., P#4’s BP was 164/115 mm Hg. PCT NN documented BP elevated. Patient stable, monitor BP. - At 12:39 p.m., P#4’s BP was 185/101 mm Hg., treatment terminated. - There was a lack of documented evidence that PCT NN followed the facility policy for elevated BP and did not notify the RN about the persistent elevated BP readings. On 1/20/24: - P#4’s BP was 164/92 mm Hg during initiation of dialysis treatment at 9:41 a.m. PCT NN documented will monitor BP. - At 10:03 a.m., P#4’s BP was 172/97 mm Hg. PCT NN documented BP elevated, will monitor BP. - At 10:33 a.m., P#4’s BP was 154/94 mm Hg. - At 11:03 a.m., P#4’s BP was 172/100 mm Hg. RN EE documented patient monitored. - At 11:34 a.m., P#4’s BP was 159/103 mm Hg. PCT NN documented BP elevated. - At 12:03 p.m. P#’4s BP was 175/105 mm Hg. PCT NN documented BP elevated, rechecking BP. - At 12:11 p.m. P#’4s BP was 148/98 mm Hg. - At 12:33 p.m., P#4’s BP was 187/104 mm Hg. PCT NN documented BP elevated, rechecking BP. - At 12:38 p.m., P#4’s BP was 172/101 mm Hg. PCT NN documented treatment terminated. - There was a lack of documented evidence that PCT NN notified the RN about the persistent elevated BP readings. - There was a lack of documented interventions taken that addressed the elevated BP readings per facility standing order. On 1/23/24: - P#4’s BP was 190/107 mm Hg during initiation of dialysis treatment at 10:18 a.m. PCT NN documented will monitor BP. - At 10:34 a.m., P#4’s BP was 171/87 mm Hg. PCT N documented BP elevated, will monitor BP. - At 11:46 a.m., P#4’s BP was 160/95 mm Hg. - At 11:04 a.m., P#4’s BP was 172/100 mm Hg. RN EE documented patient monitored. - At 11:34 a.m., P#4’s BP was 181/106 mm Hg. PCT NN documented BP elevated, will monitor BP. - At 12:04 p.m. P#’4s BP was 191/122 mm Hg. BP elevated, rechecking BP. - At 12:07 p.m. P#’4s BP was 149/93 mm Hg. - At 12:34 p.m., P#4’s BP was 151/91 mm Hg. PCT NN documented BP elevated, rechecking BP. - At 1:04 p.m., P#4’s BP was 166/102 mm Hg. PCT NN documented BP elevated, will monitor BP. - At 1:13 p.m., P#4’s BP was 153/93 mm Hg. PCT NN documented treatment terminated. - There was a lack of documented evidence that PCT NN notified the RN of the elevated BP readings. P#7: On 1/22/24: - P#7’s BP was 186/101 during initiation of dialysis treatment at 6:17 a.m. PCT KK documented pt’s BP is elevated. CN made aware. - At 6:32 a.m., P#7’s BP was 184/94. PCT KK documented pt monitored, resting. - At 7:02 a.m., P#7’s BP was 181/82. PCT KK documented pt monitored, resting. - At 7:32 a.m., P#7’s BP was 177/92. PCT PP documented pt monitored, resting. - At 8:02 a.m., P#7’s BP was 167/80. PCT KK documented pt appears to be tolerating treatment well. - At 8:32 a.m. P#7’s BP was 185/90. PCT KK documented pt awake; alert; states no complaints. - At 9:02 a.m., P#7’s BP was 182/89. PCT KK documented pt awake; alert, states no complaints at this time. - At 9:33 a.m., P#7’s BP was 174/89. PCT KK documented pt awake; alert, states no complaints at this time. - At 9:53 a.m., P#7’s BP was 189/100. PCT KK documented rechecking BP. - Post treatment BP was 197/93 sitting and 191/102 standing. - There was a lack of documented interventions taken that addressed the elevated BP readings per facility policy and standing order. - There was a lack of documented evidence that PCT PP and PCT KK followed the facility policy for BP and did not notify the RN of low BP readings. P#8: On 1/15/24: - P#8’s BP was 184/88 during initiation of dialysis treatment at 1:15 p.m. - At 1:31 p.m., P#8’s BP was 208/98. LPN HH documented BP elevated, patient awake, alert, and states no complaints at this time. - At 2:01 p.m., P#8’s BP was 179/104 mm Hg. LPN HH documented BP elevated, no distress. RN not notified. - At 2:31 p.m., P#8’s BP was 174/102 mm Hg. LPN HH documented diastolic BP elevated. - At 3:01 p.m., P#8’s BP was 188/98 mm Hg. - At 3:32 p.m. P#8’s BP was 153/85 mm Hg. LPN HH documented “vss” (vital signs stable). - At 4:00 p.m., P#8’s BP was 180/104 mm Hg. PCT KK documented BP elevated. - At 4:16 p.m., P#8’s BP was178/102 mm Hg. LPN HH documented treatment terminated. - There was a lack of documented interventions taken that addressed the elevated BP readings per facility policy and standing order. P#9: On 1/19/24: - P#9’s BP was 165/91 mm Hg during initiation of dialysis treatment at 9:33 a.m. by PCT II. - At 10:33 a.m., P#9’s BP was 160/87. - At 11:03 a.m., P#9’s BP was 190/105. - At 12:34 p.m., P#9’s BP was 193/94. PCT II did not notify RN about the elevated BP. - There was a lack of documented evidence that PCT II followed the facility policy and standing order for low BP and did not notify the RN of low BP readings. The Facility Administrator (FA) and Group Facility Administrator (GFA) were notified and confirmed the above findings on 1/25/24 and on 1/26/24 between 9:30 a.m. and 10:50 a.m. The FA stated there was a facility standing order for Clonidine HCL oral tablet 0.1 mg every 4 hours as needed for systolic BP greater than 160. If no response, or if systolic BP is greater than 180, notify the physician. During an interview on 1/24/24 at 1:29 p.m., the Medical Director stated that the normal systolic BP range is 110-150 and the diastolic range is 60-90. If patient falls outside the parameters, staff usually call the physician to get an okay to put the patient on the machine. Stated that staff should retake the BP 2-3 times and check the BP in other places due to bad vessels. If systolic BP is greater than 180, give Clonidine and if one dose did not work, call the physician for additional instructions. A review of Policy: 1-03-08 titled, “Pre-Intra-Post treatment Data Collection, Monitoring and Nursing Assessment” last revised October 2023, stated: Abnormal Findings: Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. Blood pressure: Pre-dialysis: Systolic greater than 180 mm Hg or less than 90 mm Hg Diastolic greater than or equal to 100 mm Hg Blood pressure - Intradialytic: Difference of 20 mm Hg increase or decrease from the patient’s last treatment BP reading... Blood Pressure Post Treatment: If the patient can stand: o Standing systolic BP greater than 140 mm Hg or less than 90 mm Hg o Standing diastolic BP greater than 90 mm Hg or less than 50 mm Hg If the patient is not able to stand, document reason and sitting BP: Sitting BP for patient’s that cannot stand: o Sitting systolic BP greater than 140 mm Hg or less than 90 mm Hg o Sitting diastolic BP greater than 90 mm Hg or less than 50 mm Hg A review of Policy: 1-09-01 titled, “Hypotension” last revised October 2023, stated: Procedure 1. Take vital signs. Place patient in a flat supine position. 2. Decrease ultrafiltration rate (UFR) or turn off UFR depending on patient’s condition. 3. Administer normal saline bolus of 100 - 200 mL for severe hypotensive symptoms. Patient Care Technicians may give up to 200 mL and will inform licensed nurse of intervention. For less severe signs of hypotension give oral fluids (i.e., water). 4. Administer oxygen per physician’s order. 5. Continue monitoring blood pressure. If the blood pressure stabilizes, evaluate Target Weight and adjust UF as determined by patient’s condition. 6. If patient continues to show signs of hypotension, the licensed nurse will notify physician and follow physician’s order. 7. Document event, orders, treatment and patient response in the patient’s electronic health record.”