Madison Kidney Center

“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: 52051 Based on observations, staff interviews, and a review of the National Fire Protection Association (NFPA) standards, it was determined that the facility failed to provide documentation showing that fire extinguishers were inspected monthly by a designated, trained staff member and annually by a certified technician. Additionally, there was no documented evidence that the facility’s emergency exit lighting had been inspected monthly or tested annually, as required. Furthermore, one of one Oxygen Tank (used for respiratory support) with the Emergency Crash Cart (a cart supplied with emergency medical equipment, supplies, and drugs for use by medical personnel specifically during efforts to resuscitate a patient experiencing cardiac arrest) was empty and had not been resupplied or replaced, in order to be in a ready-to-operate condition during emergencies. This deficiency has the potential to negatively impact all 10 in-center hemodialysis (ICHD) patients under the care of this facility. Findings include: During observation in the Patient Treatment Room on 7/23/25 from 9:13 a.m. to 10:30 a.m., the following was revealed: - The oxygen tank with the Crash Cart was empty, and there was no other available backup in the facility for respiratory support, in case of an emergency. - The Registered Nurse (RN AA), who was present during this observation, stated that she was aware that the oxygen tank was empty and that the Biomedical Technician (BMT) had been notified. She also confirmed that there was no backup or extra oxygen tank available, aside from the empty one. RN AA acknowledged this observation on 7/23/25 at 9:41 a.m. During a tour of the facility with the Assistant Administrator (Staff AA) on 7/23/25, between 10:35 a.m. and 11:30 a.m., the following was revealed: - There was a total of four fire extinguishers noted throughout the building. Their locations included: one in the lobby, one upon entrance into the Patient Treatment Room, one in the main hallway across the office, one right across the main Supply Room. All fire extinguishers were last documented as inspected, in May 2022. - Two of two exit door lightings leading to the back exterior of the building: one located in the right wing (Exit #1) and the other in the left wing (Exit #2) were not functioning or illuminated. During an interview on 7/23/25, at 10:51 a.m., Staff AA who was present during the observation, stated that she was unaware of when the facility’s fire extinguishers and emergency exit lights were last inspected. She indicated that the BMT was responsible for these fire extinguishers and should have the inspection records. Staff AA acknowledged that the fire extinguishers had not been serviced. In a subsequent interview with the BMT on 7/23/25, at 12:35 p.m., he confirmed that the fire extinguishers had not been inspected or monitored as required. He mentioned that another Administrative Personnel (Staff BB), who was in charge of the Human Resource Services, should have maintained the records for the fire extinguishers. During an interview with Staff BB on 7/24/25, at 9:01 a.m., she stated that the fire extinguishers had not been checked or inspected for years. According to the NFPA standards, the facility is required to conduct regular inspections and testing of its fire safety systems. Emergency exit lighting must be functionally tested monthly for a minimum of 30 seconds and undergo a full-duration test of 90 minutes annually to ensure proper operation during power outages. These inspections are to be performed by the facility owner or trained staff, with documentation maintained for review. Fire extinguishers must undergo a monthly visual inspection by a designated trained staff member to check for accessibility, pressure, and physical condition. Additionally, they must receive comprehensive annual maintenance by a certified technician, including servicing and any necessary testing in compliance with NFPA 10. All inspection and service activities must be documented and retained as part of the facility’s fire safety records. This surveyor did not receive any facility records related to the ancillary logs for fire extinguishers, emergency lighting, and building maintenance as requested.”

“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: 52051 Based on observation, staff interviews, a review of the Centers for Disease Control and Prevention (CDC) guidelines, and a review of facility Policies and Procedures (P & P), it was determined that the facility failed to ensure that one of one Patient Care Technician (PCT BB), and three of three patients at Stations (S)3, S4, and S8 observed, consistently performed hand hygiene (handwashing with soap and water or use of an alcohol-based hand sanitizer), after removing contaminated gloves, between glove changes, and after touching contaminated area/equipment. This breach in infection control techniques, such as hand hygiene, had the potential to increase the risk for cross contamination with the potential to expose patients and staff to bloodborne pathogens in the dialysis environment. The facility census was 10. Findings include: During observation in the Treatment Room on 7/23/25 from 9:13 a.m. to 10:30 a.m., the following was revealed: - PCT BB was observed charting on a paper flowsheet at S7 while wearing contaminated gloves. Afterwards, she placed the paper flowsheet on top of the dialysis machine (dirty). She then removed her gloves but did not perform hand hygiene after glove removal. PCT BB then went to the Nurses’ station (clean area) where she removed her gown (dirty). Shortly after, PCT BB put on a new pair of clean gloves, without performing hand hygiene. - Patients at S3, S4, and S8 were observed holding their access sites (dirty) with one gloved hand (after their hemodialysis treatment), until hemostasis (stopping of bleeding) was achieved. After glove removal, these same patients did not perform hand hygiene and were not offered a hand sanitizer by the DPC staff. These same patients then proceeded to the weighing scale and exited the Patient Treatment Room where they touched the door (clean) without performing hand hygiene. These patients were not reminded by the DPC staff (RN AA, PCT AA, and PCT BB) to wash or sanitize their hands before leaving the Patient Treatment Room. Additionally, the surface of the door was not disinfected after being touched by the patients mentioned above which had the potential for cross contamination. During an interview conducted on 7/23/25 at 10:28 a.m., PCT BB acknowledged that she would sometimes forget to perform hand hygiene between glove changes. 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 ... A review of the facility’s Policy titled “Handwashing Technique”, with no date, stated: 1. Indications for handwashing and hand antisepsis. b. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations. g. Decontaminate hands after contact with inanimate objects. . . in the immediate vicinity of the patient. h. Decontaminate hands after removing gloves. RN AA, charge nurse was notified of this observation on 7/23/25, at 10:30 a.m. and acknowledged the importance of consistent hand hygiene practice between glove changes.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 52051 Based on observation and staff interviews, it was determined that the facility failed to ensure that two of two clean sinks (handwashing sinks), in one of one Patient Treatment Room, was functional and had running warm water to encourage patients and staff to wash their hands. This deficient practice had the potential to discourage seven of seven patients (P#1, P#3, P#4, P#5, P#6, P#7, and P#10) and three of three Direct Patient Care (DPC) Staff (Registered Nurse - RN AA and Patient Care Technicians - PCT AA and PCT BB), who were present during this observation, to wash their hands to prevent cross contamination. The facility census was 10. Findings include: During observation in the Patient Treatment Room on 7/23/25 from 9:13 a.m. to 10:30 a.m., the following was revealed: - There were a total of two handwashing sinks which were designated as “clean sinks”. - Sink #1 right across Station (S)11 was out of order. - Sink #2 right across S5 did not have warm running water after this surveyor ran it for three minutes. During interviews with DPC staff on 7/23/25, between 9:25 a.m. and 10:15 a.m., the following was revealed: - At 9:25 a.m., PCT BB stated that one “clean” sink had not been repaired and that all sinks, including two “dirty” sinks (used for discarding fluids and rinsing used equipment) had no warm running water for some time. - At 9:29 a.m., PCT AA mentioned that because one “clean” sink was out of order, patients and DPC staff were using one of two eye wash stations (designed to quickly flush the eyes with a continuous flow of water to wash away harmful substances) to wash their hands as needed. On 7/25/25, at 9:30 a.m., the Assistant Administrator (Staff AA) was notified of this observation. She acknowledged the observation and stated that all sinks would not run warm water since the facility’s Water Heating System was broken since the previous week.”

“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: 52051 Based on observations, staff interviews, a review of the Centers for Disease Control and Prevention (CDC) guidelines, and a review of facility Policies and Procedures (P & P), it was determined that the facility failed to ensure that that three of three Direct Patient Care (DPC) staff (Registered Nurse - RN AA and Patient Care Technicians - PCT AA and PCT BB) observed, appropriately wore their Personal Protective Equipment (PPE - such as gowns and face shields), while performing procedures where there was a risk of exposures to blood and body fluids during initiation and termination of dialysis. This deficient practice posed an increased risk of exposure to bloodborne pathogens for RN AA, PCT AA, and PCT BB that could lead to cross contamination and infection, compromising patient safety by increasing the likelihood of unintentional transmission of infectious agents. The facility had 10 in-center hemodialysis (ICHD) patients. Findings were: During observation in the Treatment Room on 7/23/25 from 9:13 a.m. to 10:30 a.m., the following was revealed: - RN AA wore her gown but had it only half-buttoned, exposing the upper part of her clothing. PCT AA wore her gown completely unbuttoned, leaving the front entirely open. PCT BB had her gown with only one button fastened at the waist, which still exposed her clothing. - PCT AA did not wear eye goggles or faceshields while terminating patient treatments including removal of access needles for patients at S2, S3, and S4, where there was a risk of blood spurting or splattering and exposure to other body fluids. During an interview with PCT AA on 7/23/25, at 9:58 a.m., she stated that she was only wearing eyeglasses. She also mentioned that although the facility had face shields available, the facility did not require DPC staff to wear them. During an interview with RN AA, the charge nurse, on 7/23/25, at 10:30 a.m., she stated that she had missed buttoning her gown and committed to doing better in the future. She acknowledged the importance of properly wearing the gown and noted that face shields had always been available for DPC staff to use. CDC guidelines recommend that staff members wear gowns, face shields, protective eyewear, and masks to ensure their safety and prevent contamination of clothing during procedures where blood may spurt or splash. This includes activities such as starting and stopping dialysis, cleaning dialyzers, and centrifuging blood. A review of the facility’s Policy (no number), titled, “Personal Protective Equipment”, with no date, stated: Personal protective equipment is made available at no cost to the employees and must be worn. . . . Each employee is responsible for complying with the use of appropriate PPEs.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 52051 Based on observation, a review of Centers for Disease and Prevention (CDC) guidelines, and staff interviews, it was determined that the facility failed to ensure that one of one Registered Nurse (RN AA) and two of two Patient Care Technicians (PCT AA and PCT BB) observed, utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of 10 in-center hemodialysis (ICHD) patients who were under the care of this facility. Findings include: During observation in the Patient Treatment Room on 7/23/25 from 9:13 a.m. to 10:30 a.m., the following was revealed: - P#1, P#3, P#4, P#5, P#6, P#7, and P#10 were undergoing hemodialysis treatment at S2, S3, S4, S5, S9, S10, and S12. The paper treatment flowsheets that were on clipboards were placed on top of the dialysis machines (dirty), then at the end of treatment, the clipboards (dirty) were not disinfected after use and were kept in the Nurses’ Station (clean area), as well as the paper treatment flowsheets. According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area), could cause cross contamination that spreads bacteria/infections. During an interview with the Assistant Administrator (Staff AA), who was also an RN on 7/23/25, at 11:16 a.m., she mentioned that it had been a long-standing practice at the facility to place paper flowsheets on top of the dialysis machines for staff to chart chairside. Staff AA acknowledged that this could potentially lead to cross-contamination. In a separate interview with RN AA, the charge nurse on 7/23/25, at 11:29 a.m., she expressed concern that this breach in infection control occurred frequently with paper charting. She stated that she would work with the Facility Administrator to address this issue. The Facility Administrator was not available for an interview.”

“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: 52051 Based on observation and staff interview, it was determined that the facility failed to ensure that the passageway to two of two Exit doors leading to the building exteriors were free from obstacles to ensure safety and easy passage for all personnel. This deficient practice had the potential to negatively affect the safety of all staff who might need access to or exit from these obstructed areas. Findings include: During a tour of the facility with the Assistant Administrator (Staff AA) on 7/23/25, between 10:35 a.m. and 11:30 a.m., revealed the following: - There was a total of two exit doors leading to the back exterior of the building: one located on the right wing (Exit #1) and the other on the left wing (Exit #2). - Exit #1 was partially obstructed by five old dialysis chairs, while Exit #2 had another five old chairs also blocking the passage. This left only about 18 to 20 inches of space to pass through each exit. As a result, access to these exits was limited and restrictive, with potential risk for safety in case of an emergency. - During an interview with Staff AA on 7/23/25, at 10:51 a.m., she acknowledged the obstructed passageways and noted that the old dialysis chairs mentioned earlier were scheduled for disposal. - During an interview with the other Administrative Personnel (Staff BB) on 7/24/25, at 8:55 a.m., she acknowledged the obstruction of the passageways leading to both exits mentioned previously and stated that the facility was awaiting trucks to pick up the old dialysis chairs.”

“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: 52051 Based on observation and staff interviews, it was determined that the facility failed to ensure that the building in which dialysis services were provided was sanitary and maintained to ensure the safety of all patients and staff. Failure to maintain the integrity of all surfaces could hinder effective cleaning and disinfection of the surfaces, thus providing a potential for microbial growth. These environmental concerns were observed in one of one Patient Treatment Room, one of one Dialysate Preparation Room, one of one Main Hallway, and one of one Mechanical Room. The facility had 10 in-center hemodialysis (ICHD) patients. Findings include: A tour of the facility on 7/23/23 between 10:35 a.m. and 11:30 a.m., revealed the following: In the Patient Treatment Room: - There was a total of seven air vents that were visibly dirty and covered with a layer of dust and grime, and with black discoloration and rust colored substance, which could indicate a lack of regular maintenance. - The ceiling tile at Station (S)8, which measured about 2 Feet by 2 Feet, was partially detached from the metal frame on one side. In the Dialysate Preparation Room: - The floor and the drain located behind the two large Acid Holding Tanks were heavily soiled with a mixture of brown and black grainy substance. Significant cracks in the tiles around the floor drain had led to the accumulation of unsightly dirt buildup. - The floor beneath the Central Water Purification (CWP - a system to purify water for dialysis) system, measuring about 8 Feet in length and 2 Feet in width, was significantly dirty, featuring a mix of charcoal bits and gray to black substances. The base of the metal frame supporting the CWP was covered with a rust-colored substance, while both floor drains on either side were partially covered by brown and black grainy substances. - The tiled floor throughout the Dialysate Preparation Room was coated with a brownish and grayish grainy substance, indicating a lack of regular cleaning. In the Main Hallway: - There were three ceiling tiles with brown colored stains in different shapes, indicating signs of water damage. One ceiling tile was noted to be missing, which created a large hole in the ceiling that measured about 2 Feet by 2 Feet. - The hallway floor that led to the Patients’ Weighing Scale and office was wet with seepage from the subfloor, resulting in the buckling of the laminate flooring. - The floor in front of the men’s restroom (staff) was slightly damp, with a small puddle of standing water near the entrance and the surrounding area next to the standing water, that measured approximately 4 Feet in length and 2 Feet in width, was wet. In the Mechanical Room: - The Water Heater Tank/equipment was leaking that resulted in water puddles on the floor at the entrance, thus creating potential for slips and falls. The wet area in front of the tank measured approximately 5 Feet in length and 1.5 Feet in width. Additionally, the base of the tank was moderately covered with a rust-colored substance. - The vinyl floor tiles throughout the mechanical room were coated with a brownish, grainy substance. During an interview with the Assistant Administrator (Staff AA) on 7/23/25, at 10:36 a.m., she explained that the missing ceiling tile was a result of a heavy leak that caused water damage in the ceiling last month. Staff AA acknowledged all other observations and stated that she would coordinate these findings with the Biomedical Technician (BMT) and another Administrative Personnel (Staff BB). This surveyor presented all these findings mentioned above to the BMT, on 7/23/25, at 12:35 p.m. He stated that the facility should change the entire water purification system. He also acknowledged the need to have all air vents cleaned but could not specify the last inspection date. Additionally, he acknowledged the leak in the water heating system and noted that while some individuals inspected the equipment, he could not provide details about the date, time, or vendor involved. During an interview with Staff BB on 7/24/25, at 8:59 a.m., she acknowledged all observations mentioned above. She also stated that the facility needed significant environmental repairs and maintenance.”

“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: 52051 Based on observation and staff interview, it was determined that the facility failed to provide a method for all patients to summon immediate assistance when needed, from one of one Patients’ Lobby and one of one Patients’ Bathroom to ensure safety for all patients; and failure of the facility to ensure that three of three hemodialysis chairs at Station (S)7, S8, and S12 were functional and free from broken mechanisms. This failure had the potential to negatively affect the health and safety of all 10 patients who dialyzed at this facility. Findings include: Patients’ Lobby and Patients’ Bathroom: - On 7/23/25, at 9:00 a.m., this surveyor observed that there was no method for patients to summon assistance such as a doorbell or call light at the Patients’ Lobby and Patients’ Bathroom. Additionally, the reception room window/mirror blocked the view for patients to see if a receptionist was available. The reception/front desk was mostly empty (no receptionist when the facility was open). A review of the Patient and Visitor Occurrence Report from January 2025 to July 2025 revealed a patient complaint about a broken doorbell. This complaint was filed on 6/18/25, and had not been addressed by the facility management to this date (37 days later). During an interview with the Assistant Administrator (Staff AA) on 7/23/25, at 10:36 a.m., she acknowledged the above observation and stated that the doorbell was broken. During observation in the Patient Treatment Room on 7/23/23 between 10:35 a.m. and 11:30 a.m., the following was revealed: - The hemodialysis chairs at S7, S8, and S12 had broken mechanisms such as reclining levers, which prevented proper adjustment of the chairs’ positions. This posed a risk for patients in emergency situations such as sudden drop in blood pressure readings when patients need to be in a Trendelenburg position (where the feet are elevated higher than the head), or if patients experience cardiac arrests (chairs need to be in a flat position), etcetera (etc.). In addition, these defective chairs were still being used by patients and were not removed from the Patient Treatment Room. - The Assistant Administrator (Staff AA) on 7/23/25 at 11:30 a.m., acknowledged the observation regarding the defective hemodialysis chairs.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 52051 Based on a review of medical records and staff interview, it was determined that the facility failed to complete an initial Plan of Care (POC) that was conducted by the entire Interdisciplinary Team (IDT) within 30 calendar days of admission or after 13 dialysis treatments for one of one patient (P) (P#1) sampled, who was admitted on 4/21/25 and was new to hemodialysis. P#1 did not have a completed Initial POC that reflected participation of all members of the IDT, including P#1 or P#1’s representative. Failure of IDT coordination and development of an effective, individualized POC for P#1 had the potential to negatively affect the health and safety of P#1 and all future new-to-dialysis patients. The facility census was 10. Findings include: During a review of medical records, the following was revealed: - P#1 was admitted and had his first day of hemodialysis at this facility on 4/21/25. - P#1’s Initial POC that was dated 6/16/25 (56 days from admission date), was incomplete and was unsigned by the IDT, P#1 or his designee. During an interview with the Assistant Administrator (Staff AA), who was also a Registered Nurse (RN) on 7/24/25, at 10:50 a.m., she stated that she was aware the IDT did not complete P#1’s POC in a timely manner. She acknowledged that the initial POC should have been completed and signed by both the IDT and P#1 within 30 days from the date of admission.”

“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: 52051 Based on observation, staff interview, and a review of the facility’s Policies and Procedures (P & P), it was determined that the Medical Director failed to ensure that one of one Registered Nurse (RN AA) observed, performed post-treatment nursing assessment to three of three patients at Station (S)3, S4, and S9, in accordance with facility procedures. Post-treatment nursing assessments are crucial for monitoring patient recovery and ensuring patients’ ongoing safety and well-being following treatment. This deficient practice could negatively impact the health and safety of 10 in-center hemodialysis (ICHD) patients under the care of this facility. Findings include: During observation in the Treatment Room on 7/23/25 from 9:13 a.m. to 10:30 a.m., the following was revealed: - Patients at S3, S4, and S8 were observed to have completed their dialysis treatment at approximately 10:00 a.m. - PCT AA ended dialysis treatment for patients at S3 and S4. While PCT BB terminated dialysis treatment for patient at S8. - All three patients mentioned above were observed holding their access sites with one gloved hand (after their hemodialysis treatment), until hemostasis (stopping of bleeding) was achieved. RN AA stayed at the Nursing Station and did not perform patients’ post assessments until they all left the facility at 10:12 a.m. - On 7/23/25, at 11:30 a.m., this surveyor discussed the observation with RN AA about the lack of post-treatment assessments for the above mentioned patients. RN AA acknowledged this oversight and stated that she would improve in the future to ensure that all patients received the necessary assessments. A review of the facility’s P & P (no reference number), titled, “Nursing Assessments Pre & Post”, with no effective or revision date, stated: II. Policy Pre and post-dialysis assessments are crucial for managing patients undergoing hemodialysis. . . IV. Procedure Post-dialysis Assessment: - Monitoring vital signs after dialysis is crucial to observe for any immediate changes or complications. - Assessing any remaining signs of fluid overload or depletion is important to adjust future dialysis prescriptions. . . - Assessing post-dialysis fatigue, muscle cramps, or other symptoms can help identify potential issues with dialysis or underlying condition.”