Southeastern Renal Dialysis, Lc - W Burlington

“PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This Standard is not met as evidenced by: 51639 Based on document review and staff interviews, the facility failed to ensure the nurse manager position, which oversees the nursing services of the facility, was filled by a registered nurse (RN). At the time of the survey, the facility reported a census of 59 dialysis patients. Findings include: 1) Review of the Nurse Manager’s nursing license revealed the individual was licensed as a Licensed Practical Nurse (LPN). 2) During an interview on 12/2/25 at 2:38 PM, the Administrator confirmed the nurse manager position was filled by an LPN. The Administrator indicated the facility will need to make immediate changes to ensure compliance. 3) During an interview on 12/2/25 at 4:17 PM, the Medical Director confirmed the nurse manager position was filled by an LPN and not an RN.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 44475 Based on review of policy, observation, and staff interview, the facility failed to ensure expired medications were removed from the facility and/or discarded to prevent future use. Failure to remove expired medications could potentially result in staff members utilizing a supply item for which the manufacturer can no longer guarantee the integrity and/or efficacy. This could potentially lead to patients being treated with a supply item that is no longer effective, leading to poor patient outcomes or illness. The facility reported a census of 49 hemodialysis patients at the time of the survey. Findings for observation of the hemodialysis area include: 1. Review of facility policy titled “Nursing Procedure-Medication Administration”, undated, included in part, “Administration: 7. Multi-dose medication vials should be labeled with date, time, and initials of individual first opening vial. Multi-dose vials should be discarded after 28 days unless otherwise indicated in manufacturers handout.” 2. Observation on 8/13/24 beginning at 8:45 AM of the med room revealed: a. 1 Vial of labetalol (medication to lower blood pressure) labeled with open date 4/6/24. b. 1 Partial vial of heparin with the septum previously punctured. In an interview with Staff A Registered Nurse (RN) acknowledged the heparin vial was a multi-dose vial and was used for multiple patients on 8/13/24. c. 1 Partial container of Vidafel Wellness Protein drink with no open date labeled on the container. 3. In an interview on 8/15/24 at 11:00 AM, the Administrator reported that medications should be discarded 30 days after the open date.”

“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: 50072 Based on observations and policy review, the facility did not ensure each patient’s vascular access site and blood line connections were within view of the staff during hemodialysis treatment. Failure to ensure the patient’s vascular access and blood line connections were visible during dialysis treatment could potentially result in the staffs’ failure to identify a dislodged needle or the disconnection of a blood line which could result in significant blood loss for a patient causing adverse patient outcomes and/or death within a short amount of time. At the time of this survey, the facility reported an in-center hemodialysis patient census of 49. 1. Observations on 08/13/24 at 8:53 am showed Patient #1’s access site covered. At 8:55 am, Staff A adjusted Patient #1’s blood pressure cuff, completed computer charting and left the chairside with Patient’s #1’s access site still covered. At 8:58 am, Patient #1 independently adjusted their blanket making their access site visible. 2. Observations on 08/13/24 at 9:35 am showed Patient #3’s access site covered with a blanket. The site remained covered until 10:00 am when Patient #3 moved their blanket making the site visible. 3. Observations on 08/14/24 at 1:47 pm showed Patient #4’s access site covered by their clothing. At 2:03 pm the access site remained covered. At 2:42 pm Patient #4’s alarm was sounding. Staff D responded to the alarm and exposed the access site to perform patient care. 4. Observations on 08/14/24 at 2:04 pm showed Patient #5’s access site covered. At 2:10 pm Staff C spoke with Patient #5 chairside and the access site remained covered. At 2:15 pm Staff E spoke with Patient #5 chairside. Staff E left the chairside and the site remained covered. At 2:21 pm Staff E returned to administered medication to Patient #5. Staff E left with the access site still covered. At 2:38 pm Staff D computer charted at Patient #5’s chairside. Staff D left the chairside with the access site still covered. 5. Review of agency policy titled “Southeastern Renal Dialysis, L.C. Clinical Procedure - Patient Physical Assessment and Reassessment,” undated, reads in part, “Procedure: 1. Patient Assessment ...D. Observe lines to access every hour to verify they are well secured. Tapes and connectors may become loose during treatment. Site must be visible at all times ...” 6. On 08/15/24 at 11:00 am, Facility Administrator acknowledged the findings.”

“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: 44475 Based on review of policy, medical record, and staff interview, the facility failed to address the patient ’ s elevated blood pressure (BP) pre-dialysis, during the dialysis treatment, and post-dialysis to show the patient ’ s health care provider was notified and that the facility staff failed to coordinate medication delivery of an oral anti-hypertensive medication ordered to be administered during dialysis treatment with the local jail. Failure to ensure staff addressed elevated pre-dialysis BPs and/or elevated BPs during the patient ’ s dialysis treatment without notification to their provider could potentially result in an ineffective dialysis treatment, ineffective fluid removal, and/or failure to provide the necessary care, services, and dialysis treatment to meet the patient needs which could result in adverse patient outcomes and a decrease in the patient ’ s quality of life. The facility reported a census of 49 hemodialysis patients at the time of the survey. Review of 1 of 5 hemodialysis patient medical records (Patient #6) findings include: 1. Review of the facility policy titled “Clinical Procedure-Hypertension”, with no date, included in part, “Definition: Elevated blood pressure: Systolic above 180 - Diastolic above 90. Cause: 1. Excessive salt and water intake. 2. Renin-mediated (occurs when blood flow to the kidneys is blocked). 3. Overcompensation of the sympathetic nervous system. Symptoms/Observations: 1. High blood pressure. 2. Signs and symptoms of increased intracranial (inside the brain) pressure: Headache, lethargy, blurred vision, bradycardia (slow heart rate), vomiting. 3. Symptoms of intracranial bleeding, such as stroke-like symptoms. 4. Most commonly, patients will be asymptomatic. Nursing Intervention: 4. Notify provider if indicated. 5. Give medication to lower BP as ordered by provider. 2. Review of the facility policy titled “Incarcerated Patients”, with no date, included in part, “Purpose: To provide a guide to staff for the management of the request of current facility patients that have become incarcerated to dialyze in the facility. The facility understands the need for outpatient dialysis services in the community and will make every attempt to serve our current patients. Arrangements will be made with the law enforcement agency in custody of the individual. For the facility to allow an incarcerated person to dialyze in the dialysis unit the following items must be addressed: 5. Home medications required for the patient will be provided by the law enforcement agency. 3. Review of Patient #6 ’ s medical record included dialysis treatment flow sheets dated 7/30/24 through 8/13/24 (5 treatments). Further review showed the following: Dialysis treatment flow sheet dated 7/30/24 showed a pre-dialysis standing BP of 200/116 and a pre-dialysis sitting BP of 205/127. Post-dialysis standing BP was 199/114 and post-dialysis sitting BP was 228/125. The medical record did not contain documentation that the patient ’ s provider was notified of the high BP readings. Dialysis treatment flow sheet dated 8/3/24 showed a post-dialysis standing BP was 177/110 and post-dialysis sitting BP was 194/107. The medical record did not contain documentation that the patient ‘s provider was notified of the high BP readings. Dialysis treatment flow sheet dated 8/8/24 showed a post-dialysis standing BP was 200/112 and post-dialysis sitting BP was 194/119. The medical record did not contain documentation that the patient ‘s provider was notified of the high BP readings. Dialysis treatment flow sheet dated 8/10/24 showed the following: Post-dialysis standing BP was 172/113 and post-dialysis sitting BP was 203/118. The medical record did not contain documentation that the patient ’ s provider was notified of the high BP readings.Order for atenolol (medication to lower blood pressure) 50 milligrams (mg) PO (by mouth) every scheduled dialysis treatment. Atenolol was not administered because it was not available. The medical record did not contain documentation of provider notification or coordination with the local jail to obtain supply of the medication. Dialysis treatment flow sheet dated 8/13/24 showed the following: Post-dialysis standing BP was 164/112 and post-dialysis sitting BP was 193/120. The medical record did not contain documentation that the patient ’ s provider was notified of the high BP readings. Order for atenolol (medication to lower blood pressure) 50 mg PO every scheduled dialysis treatment. Atenolol was not administered because it was not available. The medical record did not contain documentation of provider notification or coordination with the local jail to obtain supply of the medication. 4. In an interview on 8/15/24 at 9:35 AM, the Administrator and Staff F, Facility Educator, acknowledged that atenolol was supplied by the local jail and that the jail were not aware they needed to deliver atenolol to the facility prior to 8/14/24.”