Davita Princeton Dialysis

“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: 38262 Based on observation, record review, and interview, the facility failed to follow applicable infection control procedures when cleaning and disinfecting contaminated surfaces for 1 of 2 biohazard containers observed. (PCT 3) Findings include: A revised April 2023 policy titled “Infection Control for Dialysis Facilities” was provided by the Facility Administrator (FA) on 01/03/2024 at 10:10 AM. The policy indicated that all equipment and surfaces with visible blood should be cleaned and disinfected with 1:10 bleach when first observed. During the flash tour on 01/03/2024 from 8:20 AM to 9:15 AM, one biohazard container in the treatment area was found to have blood on the outside of the container. At 9:15 AM, Patient Care Technician (PCT) 3 placed a bloody syringe in the same biohazard container that still had blood on the outside. PCT 3 failed to clean and disinfect the biohazard container at that time. During an interview on 01/03/2024 at 11:20 AM, PCT 3 stated they saw the blood outside the biohazard container but did not clean it up then.”

“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: 38262 Based on observation, record review, and interview, the facility failed to ensure the treatment floor and water room were secured for 1 of 2 observation days. Findings include: 1. A revised April 2018 policy titled Physical Environment was provided by the Manager of Clinical Services on 01/03/2024 at 2:25 PM. The policy indicates the dialysis facility will be maintained to provide patients, staff, and the public with a safe treatment environment. Access to patient and water treatment areas are restricted to authorized personnel only. 2. A March 2015 Facility Administrator job description was provided by the Manager of Clinical Services on 01/04/2024 at 7:40 AM. The job description indicated the Facility Administrator ensures the equipment was maintained at the facility. 3. During the flash tour on 01/03/2024 at 7:50 AM, the Facility Administrator opened the door to the water room without entering a code. The facility failed to ensure staff locked the water room door. 4. During an observation on 01/03/2024 at 1:24 PM, the door from the lobby to the office area that led to an opened door to the treatment floor was unlocked. At that time, Personal Care Technician (PCT) 7 entered the water room without entering a code. The door on the other side of the water room door was taped over. The facility failed to ensure the office and treatment area were secured. The facility failed to ensure the lock to the water room functioned adequately. 5. During an interview on 01/03/2024 at 3:20 PM, the Facility Administrator stated the lock to the water room door was broken and did not know why the lobby door was unlocked.”

“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: 48387 Based on record review and interview the facility interdisciplinary team failed to report and/or treat abnormal blood pressures for 2 of 5 records reviewed. (Patient #2, Patient #6,) Findings Include: 1. A 10/2023 revised policy titled “MEDICAL RECORDS DOCUMENTATION GUIDANCE” indicates staff should document each time a physician or nurse practitioner (NP) is notified regarding the patient’s conditions. 2. A 10/2023 revised policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” indicated abnormal findings that should be reported to a licensed nurse are blood pressures with an increase or decrease of 20mm Hg from prior blood pressure reading during treatment, a standing/setting post-treatment systolic (top number) blood pressure greater than 140 mm Hg or less than 90 mm Hg, and a standing/setting diastolic (bottom number) blood pressure greater than 90 mm Hg or less than 50 mm Hg. The policy indicates the nurse should be notified immediately of abnormal findings and these findings should be documented in the patient’s medical records, the licensed nurse should use his/her clinical judgment to determine if the physician should be notified. 3. The clinical record for Patient #2 was reviewed on 01/03/2024 and evidenced the following: A treatment record dated 12/11/2023 indicates intra-treatment blood pressures of 161/78, 142/64, and 159/62. A treatment record dated 12/15/2023 indicates intra-treatment blood pressures of 138/64 and 164/63. A treatment record dated 12/20/2023 indicates intra-treatment blood pressures of 146/67, 167/73, 141/63, 143/67, 186/63, and 177/89. A treatment record dated 12/22/2023 indicates intra-treatment blood pressure of 162/55. A treatment record dated 12/24/2023 indicates intra-treatment blood pressures of 144/56, 173/78, 176/75, and 168/75. A treatment record dated 12/27/2023 indicates intra-treatment blood pressures of 163/58 and 154/65. A treatment record dated 12/29/2023 indicates intra-treatment blood pressures of 163/76, 173/73, and 159/59 38262 4. The clinical record for Patient #6 was reviewed on 1/03/2024 and evidenced the following: A treatment record dated 12/31/2023 indicated intradialytic blood pressures of 108/40, 128/46, 107/39, 110/49, 108/50, 98/31, 106/44, and 113/45. The diastolic pressures are below the agency set parameter, 50 mm Hg. A treatment record dated 12/29/2023 indicated a post-standing blood pressure of 110/44 and a sitting post-blood pressure of 103/40. The diastolic pressures are below the agency set parameter, 50 mm Hg. A treatment record dated 12/27/2023 indicated intradialyic blood pressures of 118/36, 105/36, 105/40, post sitting blood pressure of 103/40, and a post-standing blood pressure of 118/44. The diastolic pressures are below the agency set parameter, 50 mm Hg. A treatment record dated 12/24/2023 indicated intradialytic blood pressures of 110/41, 117/47, 117/41, 108/36, 106/37, 104/37, 113/47, 128/49, and a post-standing blood pressure of 110/42 and a post sitting blood pressure of 117/48. The diastolic pressures are below the agency set parameter, 50 mm Hg. A treatment record dated 12/22/2023 indicated intradialytic blood pressures of 106/39, 111/43, 101/36, 103/40, 105/39, 112/41, 103/35, and a post-sitting blood pressure of 142/48. The diastolic pressures are below the agency set parameter, 50 mm Hg. A treatment record dated 12/21/2023 indicated intradialytic blood pressures of 111/40, 119/33, 130/40, 137/54, 135/53, 142/48, and a post-standing blood pressure of 108/33 and a post-sitting blood pressure 99/35. The diastolic pressures are below the agency set parameter, 50 mm Hg. A treatment record dated 12/20/2023 indicated intradialytic blood pressures of 112/37, 94/40, 98/32, 102/38, 112/33, 95/34, 117/46, 95/36, 99/35, 123/43, 117/37, and a post-standing blood pressure of 115/39 and a post-sitting blood pressure of 105/47. The diastolic pressures are below the agency set parameter, 50 mm Hg. A treatment record dated 12/18/2023 indicated intradialytic blood pressures of 114/48, 114/49, 117/44, 109/44, 125/48, 132/46, 121/43, 94/38, 105/47, 106/45, and a post-sitting blood pressure of 104/40. The diastolic pressures are below the agency set parameter, 50 mm Hg. 5. During an interview on 01/04/2024 at 10:30 AM, the Manager of Clinical Services stated there should be a specific blood pressure parameter order when a patient’s blood pressure consistently runs low during treatment and upon leaving the facility. The Manager of Clinical Services could not locate specific physician orders for Patient #5 and Patient #6’s records regarding low blood pressure parameters. 6. During an interview on 12/04/24 at 08:45 AM, the Manager of Clinical Services indicated blood pressure readings before, during, and after treatment that are outside the parameters set by facilities in policy, should be documented. They indicated when the abnormal findings are collected, staff should start interventions to correct the abnormal findings. They indicated these interventions would include assessing the patient’s condition, re-adjusting the blood pressure cuff, retaking blood pressure, and reporting blood pressure readings to the licensed nurse. They indicated that a licensed nurse should notify the physician of abnormal findings. They concluded all staff should document the abnormal findings, interventions, and who was notified; this documentation should be done at the chair side. The Manager of Clinical Services indicated he/she was unable to locate documentation of interventions being performed or notification of nurse/ physician in the patient’s chart. They indicated physicians can provide an order for individualized parameters per patient and these orders are kept in a binder in the treatment area. They collected the binder from the treatment area but were unable to locate alternate orders for Patients #5, #6, and #7.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 38262 Based on record review and interview, the facility failed to ensure Heparin prescription orders were followed for 4 of 5 records reviewed. (Patient #1, #2, #5, #7) Findings include: 1. A revised October 2023 policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” was provided by the Manager of Clinical Services on 01/03/2024 at 10:10 AM. The policy indicated that hourly heparin infusion ordered by the physician should be monitored every 60 minutes. The policy indicated staff should review documentation for accuracy. 2. The complete clinical record for Patient #7 was reviewed on 01/03/2024 and included Prescription Information that indicated Heparin (blood thinner) to stop 60 minutes before the end of treatment. A review of the Intradialytic Treatment Details Report dated 12/31/2023 indicated the Heparin pump was not stopped at 7:52 AM by Patient Care Technician (PCT) 7 with the end of treatment at 8:52 AM. All Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin. A review of the Intradialytic Treatment Details Report dated 12/27/2023 indicated the Heparin pump was not stopped at 7:02 AM by PCT 7 or RN 6 with the end of treatment at 8:02 AM. All Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin. A review of the medication administration record indicated the heparin pump ended at 9:09 AM, 1 hour and 7 minutes after the end of treatment. The facility failed to stop the Heparin 60 minutes before the end of treatment and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/23/2023 indicated Heparin was not given. A review of the medication administration record indicated Heparin was not given due to a prescription change by RN 6. No record of a physician’s order or documentation was found regarding why the Heparin was not given. A review of the Intradialytic Treatment Details Report dated 12/22/2023 indicated that the Heparin pump was not stopped at 7:32 AM by PCT 7 with the end of treatment at 8:32 AM. The Heparin pump column was not marked yes or no between 7:32 AM and 8:32 AM. A review of the medication administration record indicated the heparin pump ended at 8:37 AM, 5 minutes after the end of treatment. The facility failed to stop the Heparin 60 minutes before the end of treatment and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/20/2023 indicated the Heparin pump was not stopped at 8:03 AM by PCT 8 with the end of treatment at 9:03 AM. All Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin. A review of the medication administration record indicated the heparin pump ended at 9:08 AM, 5 minutes after the end of treatment. The facility failed to stop the Heparin 60 minutes before the end of treatment and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/19/2023 indicated that the Heparin pump was not stopped at 7:38 AM by Registered Nurse (RN) 5, with the end of treatment at 8:38 AM. The Heparin pump column was not marked yes or no around the time the Heparin should have ended. A review of the medication administration record indicated the heparin pump ended at 8:56 AM, 18 minutes after the end of treatment. The facility failed to stop the Heparin 60 minutes before the end of treatment and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/15/2023 indicated a late entry by PCT 6 at 8:02 AM, indicating the Heparin was stopped 60 minutes before the end of treatment at 8:32 AM. A review of the medication administration indicated the heparin pump ended at 8:58 AM, 26 minutes after the end of treatment. The facility failed to stop the Heparin 60 minutes before the end of treatment and failed to accurately document when the Heparin ended. 48387 3. The complete clinical record for Patient #1 was reviewed on 01/03/2024 and included Prescription Information that indicated Heparin to stop 60 minutes before the end of treatment. A review of the Intradialytic Treatment Details Report dated 12/11/2023 indicated the Heparin pump was stopped at 11:11 AM by PCT 7, the treatment ended at 10:34 AM. Heparin pump columns were marked as N (no), meaning that the patient was not receiving Heparin from 8:34 to 10:34 AM during the treatment, and a note by PCT 10 indicated the Heparin infusion was completed at 9:04 AM. A review of the medication administration indicated the heparin pump ended at 11:11 AM, 77 minutes after the end of treatment. The facility failed to stop the Heparin 60 min before the end of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/13/2023 indicated the Heparin pump was stopped at 10:53 AM by PCT 10, the treatment ended at 10:34 AM. Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin and a note from PCT 10 at 10:34 AM Heparin stopped 60 minutes before the end of treatment. A review of the medication administration indicated the heparin pump ended at 10:53 AM, 19 minutes after the end of treatment. The facility failed to stop the Heparin 60 min before the end of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/27/2023 indicated the Heparin pump was stopped at 10:45 AM by PCT 7, the treatment ended at 10:28 AM. Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin for the entire treatment except at 9:35 AM where the heparin column was marked N (no), and the note stated Heparin infusion was complete. A review of the medication administration indicated the heparin pump ended at 10:45 AM, 17 minutes after the end of treatment. The facility failed to stop the Heparin 60 min before the end of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/29/2023 indicated the Heparin pump was stopped at 10:39 AM by PCT 10, the treatment ended at 10:24 AM. Heparin pump columns were marked as N (no), meaning that the patient was not receiving Heparin from 10:05 AM to the end of treatment at 10:24 AM. A review of the medication administration indicated the heparin pump ended at 10:39 AM, 15 minutes after the end of treatment. The facility failed to stop the Heparin 60 min before the end of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/31/2023 indicated the Heparin pump was stopped at 10:35 AM by PCT 7, the treatment ended at 10:05 AM. Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin during the entire treatment. A review of the medication administration indicated the heparin pump ended at 10:35 AM, 30 minutes after the end of treatment. The facility failed to stop the Heparin 60 min before the end of treatment as ordered and failed to accurately document when the Heparin ended. 4. The complete clinical record for Patient #2 was reviewed on 01/03/2024 and included Prescription Information that indicated Heparin to stop 60 minutes before the end of treatment. A review of the Intradialytic Treatment Details Report dated 12/18/2023 indicated the Heparin pump was stopped at 8:48 AM by PCT 7, the treatment ended at 8:02 AM. All Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin during the entire treatment. A review of the medication administration indicated the heparin pump ended at 8:48 PM, 46 minutes after the end of treatment. The facility failed to stop the Heparin 60 min before the end of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/20/2023 indicated the Heparin pump was stopped at 9:51 AM by PCT 10, the treatment ended at 9:25 AM. All Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin during the entire treatment. A review of the medication administration indicated the heparin pump ended at 9:51 PM, 26 minutes after the end of treatment. The facility failed to stop the Heparin 60 min before the end of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/27/2023 indicated the Heparin pump was stopped at 8:37 AM by PCT 10, the treatment ended at 8:34 AM. All Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin during the entire treatment. A review of the medication administration indicated the heparin pump ended at 8:37 PM, 3 minutes after the end of treatment. The facility failed to stop the Heparin 60 min before the end of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/31/2023 indicated the Heparin pump was stopped at 9:03 AM by PCT 7, the treatment ended at 8:34 AM. All Heparin pump columns were marked as Y (yes), meaning that the patient was receiving Heparin during the entire treatment. A review of the medication administration indicated the heparin pump ended at 9:03 AM, 69 minutes after the end of treatment. The facility failed to stop the Heparin 60 min before the end of treatment as ordered and failed to accurately document when the Heparin ended. 5. The complete clinical record for Patient #5 was reviewed on 01/03/2024 and included Prescription Information that indicated an order for Heparin to be given during the entire treatment time. A review of the Intradialytic Treatment Details Report dated 11/02/2023 indicated that the Heparin pump was not stopped at 2:20 PM by RN 6; the treatment ended at 3:24 PM. The Heparin pump column was marked N(no), meaning the patient was not receiving Heparin from 2:28 PM to 3:24 PM treatment. A review of the medication administration indicated the heparin pump ended at 2:20 PM, 104 minutes before the end of treatment. The facility failed to administer the Heparin for the entire length of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 11/07/2023 indicated that the Heparin pump was not stopped at 2:40 PM by RN 6; the treatment ended at 3:33 PM. The Heparin pump column was marked N(no), meaning the patient was not receiving Heparin from 2:03 PM to 3:33 PM treatment. A review of the medication administration indicated the heparin pump ended at 2:40 PM, 93 minutes before the end of treatment. The facility failed to administer the Heparin for the entire length of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 11/09/2023 indicated that the Heparin pump was not stopped at 12:33 PM by RN 6; the treatment ended at 1:54 PM. The Heparin pump column was marked Y(yes), meaning the patient was receiving Heparin during the entire treatment. A review of the medication administration indicated the heparin pump ended at 12:33 PM, 121 minutes before the end of treatment. The facility failed to administer the Heparin for the entire length of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 11/20/2023 indicated that the Heparin pump was not stopped at 1:40 PM by RN 6; the treatment ended at 2:30 PM. The Heparin pump column was marked Y(yes), meaning the patient was receiving Heparin during the entire treatment. A review of the medication administration indicated the heparin pump ended at 1:40 PM, 50 minutes before the end of treatment. The facility failed to administer the Heparin for the entire length of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 11/21/2023 indicated that the Heparin pump was not stopped at 12:47 PM by RN 6; the treatment ended at 1:47 PM. The Heparin pump column was marked Y(yes), meaning the patient was receiving Heparin during the entire treatment. A review of the medication administration indicated the heparin pump ended at 12:47 PM, 60 minutes before the end of treatment. The facility failed to administer the Heparin for the entire length of treatment as ordered and failed to accurately document when the Heparin ended. A review of the Intradialytic Treatment Details Report dated 12/15/2023 indicated that the Heparin pump was not stopped at 1:53 PM by PCT 9; the treatment ended at 1:52 PM. The Heparin pump column was marked N(no), meaning the patient was not receiving Heparin from 1:29 PM to 1:41 PM treatment. A review of the medication administration indicated the heparin pump ended at 1:53 PM, the facility failed to accurately document when the Heparin was given. A review of the Intradialytic Treatment Details Report dated 12/22/2023 indicated that the Heparin pump was not stopped at 1:35 PM by PCT 10; The Heparin pump column was marked N(no), meaning the patient was not receiving Heparin from 1:04 PM to 1:18 PM during treatment. A note entered by PCT 10 indicated Heparin was stopped 60 minutes before the end of treatment. A review of the medication administration indicated the heparin pump ended at 1:35 PM, the facility failed to accurately document when the Heparin was given. 6. During an interview on 01/04/2024 at 10:30 AM, the Manager of Clinical Services reviewed the Intradialytic Treatment Details Reports and medication administration record. The Manager of Clinical Services needed to determine why documentation wasn’t consistent and why staff did not follow physician orders.”

“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: 38262 Based on observation, record review, and interview, the facility failed to accurately label the Bicarb mixing tank for 1 of 1 Bicarb mixing tank observations. (PCT 4, PCT 7) Findings include: 1. A revised July 2015 policy titled “Better Water-Central Bicarb Mixing and Delivery” was provided by the Bio Med personnel on 01/04/2024 at 8:11 AM. The policy indicated the Bicarb mixing tank was to be labeled with the correct date, time, and initials. 2. During the water room tour on 01/03/2024 at 12:20 PM, the Personal Care Technician (PCT) 7 was asked why the Bicarb mixing tank had a date of 02/03/24. PCT 7 stated they wrote the wrong date on it. PCT 7 did not correct the date at that time. 3. During an interview on 01/03/2024 at 12:35 PM, PCT 4 stated they knew the date on the Bicarb mixing tank was wrong and did not correct it. 4. During an interview on 01/04/2024 at 8:00 AM, the Bio Med personnel stated the accurate date, time, and initials should be labeled on the Bicarb mixing tank.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 48387 Based on record review and interview the facility failed to document accurate interventions, treatments, details of the event that occurred, and the care provided by the facility personnel, in 1 of 1 CVC record reviews. (Patient #7) Findings include: 1. A 10/2023 revised policy titled “MEDICAL RECORDS DOCUMENTATION GUIDANCE” indicated staff is not allowed to sign, date, or time a medical record entry on behalf of another teammate or other individual and all entries must be accurate. 2. A 10/2023 revised policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” indicated all findings, interventions, and patient responses should be documented in the patient’s medical records.The policy indicates the nurse should be notified immediately of abnormal findings and these findings should be documented in the patient’s medical records. 3. A 03/2015 document titled “Job Description” for Facility Administrator (FA) indicated FA should ensure patient and treatment information are accurate in the system. The document also indicated FA should know, understand, and follow policies and procedures. 4. A document received on 01/04/2024 from the Manager of Clinical Services computer screenshot revealed Patient #7’s treatment for 11/29/2023 from 11:33 AM to 12:19 PM. The document indicated on 11/29/2023 at 12:03 PM, the patient was checked by PCT 8, at that time patient’s bp was 86/47, the note indicated patient had an alert face, and the access site was visible and the blood line was secure. Blood pressure (BP) was low, the blood pressure cuff was readjusted, blood pressure (BP) was rechecked and the nurse was notified. 5. A document received on 01/04/2023, titled “Treatment Detailed Report” included staff entries made during Patient #7 treatment on 11/29/2023, this included time-stamped entries and what information was entered at that time. The Information Technology (IT) for the facility had to be contacted to retrieve this information. This document indicated on 11/29/2023 at 12:24 PM PCT 8 returned to FA entry made at 12:06 PM and documented the patient blood pressure was low, the blood pressure cuff was readjusted, and the blood pressure was retaken, and the nurse was notified. PCT 8 documented under FA’s name. 6. The complete clinical record for Patient #7 was reviewed on 01/03/2024 and included the Treatment Details Report from 11/15/2023 and 11/29/2023. A review of the Treatment Details Report for 11/29/2024 indicated the following: At 12:03 PM the Facility Administrator (FA) checked on Patient #7 whose bp was 86/47. The FA documented the patient had an alert face, access was visible, and the line was secure. At 12:24 PM, an updated entry was made to FA original 12:03 PM entry, no blood pressure was taken, the PCT 8 documented the patient’s blood pressure was low, the blood pressure cuff was adjusted, blood pressure was rechecked, and the nurse was notified. 7. During an observation on 01/03/2024 at 10:45 AM, the FA was seen at station 11, where the dialysis machine was alarming. The FA silenced the alarm and walked away from the station. No interventions or documentation was done at the chair side. 8. During an interview on 01/03/24 at 10:50 AM, the PCT 3 indicated that if a machine alarms for low blood pressure the staff should ask the patient if they are “OK”, the blood pressure cuff should be readjusted and retaken then the nurse should be notified if interventions did not correct low blood pressure. 9. During an interview on 12/04/24 at 11:05 AM, the Manager of Clinical Services indicated blood pressure readings before, during, and after treatment that are outside the parameters set by facilities in policy should be documented. They indicated when the abnormal findings are collected, staff should start interventions to correct the abnormal findings. They indicated these interventions would include assessing the patient’s condition, re-adjusting the blood pressure cuff, retaking blood pressure, and reporting blood pressure readings to the licensed nurse. They indicated that a licensed nurse should notify the physician of abnormal findings. They concluded all staff should document the abnormal findings, interventions, and who was notified; and this documentation should be done at the chair side. The Manager of Clinical Services indicated they were unable to locate documentation in the electronic patient’s chart. 10. During a phone interview on 01/04/2024 at 12:00 PM, PCT 8 indicated in November 2023, she found Patient #7’s blood pressure low alarm had been silenced by FA. She notified the nurse. PCT 8 and the nurse returned to the patient at that time PCT 8 was documenting on the computer while the nurse was administering 100 milliliters of normal saline and rechecking blood pressure at that time facility administrator was brought over to the patient and the nurse discussed with FA regarding silencing alarms, reporting low blood pressure alarm to the nurse and what interventions should have been performed. PCT 8 indicated he/she returned to caring for other patients and did not return to document on Patient #7’s chart, regarding this subject. He/she was not able to confirm why they would have documented information regarding taking blood pressure and notifying the nurse under the same entry as FA. PCT 8 indicated, that if he/she documented a bp was retaken, then the system would have a blood pressure and a time stamp for it.”