Usrc Pearlridge Dialysis

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 39754 Based on staff interview, review of facility Emergency Management Plan, review of facility Emergency Preparedness Risk Assessment Tool and review of policies, the facility failed to show that all employees were continuously trained on natural disasters, hurricanes. Findings include: Staff interview on 09/13/24 at 09:55 AM, Clinical Specialist (CS)1 provided their policy on Natural Disasters Plan which read; The facility will develop a plan to include policies and training for both employees and patients. This will enable facility, their patients, and staff to be ready to handle an emergency caused by a natural disaster in the most efficient way possible in order to provide necessary services to the patient population prior to, during, and after a natural disaster. Purpose, The facility must complete the Facility Emergency Preparedness Risk Assessment Tool in order to determine the natural disasters for which the facility is at highest risk. This will enable the facility to develop their Emergency Preparedness Plan utilizing the policies which apply based on the level of risk. CS1 was not able to provide documentation to show that all employees were continuously trained on natural disasters, hurricanes. Review of facility Emergency Preparedness Risk Assessment Tool dated November 2023 identified Natural Disaster/Hurricanes as Moderate Risk to the facility. The risk score was Possible = Probability, Minor = Consequence, Moderate = Preparedness, Risk Score = 12 (5-20 Moderate Risk). Review of facility Emergency Management Plan, date of implementation/review/update 03/25/24 read; Overview, An emergency is any unplanned event that can cause death or significant injuries to employees and/or patients or that can shut down the facility, disrupt operations or cause physical or environmental damage ... Emergencies include, but are not limited to, fire, equipment or power failures, care related emergencies, water supply interruption, natural disasters likely to occur in the facility’s geographic area and emergent infectious diseases ... This facility will train and educate staff and patients on the process through drills and conduction of emergency preparedness exercises ... All staff including physicians will be educated at least annually or per stricter state regulations regarding the Emergency Preparedness binder including emergency preparedness policies and procedures as well as this facility specific emergency plan. Review of policy on Emergency Preparedness Training read; Purpose, To ensure staff and patients are knowledgeable regarding facility procedures during an emergency situation. Procedure; Staff training program, must include and/or demonstrate the following: Initial training in emergency preparedness policies and procedures for all new staff, individuals providing on-site services under arrangement (e.g. research personnel) and volunteers, consistent with their expected roles. Subsequent training in emergency preparedness policies and procedures for all existing staff, individuals providing on-site services under arrangement (e.g. research personnel) and volunteers, consistent with their expected roles will be completed at least every 3 months. Review of facility specific emergency preparedness procedures by the FA and/or designee with ALL staff including per-diem/PRN staff and physicians/physician extenders. This review will include ... Procedures for the specific natural or man-made disaster(s) identified on the facility risk assessment ...”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 48351 Based on observations, staff interviews, and facility policy review, the facility failed to clean and disinfect an item that was brought into the dialysis station and brought back to a common area. The facility also failed to discard a disposable item in the station during the cleaning process. This deficient practice places the facility at risk for transmitting blood borne pathogens and infections and has the potential to negatively impact all 250 patients receiving in-center hemodialysis treatments. Findings Include: 1) Observation was conducted on 09/10/24 at 10:46 AM. Patient Care Technician (PCT) 10 was observed testing for conductivity and pH using the Phoenix Meter at one of the dialysis stations. PCT10 was then observed walking to a sink labeled, “clean sink.” PCT10 emptied the meter and placed it back on the station without cleaning it with disinfectant wipes. Interview was conducted with Clinical Specialist (CS) 1 on 09/13/24 at 11:05 AM. CS1 confirmed that any equipment brought into the dialysis station needs to be discarded or wiped down with disinfectant wipes. 2) Concurrent observation and interview were conducted on 09/10/24 at 11:34 AM at one of the stations. PCT15 was observed cleaning the station and failed to discard a paper tape that was left on one of the station baskets. After PCT15 confirmed that she was done cleaning the station, PCT15 was shown the paper tape that was left in the basket. PCT15 confirmed that it should have been discarded during the cleaning process. Interview was conducted with the Group Facility Administrator (GFA) 2 in the conference room on 09/10/24 at 01:30 PM. The GFA2 confirmed that tape left in the stations should be discarded during the cleaning process. A review of the facility policy titled, “Disinfection and Cleaning of Dialysis Machine Equipment,” with a revision date 07/23, was conducted. The facility policy documented, “After each treatment, remove bloodlines and disposable supplies ...disinfect non-disposable medical equipment.””

“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: 48351 Based on observations, staff interviews, and facility policy review, the facility failed to separate clean areas from contaminated areas, where used supplies and equipment are handled. This deficient practice places the facility at risk for transmitting blood borne pathogens and infections and has the potential to negatively impact all 250 patients receiving in-center hemodialysis treatments. Findings Include: 1) Concurrent observation and interview were conducted on 09/10/24 at 11:36 AM near the waiting room. Patient Care Technician (PCT) 10 was observed walking out into the waiting room with gloves and face shield on. On a wall by the exit to the waiting room was a sign that noted, “No PPE [Personal Protective Equipment] beyond this point.” When PCT10 was queried about the use of her PPEs in the waiting room, PCT10 confirmed that she should have removed her gloves and face shield prior to entering the waiting room area. 2) Concurrent observation and interview were conducted on 09/12/24 at 03:50 PM near the waiting room. PCT 20 was observed walking out into the waiting room with gloves on. When PCT20 was queried about the use of her PPEs in the waiting room, PCT20 confirmed that she should have removed her gloves prior to entering the waiting room area. A review of the facility policy titled, “Personal Protective Equipment (PPE),” with a revision date of 07/2023, was conducted. The facility policy documented, “9. PPE (gowns, goggles, face shield, or gloves) is not to be worn in: Office areas, clean supply storage room (except when transporting biohazard waste), patient lobby ...””

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 48351 Based on observations, staff interviews, and facility policy review, the facility failed to properly dispose of potentially infectious waste. This deficient practice places the facility at risk for transmitting blood borne pathogens and infections and has the potential to negatively impact all 250 patients receiving in-center hemodialysis treatments. Findings Include: Observation was conducted on 09/10/24 at 10:44 AM at one of the facility dialysis stations. Patient (P) 16 was observed throwing a blood-soaked gauze into the regular trash bin after applying pressure to his access site. Interview was conducted with Patient Care Technician (PCT) 15 at one of the dialysis stations on 09/10/24 at 11:34 AM. PCT15 confirmed that he/she should have assisted P16 with discarding the blood-soaked gauze into the biohazard waste container. Interview was conducted with the Group Facility Administrator (GFA) 2 in the conference room on 09/10/24 at 01:30 PM. GFA2 confirmed that the blood-soaked gauze should have been discarded in the biohazard waste container. A review of the facility policy titled, “Guidelines for the Handling and Disposal of Infectious Medical Waste,” with a revision date of 04/23, was conducted. The facility policy documented, “Dispose of all contaminated items in the biohazard waste container. This includes ...blood ...gauze pads, dressings ...””

“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: 48351 Based on observation, staff interviews, and review of the facility’s policy, the facility failed to ensure that staff thoroughly disinfected all surfaces of the dialysis station. The failure to thoroughly disinfect contaminated areas of the dialysis station had the potential to transmit blood borne pathogens and infections, and negatively impact the 250 patients receiving in-center hemodialysis treatments at this facility. Findings Include: Concurrent observation and interview were conducted on 09/10/24 at 11:21 AM at one of the dialysis stations. Patient Care Technician (PCT) 15 was observed wiping down a dialysis station after a treatment was provided. PCT15 failed to wipe down the television arms of the dialysis station and a blood pressure cuff that was placed in a basket attached to the dialysis machine. PCT15 was informed of the observation and PCT15 confirmed that she should have wiped down the arm of the television and the blood pressure cuff in the basket. Interview was conducted with the Group Facility Administrator (GFA) 2 in the conference room on 09/10/24 at 01:30 PM. GFA2 confirmed that during the cleaning of the dialysis station, everything needs to be wiped down, including the arm of the television and the blood pressure cuff. A review of the facility policy titled, “Disinfection and Cleaning of Dialysis Machine Equipment,” with a revision date 07/23, was conducted. The facility policy documented, “Clean all external surfaces of the dialysis machine to include top, sides, front and back. BP cuffs and basket ...attached computer monitors ...””

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 47783 Based on observation and interviews, the facility failed to secure the location for the water treatment system and restrict access to authorized personnel only. Failure to restrict the water treatment system to only individuals responsible for monitoring and maintenance the water treatment system has the potential to negatively impact the safety and well-being of the 250 in-center hemodialysis patients receiving dialysis treatments at this facility. Findings include: On 09/09/24 at 08:51 AM during the flash tour, observed a keypad lock on the door to the water treatment room. Biomed Technician (BMT) 2 entered a numeric code on the keypad but the door opened as he was pressing the buttons without turning the door handle. As observations were being made in the water room, another staff member entered the room to check on the bicarbonate mixer. Observed staff did not enter a code when she entered and just pushed the door open. At 09:20 AM, as we exited the water room, asked BMT2 to push the door without entering the code. BMT2 pulled the door close and was able to open the door by just pushing it. Asked BMT2 if the door is secured. BMT2 confirmed that the door does not lock unless it is lifted up and pushed against the locking mechanism. At this time, BMT1 joined the interview and said, “It’s been like that for a while now, not locking.” On 09/09/24 at 12:12 PM, an interview was conducted with the Area Biomed (ABM) in the water room. ABM confirmed that the door to the water room was not secured, that it should be secured at all times and only authorized personnel should have access.”

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 39754 Based on observation, staff interview, review of policy and review of manufacturer recommendations, the facility failed to discard an expired container of Micro-X Test Strips. As a result of this deficiency, there was a risk of increased disinfection residual in the dialysis water system. Findings include: During observation of the Home Hemodialysis training room on 09/10/24 at 09:50 AM, a container of Micro-X Test Strips was noted to have been expired with an expiration date of 08/31/24. Registered Nurse (RN)10 was queried on 09/10/24 at 10:00AM about the expired Test Strips and acknowledged that they were expired and should have been discarded. Review of policy on TABLO Disinfection Protocols read; Purpose, to ensure the TABLO system is cleaned and disinfected on a regular basis and in response to elevated bacteria and/or endotoxin test results. To ensure machine disinfection is completed per manufacturer recommendations. Policy ... once the Full Chem completes, perform a water test to confirm the TABLO system is free of chemical residual. Review of manufacturer recommendations for Micro-X Residual Test Strips read; Indications for use, Micro-X Residual Test Strips are intended for use in the determination of the residual levels of Peroxyacetic Acid germicides ... Storage and Handling, do not use a test strip (from an opened or unopened bottle) after the expiration date.”

“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: 47783 Based on observations and interviews, the facility failed to ensure the integrity and cleanliness of countertops, cabinets, walls, drains and equipment in the water treatment room and dialysis treatment floor. Failure to maintain the integrity of surfaces and cleanliness of walls, equipment and drains increases the potential of microbial growth, placing all 250 in-center patient’s health and safety at risk. Findings include: 1) On 09/09/24 at 08:51 AM, a flash tour of the water treatment room was conducted, and the following were observed: Rust on four of the nine light fixtures above the components of the water treatment system and dialysate mixing equipment. Dark grayish build-up on the wall behind the water treatment system and air vents. Black residue on three of four floor water drains. Brownish build-up on the pump for the Granulfo (dry acid concentrate used for dialysate) mixer. Whitish build-up on top of the bicarbonate (component of dialysate to help maintain acid-base balance) storage tank that was mounted close to the ceiling. On 09/11/24, concurrent observations and interview was conducted with the Area Biomed (ABM) and Biomed Technicians (BMT) in the water treatment room. ABM, BMT1 and BMT2 acknowledged all observations made on 09/09/24 and that they were still in the same condition. The light fixtures had rust, the wall and air vents had a build-up of dust, there was blackish residue on the drains, there was a brownish build up on the Granuflo mixer pump and there was a whitish substance build-up on the top of the bicarbonate storage tank. 2) On 09/10/24 at 07:53 AM, concurrent observations and interview was conducted with ABM and Clinical Specialist (CS) 2 on the treatment floor. The following were found: Chipped Formica countertops at the sink areas for three of the four bays exposing pressed wood, and tape was also applied to cover up holes on the countertops. Water damage to the walls by the dirty sink areas in three of the four bays exposing crumbling drywall and rusted metal frame. Cabinets by the sink areas with sections peeling and swelling caused by water damage. ABM and CS2 acknowledged observations and said there are plans to do renovations to the facility but were not certain when it will be scheduled.”

“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: 47783 Based on record reviews, and interview, the facility did not ensure the physician prescribed dialysis orders were followed for two of 15 patients (Patient (P) 6 and 9) sampled for record review. This deficient practice placed the patients at risk for not achieving or sustaining desired adequacy outcomes of dialysis. Findings include: 1) Review of Hemodialysis Flowsheets from 08/20/24 to 08/30/24 for P6 was conducted. Dialysis treatment orders included: Estimated Dry Weight (EDW) of 139 kg (kilograms), frequency of three days a week, treatment time of four hours, BFR (blood flow rate) of 400 ml/min (milliliters per minute) and DFR (dialysate flow rate) of 600 ml/min. Treatment record for 02/05/24 noted that dialysis treatment was initiated at 12:05 PM and ended at 03:39 PM. BFR documented from 12:09 PM to 03:24 PM was 300 ml/min. No information was found in the treatment record and Electronic Health Record (EHR) why the BFR order was not followed. 2) Review of Hemodialysis Flowsheets from 08/10/24 to 09/07/24 for P9 was conducted. Dialysis treatment orders included: EDW of 88.5 kg, frequency of three days a week, treatment time of four hours, BFR of 375 ml/min, and DFR of 800 ml/min. Treatment record for 08/10/24 noted that dialysis treatment was initiated at 11:53 AM and ended at 03:57 PM. BFR documented from 12:01 PM to 12:21 PM was 250 ml/min, and from 12:41 PM to 03:21 PM was 300 ml/min. No information was found in the treatment record and EHR why the BFR order was not followed. During an interview with Clinical Specialist (CS) 1 in the conference room on 09/13/24 at 10:28 AM, CS1 acknowledged that there was no documentation why the prescribed BFR for both P6 and P9 were not followed or if the staff did any interventions. CS1 said the staff are expected to report to the RN if the BFR is not achieved. Review of facility policy titled “Initiation of Dialysis Treatment” stated, “. . . 13. Prior to walking away from patient’s dialysis machine, verify all prescribed orders are followed. If unable to follow any part of the patient’s prescription after troubleshooting, notify the charge nurse and document notification. Charge nurse will notify physician if indicated and document any follow up or new orders. . .””

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 48351 Based on interview and record review, the facility failed to provide the necessary care and services to manage the patient’s volume status for four out of 15 sampled patients (Patient (P) 1, P5, P7 and P8 ). The deficient practice placed the patients at risk for adverse health outcomes and had the potential to negatively impact the health status of the 250 patients receiving in center hemodialysis treatment. Findings Include: 1) A review of P8’s Electronic Health Record (EHR) was conducted. P8’s EHR documented that, on 08/31/24, P8’s Blood Pressure (BP) reading during dialysis treatment was 154/103. P8’s EHR also documented that, on 08/31/24 at 06:40 PM, P8’s BP reading was 160/105. Both documented BPs failed to include a nurse assessment or documentation of what interventions were provided during that time. Interview was conducted with the Clinical Specialist (CS) 1 on 09/13/24 at 11:05 AM near the conference room. CS1 confirmed that a Registered Nurse (RN) should have assessed the patient during the two incidences that P8’s BP was out of range of the facility identified parameters. CS1 added that the RN should have documented what interventions were done. 47783 2) Review of Hemodialysis Flowsheets from 08/26/24 to 09/09/24 for P1 conducted. Noted the BP readings during treatments on 08/30/24 at 08:02 was 193/100, and on 09/04/24 at 06:05 AM was 196/97. There was no documentation that the RN was notified. 3) Review of Hemodialysis Flowsheets from 08/29/24 to 09/10/24 for P5 conducted. Noted the BP readings during treatment on 09/07/24 at 11:41 AM was 94/53 and 11:44 AM was 98/53. There was no documentation that the RN was notified. 4) Review of Hemodialysis Flowsheets from 08/26/24 to 09/09/24 for P7 conducted. Noted the BP readings during treatment on 08/26/24 at 06:02 was 206/93, at 06:05 AM was 187/83, at 06:20AM was 201/83, and on 09/02/24 at 06:06 AM was 188/86, at 06:21 AM was 219/98, at 06:30 am was 208/94. There was no documentation that the RN was notified for the above instances. For the BP readings of 202/83 at 07:31 AM, 225/92 at 07/47 AM, 201/83 at 07/49 AM, PCT documented that the RN was notified but there was no documentation of RN assessment or interventions. On 09/12/24 at 02:12 PM, a concurrent interview and record review was conducted with CS1 in the conference room. CS1 reviewed the Hemodialysis Flowsheets and confirmed that the PCTs are supposed to notify the RN if the BP readings are outside the facility identified parameters. CS1 added that the RNs are also expected to assess and take action to address the high or low BP readings, and document it in the flowsheets. A review of the facility policy titled, “Reportable Parameters to CN [Charge Nurse],” with a revision date of 01/2020 was conducted. The policy documented, “PCT [Patient Care Technician]/CCHT [Certified Clinical Hemodialysis Technician]/LPN [Licensed Practical Nurse]: Report to Charge Nurse INTRA-DIALYSIS. B/P: Systolic > (greater than) 180 or < (less than) 100 Diastolic >100.””

“MD RESP-DEVELOP, REVIEW & APPROVE P&P CFR(s): 494.150(c)(1) The medical director must- (1) Participate in the development, periodic review and approval of a “patient care policies and procedures manual” for the facility; This Standard is not met as evidenced by: 39754 Based on record review, staff interview and review of policy on Intradialytic Monitoring of the Patients receiving Home Hemodialysis (HHD), the policy failed to show blood pressure parameters for monitoring/teaching and the policy failed to reflect current practice procedures for Home Hemodialysis. Findings include: Review of Electronic Health Record (EHR) for HHD Patient 1 (HHD1) showed HHD1 was newly admitted and being trained for treatments at home. EHR revealed no identified blood pressure parameters for teaching/monitoring. Staff interview on 09/11/24 @ 08:05 AM, Registered Nurse (RN)9 said that the TABLO dialysis machines have parameters for blood pressure built in the system and if blood pressure readings were out of range, the machine would automatically alarm. Staff interview on 09/11/24 @ 10:00 AM, Home Facility Administrator (Home FA) reviewed the facility policy on Intradialytic Monitoring of HHD Patient and acknowledged that it did not show parameters for monitoring/teaching of blood pressures. Home FA also acknowledged that the policy did not reflect current practice procedures for HHD. Review of policy on Intradialytic Monitoring of HHD Patients included the following language; “Purpose, the patient will receive a safe, effective and comfortable treatment. Monitoring, direct patient care staff will monitor the following parameters during each dialysis treatment. Patient, must be in direct view of a staff member at all times, if leaving the treatment area for any reason, report off to another staff member and ensure observation of the assigned patients. Vital signs, obtained and documented at least every 30 minutes and reported to charge nurse if outside of standing orders and/or reportable parameters. Volume status, indicated by changes in BP and HR parameters, lung sounds and presence or reduction of edema. Vascular access, site clean and dry, venous and arterial pressure monitoring, signs and symptoms of recirculation, signs and symptoms of infiltration. Ensure patient’s access, blood lines and face are visible at all times; during every 30 minute monitoring, the access and visualization of the face must be observed. If the patient refuses to keep access of face uncovered at all times (including eye shades or hats/caps), the charge nurse will be notified. Document patient refusal and charge nurse notifications in the flow sheet ...””

“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: 48351 Based on observations, interviews, and facility policy review, the facility failed to adhere to the facility’s policies and procedures related to patient care and safety. One of two medication fridge were left unsecured by staff. This deficient practice placed patient medications at risk for diversion. The deficient practice has the potential to negatively impact the care of the 250 patients receiving in center hemodialysis treatment. Findings Include: Observation was conducted on 09/11/24 at 08:00 AM in the medication area. One of two medication fridge was not secured, and State Agency (SA) was able to pull the fridge open. Interview was conducted with Registered Nurse (RN) 10. RN10 confirmed that it should have been locked. RN10 proceeded to lock the medication fridge in front of SA. Interview was conducted with Clinical Specialist (CS) 1 on 09/11/24 at 09:07 AM near the medication area. CS1 confirmed that the medication fridge should be locked unless the nurse is removing medications. A review of the facility policy titled, “Guidelines for Administration of Medication,” with a revision date 04/24 was conducted. The facility policy documented, “Medications will be locked in a cabinet or a medication refrigerator (if refrigeration required).””