Fmc - Northeast Indiana Kidney Center-Warsaw

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 42617 Based on observation, policy review, and interview, the dialysis facility failed to ensure all staff followed facility policy and best practice when drawing blood from an arteriovenous (AV) graft for 1 of 1 observation of home therapy staff drawing blood from an AV graft (Patient #7). Findings include: 1. The facility policy “Peripheral IV Access for Laboratory Testing or IV Solution Administration,” dated 9/01/2025, indicated when drawing blood, staff should clean the site “with approved antimicrobial agent and allow to dry per manufacturer’s guidelines.” 2. The document “WHO [World Health Organization] Guidelines on Drawing Blood: Best Practices in Phlebotomy,” dated 2010 and obtained from www.ncbi.nlm.nig.gov, indicated when drawing blood, staff should “clean the site with a 70% alcohol swab for 30 seconds and allow to dry completely (30 seconds) ....” 3. During an observation on 12/10/2025 beginning at 2:21 PM in PD Training Room 1, RN 4 was observed accessing Patient’s AV graft in order to draw blood. The nurse cleaned the site with 70% alcohol for four seconds then immediately inserted the needle, failing to allow the antiseptic to dry. 4. During an interview on 12/10/2025 beginning at 5:11 PM, RN 4 reported when drawing blood from a graft, she should clean the site with 70% alcohol for “30 seconds” prior to inserting the needle.”

“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: 44714 Based on observation, policy review, and interview, the facility failed to ensure all employees and patients followed standard infection control guidelines for 1 of 1 ICHD flash tour observations (Patient #18), 1 of 2 observations of fistula discontinuation where the patient held pressure to the access site (Patient #9), and 2 of 2 observations of home therapy clinic visits (Patient #6, #7). Findings include: 1. The facility policy on “Hand Hygiene,” dated 11/06/2023, identified acceptable hand hygiene methods included handwashing and/or the use of alcohol-based hand rub (ABHR). The policy stated, “All staff, patients ... must follow the same requirements for hand hygiene.” The policy identified when hand hygiene was needed: “Before and after direct contact with patients ... Before performing any invasive procedure such as vascular access ... Immediately after removing gloves ... After contact with inanimate objects near the patient ...” and “After contact with other objects within the patient station or treatment space.” Additionally, staff must provide a glove to any patient holding their access site(s) after treatment. Staff must offer hand sanitizer or other hand hygiene to patients who held their access site. 2. The facility policy “Routine Peritoneal Catheter Exit Site Care,” dated 11/03/2025, indicated when staff were performing a PD catheter dressing change, they should remove the old dressing, perform hand hygiene by washing hands, then apply new gloves. 3. The facility policy “Peripheral IV Access for Laboratory Testing or IV Solution Administration,” dated 9/01/2025, indicated when staff were drawing blood from a peripheral site, they should perform hand hygiene, assess the site, perform hand hygiene again, then clean the site with an antimicrobial agent. 4. During an observation of post dialysis access site care on 12/08/2025 at 09:50 AM, PCT 1 provided Patient #9 a glove to hold their access site after the needle was removed. Patient #9 held the access site until the bleeding stopped. PCT 1 taped a piece of gauze to the site and Patient #9 removed the glove. Patient #9 picked up their belongings and left the treatment area. PCT 1 failed to offer hand sanitizer to Patient #9 after they removed the glove. 42617 During an interview on 12/09/2025 beginning at 2:27 PM, PCT 1 reported “some” patients would use hand sanitizer after holding pressure to the fistula or graft cannulation sites. The technician stated the staff should ask all patients if they would like to use hand sanitizer after holding pressure to the cannulation sites and removing their glove. 5. During an ICHD observation on 12/08/2025 beginning at 10:23 AM, PCT 3 was in Station 2 providing care to Patient #18. The PCT removed their gloves, left the station, obtained supplies from a nearby cart, donned new gloves, re-entered Station 2, and resumed providing care to Patient. The technician failed to perform hand hygiene after removing their gloves and prior to donning new gloves. During an interview on 12/09/2025 beginning at 4:04 PM, Charge Nurse 2 and FA reported staff should perform hand hygiene between glove changes. 6. During an observation on 12/10/2025 beginning at 11:06 AM in PD Training Room 1, RN 4 was observed changing Patient #6’s PD catheter dressing. After removing the old dressing, the nurse obtained supplies from a drawer, donned new gloves, then applied a new dressing to the catheter site. The nurse failed to perform hand hygiene prior to donning new gloves. During an interview on 12/10/2025 beginning at 5:28 PM, RN 4 reported when changing a PD catheter dressing, she should change gloves and perform hand hygiene in between removing the old dressing and prior to donning a new dressing. 7. During an observation on 12/10/2025 beginning at 2:21 PM in PD Training Room 1, RN 4 was observed accessing Patient #7’s AV graft to obtain a blood sample. After donning PPE, the nurse prepared supplies, assessed Patient’s graft, cleaned the site with alcohol, and inserted the needle into the graft. The nurse failed to change gloves and perform hand hygiene prior to cleaning and accessing the graft. During an interview on 12/10/2025 beginning at 5:11 PM, RN 4 reported when drawing blood from a graft, she would not change gloves and perform hand hygiene in between assessing the site and cleaning it with alcohol.”

“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: 44714 Based on observation, policy review, and interview, the facility failed to secure a biohazard storage room, for 1 of 2 biohazard rooms. Findings include: 1. The agency policy, “General Cleanliness and Infection Control Guidelines,” dated 09/02/2025, indicated biohazard waste was to be stored in a secure area. 2. On 12/09/2025 at 06:45 AM, the Surveyor opened the unlocked door identified as biohazard waste. The biohazard room was located on the Home Therapy section of the agency. 3. During an interview on 12/11/2025 beginning at 01:48 PM, the Biomedical Technician indicated the biohazard rooms should remain locked. They indicated they used a number lock to limit access. The Biomedical Technician demonstrated the number lock on the main biohazard room. When they observed the biohazard room on the Home Therapy side, there was no number lock and the door opened without a key. The Biomedical Technician indicated the door should have been secured with a number lock, so it remained locked.”

“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: 44714 Based on observation and interview, the facility failed to ensure the staff completed hand hygiene after they emptied and disinfected the prime waste bucket, for 1 of 2 PCT cleaning and disinfection of the dialysis station observations (PCT 2). Findings include: 1. An observation of PCT 2 cleaning/ disinfecting dialysis station 2 occurred on 12/09/2025 beginning at 09:25 AM. During the observation PCT 2, wearing gloves, removed the prime waste bucket, walked to the dirty sink and emptied it. PCT 2 wiped the inside and outside of the bucket with cleaning cloths soaked in the disinfecting bleach solution. PCT 2 returned the bucket to the side of the hemodialysis machine. PCT 2 then cleaned the dialysis machine. PCT 2 failed to remove gloves, complete hand hygiene, and don new gloves after cleaning the prime waste bucket. 42617 2. During an interview on 12/09/2025 beginning at 1:53 PM, PCT 2 reported she should change gloves and perform hand hygiene after emptying the prime waste bucket.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 44714 Based on observation and interview, the facility failed to ensure staff followed infection control standards of care to limit the potential for contamination of the CVC for 1 of 2 observations of the initiation of dialysis with a CVC (Patient #13) and 2 of 2 observations of the discontinuation of dialysis with a CVC (Patient #10, #13). Findings include: 1. During an observation at Station 2 on 12/09/2025 at 5:56 AM, PCT 5 prepared Patient #13 for dialysis with their CVC. Before connecting the bloodlines to the CVC, PCT 5 used the computer on the hemodialysis machine. PCT 5 then connected the bloodlines. PCT 5 failed to complete hand hygiene after they used the computer and before they connected the bloodlines. During an interview on 12/09/2025 beginning at 2:22 PM, PCT 5 reported she should change gloves and perform hand hygiene prior to connecting the dialysis blood lines to a patient’s CVC. PCT 5 also stated the computer on the dialysis machine was considered “dirty.” 2. During an observation at Station 2 on 12/09/2025 at 9:15 AM, PCT 2 prepared to disconnect Patient #13 from dialysis. PCT 2 adjusted the absorbent pad under the CVC ports and proceeded with the disconnection. PCT 2 failed to use a clean field to reduce the likelihood of contamination of the CVC. 42617 3. During an observation at Station 5 on 12/08/2025 beginning at 9:47 AM, PCT 2 disconnected Patient #10 from dialysis using Patient’s CVC. The technician failed to place a clean field under the CVC ports prior to beginning disconnection procedures. During an interview on 12/09/2025 beginning at 1:53 PM, PCT 2 reported when disconnecting a patient from dialysis using a CVC, she would use the same drape that had been used for initiation procedures and had remained on the patient’s body throughout treatment. During an interview on 12/09/2025 beginning at 4:04 PM, FA and Charge Nurse 2 reported staff should place a new, clean drape under a patient’s CVC prior to disconnection from dialysis.”

“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: 44714 Based on observation, record review, and interview, the facility failed to ensure supplies were not expired, for 1 of 1 ICHD flash tour and 1 of 1 Home Therapies flash tour, which had the potential to affect all patients. Findings include: 1. The facility policy “Storage of Supplies,” dated 11/03/2025, indicated “proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired ....” Supplies were to be discarded when the product expired. 2. During the ICHD flash tour on 12/08/2025 beginning at 09:40 AM, a supply cabinet in a corner of the treatment area was found to have expired supplies. Expired supplies included: a. Six Masterguard Plus Fistula Needle Sets, expiration date 06/30/2023. b. Two SysLoc Mini 14 gauge, expired 02/12/2023 c. Nine Wingeater 15 gauge, expired 01/2023 d. Eighty-eight Povidone-iodine pads, expired 10/2022 During an interview on 12/08/2025 beginning at 10:15 AM, RN 1 indicated the PCTs stock the cabinets from a supply cart. RN 1 indicated expired supplies are thrown in the trash. RN 1 indicated the corner supply cabinet was rarely used but there should be no expired items on the treatment floor. 42617 3. During the Home Therapy flash tour on 12/08/2025 beginning at 11:30 AM, the following was observed: a. In the lab room, four BD Culture Swab Plus kits with an expiration date of 12/04/2025 were observed in a drawer. b. PD Training Room 1, one BD Culture Swab Plus kit with an expiration date of 12/04/2025 was observed in a drawer. c. In PD Training Room 2, one bottle of ExSept (antiseptic cleanser) with an expiration date of 11/08/2025 was observed in a cabinet. d. In HHD Training Room 1, four box of NxStage Sak 307 dialysate solution, one with an expiration date of 9/03/2025 and three with an expiration date of 12/01/2025, were observed on the floor. During an interview on 12/09/2025 beginning at 4:13 PM, RN 4 reported she was responsible for managing supplies for the home therapy side of the facility. The nurse stated expired supplies were to be thrown away.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 42617 Based on record review and interview, the dialysis facility failed to ensure all unstable patients were seen by an advanced practitioner in-person monthly for 1 of 2 ICHD records reviewed of an unstable patient (Patient #2). Findings include: 1. The facility policy “Use of Telehealth For Patient Visits and Other Patient Interactions,” dated 5/01/2023, defined indicated patients could be seen by an advance practitioner via telehealth (remotely via audio and/or video communications) “if the patients are considered stable.” 2. Patient #2’s clinical record evidenced Patient’s status was changed to “unstable” and a POC meeting was conducted on 2/17/2025. The record evidenced Patient was seen via telehealth by an MD or NP on 2/17/2025, 3/19/2025, 5/12/2025, 7/16/2025, 8/11/2025, and 9/08/2025. Patient was listed as “unstable” until 10/15/2025. The record failed to evidence Patient was seen in person by an advanced practitioner at least monthly while listed as unstable. During an interview on 12/10/2025 beginning at 2:28 PM, Medical Director reported all patients should be seen in-person once a month.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 42617 Based on observation, record review, and interview, the dialysis facility failed to ensure the IDT noted trends and documented re-education for patients not documenting accurate daily weights, type of dialysate used, and intra-dialysis vital signs for 3 of 3 records reviewed of patients performing dialysis at home (Patient #5, #6, #7). Findings include: 1. The facility policy “Review and Documentation of Home Therapies Patient Health Data,” dated 5/01/2023, indicated the home therapy patient was to “create a treatment record for every dialysis treatment ....” The home therapy nurse was to “perform a comprehensive monthly review of all treatment data” and discuss the data review “during the patient’s regular clinic visit and concerns will be addressed and documented accordingly.” 2. Patient #5’s clinical record indicated Patient performed PD dialysis at home. Patient’s Estimated Dry Weight (EDW, a physician-ordered goal weight after all extra fluid was removed during dialysis) was ordered at 92.0 kilograms (kg, or 202.4 pounds). Review of eight weeks of PD flowsheets between 9/28/2025 - 11/25/2025 evidenced Patient documented their weight as “200” pounds for all eight weeks of treatment. The record failed to evidence the IDT re-educated Patient to obtain and document an accurate weight daily. During an interview on 12/10/2025 beginning at 5:25 PM, RN 4 reported Patient was to obtain and document their weight daily. The nurse reported she had not performed any re-education to Patient on obtaining and documenting an accurate daily weight as she did not “have to worry about [Patient]” as he/she was “one of the most stable” patients. 3. Patient #6’s clinical record indicated Patient performed PD dialysis at home. Patient’s EDW was ordered at 92.0 kg. Patient’s orders indicated he/she could use 1.5%, 2.5% or 4.25% dextrose dialysate solution based on the amount of fluid needing to be removed. Review of eight weeks of PD flowsheets between 9/01/2025 - 10/31/2025 evidenced Patient documented their weight as “92.0 kg” from 9/01/2025 - 9/26/2026 and 10/28/2025 - 10/31/2025. Patient also failed to document the type of PD solution used during treatment. During an observation on 12/10/2025 beginning at 11:06 AM, Patient was seen for an IDT clinic visit. Patient’s flowsheets from 11/10/2025 - 12/10/2025 were reviewed by the IDT during the visit. The flowsheets evidenced Patient documented their post-treatment weight was “92.0 kg” from 11/10/2025 - 11/18/2025, “92.5 kg” from 11/19/2025 - 12/01/2025, “93.4 kg” from 12/02/2025 - 12/04/2025, and “93.8 kg” from 12/05/2025 - 12/10/2025. The flowsheets failed to evidence the type of dialysate solution used for each exchange. During the visit, the IDT failed to re-educate Patient to obtain an accurate weight daily and document the type of dialysate solution used for each exchange. During an interview on 12/10/2025 beginning at 11:23 AM, Patient reported he/she would weigh him/herself “a couple times a week.” During an interview on 12/10/2025 beginning at 5:28 PM, RN 4 reported Patient was to obtain and document their weight daily. The nurse stated Patient had previously been re-educated to obtain their weight daily, as the patient had been documenting the same weight for every treatment. RN 4 reported any education provided to Patient should be documented in the record. The nurse stated she did not review Patient’s treatment flowsheets or provide any re-education during Patient’s clinic visit. During an interview on 12/11/2025 beginning at 9:36 AM, RN 4 reported Patient should be documenting the type of dialysate fluid used for each treatment. 4. Patient #7’s clinical record indicated Patient performed hemodialysis at home. Review of 14 HHD flowsheets between 11/17/2025 - 12/05/2025 evidenced Patient failed to document vital signs were obtained and access checks performed every 30 minutes for 10 of 14 treatments. During an observation on 12/10/2025 beginning at 2:21 PM, Patient was seen for an IDT clinic visit. During the visit, the IDT failed to re-educate Patient to obtain and document vital signs and access site checks every 30 minutes while on HHD treatment. During an interview on 12/11/2025 beginning at 9:44 AM, RN 4 reported Patient should be documenting vital signs every 30 minutes while on HHD treatment. The nurse stated she had not performed any re-education with Patient on the frequency of vital sign monitoring during treatment.”

“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: 42617 Based on record review, policy review, and interview, the medical director failed to ensure all staff followed policies and procedures specific to intradialytic monitoring for 3 of 4 ICHD records reviewed (Patient #2, #3, #4) and administration of Aranesp for 1 of 1 ICHD record reviewed of a patient receiving Aranesp (Patient #4). Findings include: 1. The facility policy “Patient Assessment and Monitoring,” dated 5/01/2023, indicated during dialysis treatment, staff were to obtain the patients ’ blood pressure (BP) and heart rate “every 30 minutes or more as needed but not to exceed 45 minutes.” Staff were also to “document machine parameters and safety checks” at the same frequency. 2. The facility policy “... Anemia Algorithm Aranesp IVP [IV Push] Administration ...,” dated 2015, indicated Aranesp (a medication used to treat anemia) was to be administered once a week unless otherwise indicated. If a dose of Aranesp was missed, staff were to “maintain the patient ’ s current weekly dosing schedule.” 3. Patient #2’s clinical record included 5 flowsheets from 11/25/2025 - 12/05/2025. The flowsheets evidenced on 11/28/2025, no vital signs were obtained or access site checks were performed between 5:33 PM - 6:30 PM, which was 57 minutes between checks. During an interview on 12/09/2025 beginning at 1:53 PM, PCT 2 reported vital signs and access checks should be performed every 30 minutes, unless the nurse indicated the patient needed more frequent monitoring. During an interview on 12/10/2025 beginning at 2:10 PM, RN 3 reported vital signs and access checks should be performed every 30 minutes, unless their condition warranted closer monitoring. 4. Patient #4’s clinical record indicated Patient was to be placed on the Aranesp anemia algorithm. On 11/14/2025, Charge Nurse 2 entered an order for the facility to administer 50 mcg Aranesp once a week. The record included 6 flowsheets between 11/23/2025 - 12/05/2025. The flowsheets evidenced the following: a. On 11/23/2025, no vital signs were obtained or access site checks were performed between 2:32 PM - 3:34 PM, which was 58 minutes between checks. b. On 12/01/2025, no vital signs were obtained or access site checks were performed between 2:06 PM - 3:04 PM and 3:04 PM - 4:04 PM, which was 58 and 60 minutes between checks, respectively. c. On 12/03/025 at 3:17 PM, RN 1 documented Patient ’ s blood pressure was “trending down,” and Patient was to have BPs checked every 15 minutes. Blood pressure checks were not documented between 3:32 PM - 4:05 PM, 4:34 PM - 5:02 PM, and 5:02 PM - 5:29 PM, which was 27 - 33 minutes between checks. The record failed to evidence the 15-minute BP checks had been discontinued by the nurse. RN 1 documented she administered 50 micrograms (mcg) of Aranesp during the treatment. d. On 12/05/2025 at 3:04 PM, Patient ’ s BP was 191/79. At 3:35 PM, Patient ’ s BP dropped to 110/48, and Patient reported feeling “queazy” (sic). At 3:39 PM RN 2 documented Patient was to have BPs checked every 15 minutes. Blood pressure checks were not documented between 4:00 PM - 4:33 PM, 4:33 PM - 5:03 PM, 5:03 PM - 5:34 PM, and 5:34 PM - 5:53 PM, which was 19 - 33 minutes between checks. The record failed to evidence the 15-minute BP checks had been discontinued by the nurse. RN 2 documented she administered 50 mcg of Aranesp during treatment. This was the second dose the facility had administered during the week of 11/30/2025 - 12/06/2025. During an interview on 12/09/2025 beginning at 2:27 PM, PCT 1 reported vital signs and access checks should be performed every 30 minutes, unless the nurse indicated the patient needed more frequent monitoring. During an interview on 12/11/2025 beginning at 3:40 PM, RN 2 was unsure of the reason Patient received two doses of Aranesp in one week. During an interview on 12/11/2025 beginning at 3:49 PM, Charge Nurse 2 reported Patient’s Aranesp that was scheduled for 11/28/2025 had been rescheduled to the next week due to availability. Charge Nurse 2 stated one of the Aranesp doses administered the week of 11/30/2025 - 12/06/2025 should have been held. 44714 5. Patient #3’s clinical record included 9 flowsheets from 11/17/2025-12/05/2025. The flowsheets evidenced: a. On 11/17/25, no vital signs were obtained, or access site checks were performed between 09:03 AM and 10:07 AM, which was 64 minutes between checks. b. On 11/19/25 at 10:03 AM, RN 2 placed Patient #3 on 15-minute checks due to changes in Patient #3’s BP. No vital signs were obtained or access site checks completed between 11:02 AM - 11:29 AM (27 minutes), 11:31 AM - 12:00 PM (29 minutes), and 12:02 PM - 12:30 PM (28 minutes). c. On 11/23/25 no vital signs were obtained, or access site checks were performed between 08:27 AM - 0934 AM (66 minutes). d. On 12/03/2025 no vital signs were obtained, or access site checks were performed between 11:18 AM - 12:04 PM (46 minutes). e. On 12/05/2025 RN 1 placed Patient #3 on 15-minute checks at 10:09 AM. No vital signs were obtained, or access site checks were performed between 10:32 AM - 11:03AM (31 minutes), 11:04 AM -11:31 AM (27 minutes), 11:33 AM - 11:59 AM (26 minutes), and 12:01 PM - 12:31 PM (30 minutes). During an interview on 12/11/2025 beginning at 03:40 PM, RN 2 indicated staff performed vital signs and access site checks every 30 minutes while a patient was on dialysis. RN 2 indicated the nurses could decrease the amount of time between checks if they feel it is needed. RN 2 indicated they would notify the PCT and put a note in the nurse’s comments that the patient was placed on 15- minute checks. RN 2 indicated the patient would remain on 15-minute checks until the RN took them off the shortened checks or until the end of the treatment. RN 2 indicated the nurse’s comments would indicate if they were back to 30-minute checks. 6. During an interview on 12/10/2025 beginning at 2:28 PM, the Medical Director indicated staff should obtain vital signs and complete access site checks at least every 30 minutes while a patient was on dialysis. The Medical Director indicated the RNs could shorten the time between checks based on their clinical judgement.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 44714 Based on record review and interview, the IDT failed to reassess a patient at risk of involuntary discharge due to behavior for 1 of 2 at risk patients (Patient #1). Findings include: The facility policy “Comprehensive Interdisciplinary Assessment,” version 6, evidenced the definition of an unstable patient which included “ ...Any patient considered at risk for involuntary discharge or transfer must be considered unstable ....” According to the policy, unstable patients required the IDT to complete a monthly comprehensive assessment and update to the plan of care “ ... until the issues have been resolved.” The IDT is responsible for adjusting and implementing new interventions if the issues continue. The facility “Immediate and Non- Immediate Involuntary Patient Discharge” policy, version 5 stated, “ ... there must be evidence in the patient’s medical record of the IDT’s efforts to help the patient resolve any conflict or psychological issues contributing to the behavior.” The facility list of unstable patients dated 6/26/2025, 4/22/2025, and 1/21/2025 failed to identify Patient #1 as unstable. Review of the agency complaint log evidenced 9 complaints for 2025. Patient #1 made one complaint regarding staff harassing him/her about keeping their face uncovered. There was one complaint regarding Patient #1’s disrespectful behavior toward the staff. Patient #1’s clinical record evidenced an admission date of 10/17/2024. The record included a “letter of concern” dated 12/27/2024 to Patient #1. The letter outlined concerning behaviors such as “ ... rude behavior when interacting with staff, yelling and use of negative language with staff and behaving in a manner that causes disruption to the treatment of other patients.” The letter stated, “Please accept this letter as our first attempt at identifying any barriers to resolving the concerning behavior that has become more frequently demonstrated.” Patient #1’s medical record evidenced a 90-day Comprehensive Interdisciplinary Assessment, dated 2/4/2025. The assessment failed to identify behavioral issues. The next Comprehensive Interdisciplinary Assessment is due 2/4/2026. During a telephone interview on 6/27/2025 at 10 AM, the Medical Director briefly explained the incident on 6/14/2025 with Patient #1. The Medical Director indicated there had been a longstanding issue with Patient #1’s behavior, especially around the facility’s policies. Patient #1 often had their hood covering their face as they wanted to nap and the lights prevented it. Patient #1 became angry and verbally abusive with staff when they asked Patient #1 to remove the hood so they could visualize Patient #1’s face. The Medical Director indicated Patient #1 would say things such as “you need to walk away or I’m going to hit you.” An interview with the FA, Director of Operations, and the Social Work Manager, occurred on 6/27/2025 at 10:30 AM. They indicated the incident occurred as the Medical Director explained it, however, they indicated RN 1 called the police for assistance. The officers attempted to help redirect Patient #1 while staff ended their dialysis treatment. Police escorted Patient #1 off the premises. IDT held a phone call on 6/16/2025 and made the decision to do an immediate involuntary discharge. The Medical Director wrote an order for immediate discharge and the FA notified Patient #1 by phone and a certified letter of immediate involuntary discharge. The MSW notified the End Stage Renal Disease Network of the details of the immediate involuntary discharge. The Social Work Manager indicated the first MSW contact with Patient #1 regarding their behavior was 12/27/2025, when they developed the letter of concern with the FA. The Social Work Manager indicated the MSW was involved in the attempts to de-escalate Patient #1.”