Usrc West Oahu 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: 47783 Based on observations, interviews and record review, the facility failed to ensure staff consistently adhere to requirements for performing hand hygiene and changing of gloves. This deficient practice placed the patients at risk for potential exposure to infectious pathogens. Findings include: 1) On 08/12/24 at 09:56 AM, observed Patient Care Technician (PCT) 12 at station 10 discontinuing hemodialysis treatment for Patient (P) 13. After disconnecting the lines from the patient, PCT12 changed her gloves without performing hand hygiene prior to donning new gloves. Continued to observe PCT12 as she removed the needles from P13’s vascular access. After applying the dressing to the needle insertion sites, PCT12 removed her gloves, did not perform hand hygiene, and went to the clean area to get the thermometer. 37954 2) On 08/12/24 at 08:35 AM observed PCT 11 at station one discontinuing hemodialysis treatment for P14. PCT11 was seen removing his dirty gloves, threw dirty gloves away and no hand hygiene was observed such as washing his hands or using hand sanitizer. PCT11 then pulled out three clean gloves from the gloves box, returning one glove back to the box and put on the clean gloves. 3) On 08/12/24 at 01:30 PM while observing a patient receiving training on how to perform home hemodialysis, PCT14 was observed taking off his dirty gloves after doing ultrasound of patient’s AV (arteriovenous) fistula (surgical connection made between an artery and a vein). PCT14 threw away the gloves, no hand hygiene was performed and PCT14 was observed putting on clean gloves. PCT14 proceeded to take out all the supplies needed and placed them on the clean area. On 08/12/24 at 01:45 PM interviewed PCT14. Notified staff of what was observed during 01:30 PM observation. Inquired what he should do once he takes off dirty gloves and he stated “Wash my hands.” Review of facility policy titled “Hand Hygiene” stated, “. . . Hand Hygiene will be performed: . . . 9. After gloves are removed . . .””

“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: 47783 Based on observations, staff interview and record review, the facility failed to ensure that items taken into the dialysis station were either disposed of, dedicated for use on a single patient or disinfected before being returned to a common area. As a result of this deficient practice, the patients were placed at risk for the potential exposure to infectious pathogens. Findings include: 1) On 08/13/24 at 08:36 AM, Observed Patient Care Technician (PCT) 12 check the temperature of the patient dialyzing in station five. After checking the temperature PCT12 returned the thermometer to the clean area without disinfecting it. Then at 08:42 AM, PCT12 checked the conductivity (measure of the salt content of the dialysate) and pH (measure of how acidic or basic a solution is) of the dialysate (solution of electrolytes and bicarbonate used for dialysis treatments) in station five using an independent meter. After entering the readings into the machine and showing it to another PCT, she returned the meter back to the clean area without disinfecting it. 2) On 08/13/24 at 11:49 AM while making observations on the treatment floor with the Clinical Specialist (CS), PCT7 was checking the conductivity and pH of the machine in station 22. After recording the readings and showing it to another PCT, she returned the meter to the clean area without disinfecting it. CS asked PCT7 to disinfect the meter with a bleach wipe. Asked CS if the staff are supposed to disinfect items and equipment brought to the patient’s stations. CS confirmed that if the items or equipment are brought into the patient station and will be used for another patient, they must be disinfected. Review of facility policy titled “Infection Control and Precautions for all Patients” stated, “. . . 3. Items taken into the dialysis station will 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 . . .””

“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: 37954 Based on observation and interview, the facility failed to store their oxygen (O2) concentrator machines away from the possibility of exposure to patient’s bodily fluids from nearby dialysis stations. This deficient practice could affect all the patients in the facility exposing them to infectious diseases. Findings Include: On 08/13/24 at 09:45 AM observed Patient Care Technician (PCT) 2 breaking down station six after the pateint was done with his treatment. While she was removing the used bloodlines from the machine, observed two O2 concentrator machines that were stored next to station six and the O2 concentrator machines were not covered. PCT2 pulled gently on the used bloodlines and the dialyzer port cap popped off and fluid leaked out onto the ground and splattered the surrounding area near the O2 concentrator machines where they were stored. On 08/13/24 at 10:05 AM PCT7 was observed wiping down an O2 concentrator machine which she then brought over to store near station six. Inquired of PCT7 who had told her to place the O2 concentrator machine there and she stated she believes it was the “Biotech guy” stated to store in this area or around corners of the room or near wall where there are no chairs.” At this time asked Clinical Specialist (CS) to come over to station six to see what had occurred with the used dialysis equipment leakage and see where the fluid had splashed near the O2 concentrators. CS confirmed this was not a safe space to store clean O2 concentrators, which are used by the patients receiving dialysis, and proceeded to move them away from station six.”

“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: 37954 Based on observations, record review, and interviews, the facility did not ensure the cleaning and disinfection of the station and equipment that was potentially contaminated with patients’ blood was done in accordance with the facility’s policy and procedures. This deficient practice has the potential to spread infectious diseases and affect all the patients in the facility. Findings include: 1) On 08/12/24 at 09:55 AM, observed Patient Care Technician (PCT) 5 preparing station five for the next dialysis patient. PCT5 was priming the bloodlines by having the fluid (normal saline) flow through it. The residual fluid flowed into the prime bucket (container that collects fluids used to prime the bloodlines). At this time observed two yellow hemostat clamps in the prime bucket and inquired of PCT5 where they came from. PCT5 confirmed the hemostat clamps came from the previous patient who had previously completed their hemodialysis at station five. Inquired if he can continue to set up for the next patient using this machine and tubing as it is and he stated, “No.” 2) On 08/12/24 at 10:02 AM, observed bleach solution container near the dirty sink was left open, lid off of the container. At 10:20 AM observed the bleach container near the dirty sink was still open. At 10:32 AM observed the bleach container was covered. 3) On 08/12/24 at 03:13 PM, observed PCT10 preparing station one for the next dialysis patient. PCT10 was observed setting up the bloodlines on the dialysis machine and put the dialyzer (artificial kidney, filter used to remove waste and excess fluid from the patient’s blood) into the holder. Blood was observed on the dialyzer holder. At this time inquired if PCT10 would be able to continue to prep this machine and use if for the next patient with what was observed on the machine. PCT10 was able to see and confirm that she could not continue with the set up for the next patient as there was blood on the dialyzer holder. 47783 4) On 08/12/24 at 10:18 AM, observed PCT12 at station 10 clean the dialysis machine and recliner. After wiping the machine, PCT12 took the prime bucket on the side of the machine that contained blood-tinged fluid, emptied it in the designated dirty sink, rinsed it with water and wiped the outside surfaces only. PCT12 then returned the prime bucket to the side of the machine and was preparing to set up the machine for the next patient. Asked PCT12 if the inside surface of the prime bucket was already wiped. PCT12 acknowledged that she did not. 5) On 08/12/24 at 10:52 AM, observed PCT5 at station 24 clean the dialysis machine and recliner. PCT5 wiped all the external surfaces of the machine but did not wipe the prime bucket after it was emptied in the designated dirty sink. Asked PCT5 if he was supposed to disinfect the prime bucket between patients. PCT5 replied, “Yes.” On 08/15/24 at 09:22 AM, an interview with the Clinical Specialist (CS) was conducted in the in the conference room. CS confirmed that the staff are supposed to wipe the outside and inside surfaces of the prime bucket after use. Review of the facility policy titled “Disinfection and Cleaning of Dialysis Machine Equipment” stated, “. . . Label bleach container with concentration, date time and initials of individual mixing the bleach solution . . . Container will remain covered at all times . . . Disinfect all surfaces of the prime waste container, inside and out, with a moistened 1:100 bleach cloth . . .””

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 47783 Based on observation, interview and record review, the facility failed to ensure that the testing for chlorine/chloramine (disinfectant used in drinking water) in the water was performed correctly per the test strip manufacturer’s directions for use. This deficient practice has the potential to cause an unidentified chlorine breakthrough that can cause harm to all the patients receiving hemodialysis treatment at the facility. Findings include: On 08/13/24 at 08:08 AM, observed Patient Care Technician (PCT) 7 perform water testing for total chlorine using the RPC Ultra-Low Total Chlorine Test Strips. PCT7 rinsed the sample cup three times and filled it with sample water. Sample cup used was graduated with the top line marked as 100 ml (milliliters). PCT filled the sample cup well above the 100 ml line. After PCT7 set up the timer and opened the test strip, asked how much water was supposed to be in the cup when testing the water for total chlorine using the test strips. PCT7 said, “100 ml.” PCT7 confirmed there was more than 100 ml of water in the sample cup. On 08/15/24 at 10:46 AM, an interview was conducted with the Biomed Technician (BMT) in the machine repair room. BMT stated that the staff are supposed to place the sample cup on a flat surface to ensure there is exactly 100 ml of water before performing the test. Review of the company document titled “Ultra-Low (K100-0118) Total Chlorine Test Procedure” stated, “. . . 1) Rinse sample cup 3x (three times) with sample solution to be tested. Collect a fresh 100 ml sample of solution to be tested . . .””

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 47783 Based on record reviews and interview, the facility failed to ensure the staff followed the manufacturer’s instructions regarding dialysate conductivity (measure of the salt content of the dialysate) testing before initiating dialysis treatment for one of 11 patients (Patient (P) 11) sampled for record review. The machine and independent meter conductivity readings were outside the manufacturer’s stated parameter when compared to the Theoretical Conductivity (TCD - conductivity based on the machine settings and dialysate ordered). This deficient practice has the potential to adversely affect all patients who receive dialysis treatments by potentially exposing the patient’s blood to high or low conductivity or pH which could cause damage to the red blood cells that carry oxygen throughout the body. Findings include: Review of hemodialysis treatment sheets for Patient (P) 11 was conducted. For P11’s hemodialysis treatment on 08/06/24, machine conductivity documented was 14.2 and independent meter conductivity was 14.1. The TCD was 13.6, which was 0.5 and 0.6 lower that the machine and independent meter readings. On 08/15/24 at 09:18 AM, an interview was conducted with the Biomed Technician (BMT) in the machine repair room. Asked BMT what the staff are supposed to do when the conductivity readings from the machine and independent meter are higher or lower than the TCD. BMT said the staff are supposed to pull the machine if the difference is more than 0.4 above or below the TCD so he can check the machine. Reviewed 08/06/24 treatment sheet for P11 with BMT to see if the machine used that day was pulled. BMT checked his logs and confirmed that the machine used for the treatment was not pulled out of service. Review of the facility policy titled “Verification of Final Dialysate - Conductivity and pH” stated, “. . . 4. Compare meter and machine values. Fresenius Machine: Verify that both the actual conductivity value on the machine and the meter value are within +/- 0.4 mS of TCD . . . 6. Prior to initiating each dialysis treatment ensure all parameters meet required ranges. If values are out of range do not begin treatment, follow corrective action below: . . . if readings are still outside parameters, pull machine, label ‘Do Not Use’ tag and notify biomedical technician to troubleshoot accordingly . . .””

“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: 47783 Based on observations, interview and record review, the facility failed to keep the vascular access sites (a way to reach the blood for hemodialysis) for three of 13 patients in view of the staff during their hemodialysis treatments. This deficient practice has the potential for accidental needle dislodgement or line separation to go undetected and could result in exsanguination (severe loss of blood). Findings include: 1) On 08/12/24 at 01:51 PM, observed patient dialyzing in station 19 with a blanket covering her body up to her neck. Vascular access site was not in view. Expanded observations to other stations. There were 13 patients dialyzing at the time and at 01:58 PM, observed patient in station 22 with his vascular access sites and line connections also covered with a blanket. At 02:01 PM, observed seven staff members that included the Facility Administrator and Clinical Specialist (CS) around the area of station 19. The vascular access for the patient in station 19 remained covered with a blanket. On 08/12/24 at 02:24 PM, a concurrent interview and observation was conducted with the Administrator and Registered Nurse (RN) 7 at the nurse’s station. Observations were pointed out to Facility Administrator and RN7 and both acknowledged that the patients did not have their vascular access and line connections in view of the staff. Administrator confirmed that the patients’ vascular access and line connections must not be covered while they are dialyzing. 37954 2) On 08/12/24 at 2:20 PM observed patient sleeping in the chair at station five while her dialysis was running with her access site covered by a blanket. On 08/12/24 at 2:25 PM inquired of Patient Care Technician (PCT) 1 if patients are to cover their access site and she confirmed patient’s are not to cover their access sites. Inquired of PCT1 where the patient’s access site is at station five and PCT1 pulled the blanket off of the patient’s left arm. At this time the patient stated she was “cold” and PCT1 stated “You’re not supposed to do that.” Review of the facility policy titled “Intradialytic Monitoring of Patient” stated, “. . . Ensure patient’s access, blood lines and face are visible at all times . . .””

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 47783 Based on observations and interview, the facility failed to ensure the ESRD (End Stage Renal Disease) Network telephone number was prominently displayed where it can be easily seen and read by the patients. As a result of this deficient practice, there was a potential for the patients to not being able to file a grievance or complaint. Findings include: On 08/12/24 at 12:03 PM, observations of the postings in the waiting room were made. There was a locked bulletin board on the wall fronting the main entrance to the facility and next to the entrance to the home therapies. Posted on the bulletin board were a copy of the patient’s rights, telephone numbers for the management team, patient grievance line and state agency. ESRD Network information only listed an address without a telephone number. On 08/15/24 at 09:18 AM, a concurrent observation and interview was conducted with Clinical Specialist (CS) in the waiting room. Asked CS where the information for the ESDR network is posted. CS pointed out the locked bulletin board and said, “It should be posted in there.” CS walked over to the bulletin board and looked at the information posted for the ESRD Network and confirmed that the telephone number was not included. CS also added that the phone number is important since the patients are more likely to call instead of writing a letter when making a complaint.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 47783 Based on record reviews and staff interview, the facility failed to provide necessary care and services to manage the volume status for two of 11 patients (P) sampled for record review. The Patient Care Technician (PCT) failed to notify the Registered Nurse (RN) when the blood pressures (BP) for P7and P8 were high during their dialysis treatments. This deficient practice placed the two patients at risk of serious health complications related to hypertension (high blood pressure). Findings include: 1) Review of P7’s Hemodialysis Flowsheets from 08/05/24 to 08/13/24 conducted. Noted BP readings on 08/06/24 were 184/92 at 06:07 AM, 188/95 at 06:47 AM and 083/96 at 07:01 AM. There was no documentation found of PCT notifying the RN of P7’s elevated BP. 2) Review of P8’s Hemodialysis Flowsheets from 08/02/24 to 08/14/24 showed the following BP readings on 08/12/24: 188/83 at 07:01 AM, 193/86 at 08:02 AM, 184/77 at 09:01 AM and 187/81 at 09:32 AM. No documentation was found on the record that the PCT notified the RN of P8’s elevated BP. On 08/14/24 at 03:43 PM, an interview was conducted with the Clinical Specialist (CS) in the conference room. CS confirmed that the PCTs are supposed to notify the RN if the patient’s BP readings are outside the facility identified parameters or individual patient’s standing orders. Review of the facility policy titled “Reportable Parameters to CN (Charge Nurse)” stated, “. . . Report to Charge Nurse . . . Systolic (top number in a blood pressure reading) > (greater than) 180 . . .””

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 47783 Based on record reviews and interviews, the facility failed to develop and implement a written individualized care plan for two of the 11 patients (Patient (P) 11 and P6) in the sample. There was no care plan developed for P11 to address her vascular access (a way to reach the blood for hemodialysis), and P6’s anemia management. Findings include: 1) On 08/14/24, review of P11’s medical record was conducted. Record review revealed that P11 uses a CVC (Central Venous Catheter - a plastic tube placed under the skin and into a large vein to gain access to the blood) for her hemodialysis treatments and also has an AV (arteriovenous) fistula (surgical connection made between an artery and a vein) that is not yet ready for use . Review of the comprehensive plan of care also revealed that under “Dialysis Access”, there were no goals or interventions documented. An interview was conducted with the Clinical Specialist (CS) on 08/14/24 at 03:43 PM in the conference room. CS confirmed that the IDT did not develop and implement a plan to address P11’s CVC and maturing AV fistula. Review of facility policy titled, Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA/POC)” stated, “. . . 1. The interdisciplinary team (IDT) is responsible for CIPA completion which will be utilized to develop and implement the written, individualized comprehensive POC . . . 3. The CIPA/POC will address . . . f. Access type and maintenance: i. Evaluation and appropriateness of patient access. ii. Monitoring to prevent access failure and complications. . .” 37954 2) On 08/14/24 during record review of P6’s care plan, found the IDT had not included information specific to the patient for his Anemia Care Plan which included his hemoglobin (HGB - red blood cells that carries oxygen from the lungs to the body’s tissues and organs). The care plan stated, “HGB Goal: 10-11.” Review of R6’s HGB’s found the following results: 03/21/23 13.7 04/04/23 13.3 05/02/23 13.3 05/16/23 13.4 06/06/23 12.9 07/04/23 12.9 07/18/23 12.5 08/08/23 12.5 All of P6’s HGB levels were outside of the HGB Goal of 10-11. Review of P6’s Anemia care plan found the following areas blank: Patient specific goal, Problems:, Comments:, Actions:, Comments:, Goal Met: and Goal Timeframe:. On 08/15/24 at 09:55 AM interviewed facility administrator who confirmed these areas on P6’s care plan should have been filled out and not left blank.”

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 47783 Based on record reviews and interviews, the facility failed to ensure staff documented promptly and completely into the chairside computers for Blood Pressure (BP) readings and patient monitoring for seven of 11 patients (Patient (P) 4, P6, P7, P8, P9, P10 and P11) sampled for record review. This deficient practice has the potential to negatively impact the safety of the patients if they are not monitored closely during their treatments. Findings include: 1) On 08/14/24, a review of P4’s Hemodialysis Flowsheets from 08/01/24 to 08/13/24 was conducted and the following was noted: 08/01/24 at 09:31 AM, BP and machine readings were checked, and staff documented observations at 10:17 AM. 08/03/24 at 10:05 AM, BP and machine readings were checked, and staff documented observations at 11:14 AM. 08/06/24 at 09:31 AM, BP and machine readings were checked, and staff documented observations at 10:13 AM. At 10:31 AM, BP and machine readings were checked, and staff documented observations at 11:15 AM 08/08/24 at 08:01 AM, BP and machine readings were checked, and staff documented observations at 08:34 AM. At 09:32 AM, BP and machine readings were checked, and staff documented observations at 10:01 AM 08/10/24 at 10:02 AM, BP and machine readings were checked, and staff documented observations at 11:33 AM. 08/13/24 at 10:31 AM, BP and machine readings were checked, and staff documented observations at 11:49 PM. 2) Review of P7’s Hemodialysis Flowsheets from 08/05/24 to 08/13/24 showed the following: 08/05/24 at 08:02 AM, BP and machine readings were checked, and staff documented observations at 08:26 AM. 08/06/24 at 06:19 AM, BP and machine readings were checked for initiation of treatment, and staff documented observations at 06:40 AM 08/10/24 at 06:32 AM, BP and machine readings were checked, and staff documented observations at 07:37 AM 08/12/24 at 12:01 PM, BP and machine readings were checked, and staff documented observations at 12:38 PM. 08/13/24 at 08:01 AM, BP and machine readings were checked, and staff documented observations at 09:05 AM. 3) Review of P8’s Hemodialysis Flowsheets from 08/02/24 to 08/14/24 showed the following: 08/05/24 at 07:01 AM, BP and machine readings were checked, and staff documented observations at 07:47 AM. 08/07/24 at 09:01 AM, BP and machine readings were checked, and staff documented observations at 09:43 AM. 08/09/24 at 05:37 AM, BP and machine readings were checked, and staff documented observations at 07:26 AM. At 06:01 AM and 06:31 AM, BP and machine readings were checked, and staff observations for both times were documented at 07:27 AM. 08/12/24 at 08:02 AM, BP and machine readings were checked, and staff documented observations at 08:26 AM. 4) Review of P9’s Hemodialysis Flowsheets from 08/02/24 to 08/13/24 showed the following: 08/02/24 at 09:40 AM, BP and machine readings were checked, and staff documented observations at 10:33 AM. 08/08/24 at 09:01 AM, BP and machine readings were checked, and staff documented observations at 09:27 AM. At 10:01 AM, BP was checked, and staff documented observations at 10:21 AM. 08/10/24 at 09:01 AM, BP and machine readings were checked, and staff documented observations at 10:14 AM. 08/13/24 at 09:30 AM, BP and machine readings were checked, and staff documented observations at 10:12 AM. 5) Review of P11’s Hemodialysis Flowsheets from 07/22/24 to 08/12/24 showed the following: 07/24/24 at 10:01 AM, BP and machine readings were checked. Staff documented observations at 10:54 AM. 07/29/24 at 11:04 AM, BP and machine readings were checked, and staff documented observations at 11:45 AM. 07/31/24 at 12:32 PM, BP and machine readings were checked, and staff documented observations at 01:02 PM. 07/30/24 at 11:28 AM, BP and machine readings were checked for treatment initiation, but staff documented observations at 12:55 PM. 08/02/24 at 08:01 AM, BP and machine readings were checked, and staff documented observations at 09:58 AM. 08/09/24 at 11:01 AM, BP and machine readings were checked, and staff documented observations at 12:12 PM. None of the above records noted if the staff documentations for their observations were late entries. On 08/14/24 at 03:43 PM, an interview and concurrent record review was conducted with Clinical Specialist (CS) in the conference room. CS reviewed the Hemodialysis Flowsheets and confirmed that the staff are supposed to document their observations immediately after the BP and machine readings are checked. CS added that there are some instances when the staff are not able to document immediately so they were supposed to note on the flowsheets if it was a late entry. Review of facility policy titled “Medical Records” stated, “. . . When documenting a late entry, present date/time will be used, followed by the words “late entry”. The original date/time will be documented after the words “late entry”. . .” Review of facility policy titled, “Intradialytic Monitoring of Patient” stated, “. . . Vital signs: Obtained and documented at least every 30 minutes . . .” 37954 6) On 08/14/24 reviewed P6’s Hemodialysis Flowsheet and found on 08/03/24 P6 had their dialysis from 06:51 AM - 10:29 AM. At 09:31 AM P6’s vital signs were documented along with the flow rate. On 08/03/24 at 10:29 AM, Patient Care Technician (PCT) 9 documented “Patient resting and eyes closed. Dialysis in Progress. Respirations regular. Access visualized and lines secure.” This was 58 minutes after the check was done. PCT9 did not include late entry with this documentation for the check at 09:31 AM. Also, on 08/03/24 at 10:33 AM P6’s check was done that included their vital signs and RN4 documented “Dialysis Ended. UF (ultrafiltration) turned off. BP checked and documented.” which was documented on 08/03/24 at 01:12 PM, 2 hours and 39 minutes after the check was done. RN4 did not include late entry for this documentation. On 08/14/24 reviewed P6’s Hemodialysis Flowsheets and found on 08/06/24, P6 had their dialysis from 07:03 AM - 10:37 AM. On 08/06/24 at 11:00 AM PCT13 documented “Treatment completed. Patient reinfused without difficulties. Removed needles X 2 and pressure held until bleeding stopped. Applied clean dressing to each site.” On 08/06/24 at 12:53 PM RN 3 documented “Patient came off 0.6 kg above EDW (estimated dry weight). Denies SOB (shortness of breath), DOB [sic], chestpain or lightheadedness. Instructed to limit fluid intake and salt in the diet. Advised to seek ER (emergency) services should he feel any symptoms of fluid overload such as SOB or chest pain. Verbalized understanding, no other complaints upon discharge.” This documentation was 1 hour and 53 minutes after P6’s last set of vital signs were taken and documented. RN3 did not document this entry as a late entry for P6. On 08/14/24 reviewed P6’s Hemodialysis Flowsheet from 08/13/24. P6 had their dialysis from 06:57 AM - 11:31 AM. On 08/13/24 at 12:14 PM, P6’s last set of vital signs was documented. On 08/13/24 at 03:37 PM, RN9 documented “1 kg over DW (dry weight). Fluid & na+ (sodium) control reinforced; pt (patient) agreed. No complaint upon discharge.” This documentation was 3 hours and 23 minutes after the last set of vital signs was taken and documented. RN9 did not document this entry as a late entry for P6. On 08/15/24 at 10:00 AM interviewed Facility Administrator. Inquired if documentation reviewed for P6 should include late entry notation, and she confirmed this.”