Davita Newburgh Dialysis

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 48387 Based on Observations, record reviews, and interviews, the facility failed to update the patient treatment list in the emergency preparedness binder every month. Findings include: A 04-2024 revised policy titled “Facility Emergency Management Plan” indicated that the evacuation kit should contain a copy of each patient’s treatment orders and medication list, which should be updated monthly. The facility failed to update the patient treatment orders and medication list in the evacuation kit in May, June, and July, which were last updated in April 2024. During an interview on 07/26/2024 at 10:30 AM, the Peritoneal Dialysis Administrator indicated that the Emergency patient list should be updated monthly and placed in a binder.”

“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: 38262 Based on observation, record review, and interview, the facility staff failed to remove gloves and perform hand hygiene after a Central Venous Catheter (CVC) exit site care and before initiating dialysis for 3 of 3 CVC observations. (PCT 3, PCT 4, and RN 1) Findings include: 1. A policy titled “Infection Control for Dialysis Facilities,” indicated that staff should change gloves when moving from a dirty to a clean area or from a contaminated body site to a clean body site. 2. During an observation on 07/26/2024 at 10:45 AM, PCT 3 removed Patient #1’s old CVC dressing and then began cleaning the CVC exit site with an antiseptic without removing gloves or performing hand hygiene. PCT 3 drew blood from Patient #1’s CVC site, removed her gloves, and transported the vial to the designated lab area. PCT 3 then returned to the clean “snappy” computer and typed on the keyboard without removing gloves or performing hand hygiene. PCT 3 stated that the “snappy” computer was a designated clean area. During an interview on 07/29/2024 at 2:24 PM, the MCS stated hand hygiene should be performed after removing gloves and before touching cleaning items. 3. During an interview on 07/26/2024 at 8:55 AM, Registered Nurse (RN) 1 stated he had received training on when to change gloves and perform hand hygiene. RN 1 stated he does monthly visual audits while the Patient Care Technicians are on the treatment floor to ensure they follow infection control standards. 48387 4. During an observation on 07/26/2024 at 2:20 PM, PCT 4 removed gloves and used the computer keyboard without performing hand hygiene. PCT 4 touched the computer keyboard and then applied new gloves to provide care to Patient #2 without performing hand hygiene. After picking up the access needle from the floor, PCT 4 returned to the patient’s access site and placed a clean dressing without changing gloves or performing hand hygiene. PCT 4 also placed used supplies from Patient #2’s chairside table in the trash and touched the patient’s items without changing gloves or performing hand hygiene. Finally, PCT 4 completed post-access care at the access site and removed gloves without performing hand hygiene. 5. During an observation on 07/29/2024 at 9:00 AM, PCT 3 removed gloves and then donned new gloves to provide care for Patient #3 without performing hand hygiene. 6. During an observation on 07/29/2024 at 9:08 AM, RN 1 cleaned Patient #12’s access site and then touched the computer keyboard without removing gloves or performing hand hygiene. He then touched the dialysis machine, the computer keyboard, and inserted cannulation needles on Patient #12, without removing gloves or performing hand hygiene between these actions. 7. During a random interview on 07/29/2024 at 9:00 AM, PCT 8 indicated that staff should perform hand hygiene and change gloves after touching the computer and before providing care to patients or touching the dialysis machine.”

“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: 38262 Based on observation, record review, and interview, the facility staff failed to ensure common supplies were kept away from areas where spurting or spattering of blood or fluids may occur for 1 of 2 dialysis supply management and contamination prevention observations. (PCT 3) Findings include: 1. A policy titled “Infection Control for Dialysis Facilities” was provided by the Manager of Clinical Services (MCS) on 07/29/2024. The policy indicated all surfaces of the treatment chair will be disinfected. Clean supplies should be kept in a clean area. Items taken to the station should not be returned to the common clean area. 2. During an observation on 07/26/2024 at 10:35 AM, Patient Care Technician (PCT) 3 brought the pH test (testing the alkalinity or acidity of a liquid) strip bottle to station 12 and sat the bottle on top the dialysis machine while the Patient #1 was at the station. PCT 3 removed a test strip from the bottle to test the machine’s pH level and then returned the pH bottle back to the designated clean sink area. PCT 3 stated the pH bottle could sit on top of the dialysis machine but the bottle should be kept in a clean designated sink area. PCT 3 failed to ensure common supplies were kept in a designated clean area. 3. During a treatment floor observation on 07/29/2024 at 8:45 AM, the pH test strip bottle was sitting on the designated dirty sink ledge. At that time, Registered Nurse (RN) 5 stated the pH test strip bottle could sit on the ledge of the designated dirty sink area. RN 1 stated staff are not to place the pH strip bottle on top of the dialysis machine. The bottle should be kept in the designated clean area. The facility staff failed to ensure common clean supplies were kept in a designated clean area. 4. During an interview on 07/30/2024 at 8:55 AM, the Facility Administrator (FA) and the MCS stated the expectation was for staff to place the pH test strip bottle in a clean designated area, not on top of the dialysis machine.”

“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 and equipment for 1 of 3 observations of cleaning and disinfecting the dialysis station (PCT 3), and failed to use a clean barrier for access set-up for 1 of 2 access of an arteriovenous (AV) site observations. (PCT 3) Findings include: 1. A policy titled “Infection Control for Dialysis Facilities” indicated all surfaces of the treatment chair will be disinfected. Clean supplies should be kept in a clean area. Items taken to the station should not be returned to the common clean area. 2. During an observation on 07/26/2024 at 2:05 PM, Patient Care Technician (PCT) 3 failed to fully recline station 11’s treatment chair while cleaning and disinfecting. At that time, PCT 3 was interviewed and stated no further cleaning was required for the chair. During an interview on 07/29/2024 at 3:15 PM, the Facility Administrator (FA) stated staff should fully recline the treatment chair during cleaning and disinfecting. 48387 3. On 07/29/2024 at 9:00 AM, PCT 3 placed Patient #3’s access site supplies on the table without using a protective covering. During an interview on 07/29/2024 at 2:24 PM, the Manager of Clinical Services (MCS) indicated that staff should place a barrier on the chairside table prior to placing supplies on the surface.”

“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: 38262 1. A policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” indicated intradialytic treatment monitoring and data collection would be completed every 30 minutes and include but not limited to obtaining blood a dialysate flows, and if the dialysis prescription was not being met (including dialysis flow rate or change to blood flow rate) the reason would be documented, and the licensed nurse informed. The policy indicated that Intradialytic blood pressures (BP) with a systolic greater than 180 mm/Hg less than 90 mmHg or a diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg should be reported to a licensed nurse. The policy indicated a license nurse should assess the patient within 1 hour of the initiation of the treatment. 2. A review of Patient #6’s Treatment Detail Report dated 07/09/2024, Patient Care Technician (PCT) 4 recorded blood pressures (B/P) of 133/115 at 4:28 AM, 198/101 at 4:49 AM, 198/99 at 4:57 AM, 189/167 at 5:57 AM, 192/91 at 7:27 AM, 203/104 at 8:27 AM, and finally 200/106 at 8:32 AM; and PCT 8 recorded blood pressure of 203/102 at 7:57 AM and 198/95 as a recheck at 7:58 AM. PCT 4 failed to recheck B/Ps that were outside of range and both PCT 4 and PCT 8 failed to report the high B/P to a nurse or physician. During an interview on 07/30/2024 at 10:39 AM, the Medical Director stated staff should be mindful of the blood pressures they record in the record during the treatment. The Medical Director stated that staff should recheck the B/P again or recheck the B/P on the ankle. The Medical Director stated the expectation was for staff to follow the facility policy’s. 3. A review of Patient #7’s record failed to evidence timely assessments and reporting of abnormal B/P readings to the nurse for the following dates: A review of Patient #7’s Treatment Detail Report dated 06/26/2024, indicated Patient #7 started treatment at 11:30 AM. RN 3 assessed Patient #7 at 1:24 PM, 1 hour 54 minutes later. A review of Patient #7’s Treatment Detail Report dated 07/11/2024, indicated Patient #7 started treatment at 9:56 AM. RN 1 assessed Patient #7 at 12:33 PM, 2 hours 37 minutes later. A review of Patient #7’s Treatment Detail Report dated 07/11/2024 indicated that PCT 9 recorded a B/P of 164/108 at 12:26 PM, followed by consecutive B/P readings of 152/97 at 1:05 PM, B/P of 176/111 at 1:27 PM, B/P of 161/108 at 1:29 PM, B/P 176/109 at 1:56 PM, and a B/P of 180/105 at 2:26 PM. PCT 9 failed to report the consecutive high B/P readings to the nurse or physician. A review of Patient #7’s Treatment Detail Report dated 07/19/2024 indicated that PCT 4 recorded a B/P of 148/96 at 11:43 AM, followed by consecutive B/P readings of 159/105, at 12:13 PM, B/P of 159/108 at 12:43 PM, and a B/P of 149/100 at 1:13 PM. PCT 4 failed to recheck Patient #7’s consecutive high B/P readings and failed to report the high B/P to a nurse or physician. A review of Patient #7’s Treatment Detail Report dated 07/24/2024 indicated that Patient Care Technician (PCT) 5 recorded a B/P of 158/109 at 11:53 AM. PCT 2 recorded a B/P of 155/112 at 12:22 PM and a B/P of 168/113 at 12:52 PM. PCT 2 and PCT 5 failed to recheck Patient #7’s consecutive high B/P readings and failed to report the high B/P to a nurse or physician. During an interview on 07/26/2024 at 8:55 AM, Registered Nurse (RN) 1 stated he has 1 hour to complete the nursing assessment and prescription check once initiating the patient’s treatment. RN 1 stated there were enough nurses and PCTs staffed but sometimes they call in a float nurse to help out. RN 1 stated the PCTs are expected to let him know if B/Ps are above 180/90 and are displaying symptoms of nausea or shortness of breath. During an interview on 07/29/2024 at 12:30 PM, the MCS stated the nurse was to assess Patient #7 within an hour and was unsure why the assessment was not done timely. The MCS stated the expectation was for the PCT to recheck high B/Ps, report high B/Ps to the nurse, and document it on the Treatment Detail Report. The MCS stated they would re-educate the staff. 4. A review of Patient 10’s record failed to evidence timely assessments and reporting of abnormal B/P readings to the nurse for the following dates: A review of Patient #10’s Treatment Detail Report dated 07/17/2024 indicated that PCT 2 recorded a B/P of 85/58 at 13:31 PM, 78/46 at 14:32 PM, and 82/55 at 14:33 PM. PCT 2 failed to recheck Patient #10’s consecutive low B/P readings and/or failed to report the low B/P to a nurse or Physician. A review of Patient #10’s Treatment Detail Report dated 07/17/2024 indicated Patient #10 started treatment at 11:03 AM. RN 3 assessed Patient #10 at 12:16 PM, 1 hour and 12 minutes late. During an interview on 07/30/2024 at 10:05 AM, the Facility Administrator indicated that Patient #10’s blood pressure on 07/17/2024 should have been reported to the RN and rechecked. She also confirmed on 07/17/2024, the RN should have assessed Patient # 10 within an hour of starting treatment. 5. A review of Patient #11’s record failed to evidence timely assessments and reporting of abnormal B/P readings to the nurse for the following dates: A review of Patient #11’s Treatment Detail Report dated 07/05/2024 indicated Patient #11 started treatment at 9:37 AM. RN 1 assessed Patient #11 at 11:50 AM, 2 hours 13 minutes later. A review of Patient #11’s Treatment Detail Report dated 07/08/2024 indicated Patient #11 started treatment at 9:53 AM. RN 1 assessed Patient #11 at 11:12 AM, 1 hour 19 minutes later. A review of Patient #11’s Treatment Detail Report dated 07/22/2024 indicated that PCT 1 recorded a blood pressure (B/P) of 161/103 at 11:58 AM, followed by readings of 160/105 at 12:28 PM, and 173/102 at 12:58 PM. PCT 1 failed to recheck Patient #11’s high B/P and failed to report the high B/P to a nurse or physician. During an interview on 07/26/2024 at 8:55 AM, Registered Nurse (RN) 1 stated he has 1 hour to complete the nursing assessment and prescription check once initiating the patient’s treatment. RN 1 stated there were enough nurses and PCTs staffed but sometimes they call in a float nurse to help out. RN 1 stated the PCTs are expected to let him know if B/Ps are above 180/90 and are displaying symptoms of nausea or shortness of breath. During an interview on 07/29/2024 at 12:30 PM, the MCS stated the nurse was to assess Patient #11 within an hour. The MCS stated the expectation was for the PCT to recheck high B/Ps, report high B/Ps to the nurse, and document it on the Treatment Detail Report. The MCS stated they would re-educate the staff.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 38262 2. A review of Patient #7’s Patient Summary Report indicated a prescribed BFR of 400 mL/min. Patient #7’s BFR was not achieved or maintained throughout the dialysis treatment on the following dates: A review of Patient #7’s Treatment Detail Report dated 07/19/2024 evidenced a BFR of 310 for the entire treatment. The record failed to indicate a reason for not achieving or maintaining the prescribed BFR of 400 throughout the dialysis treatment. A review of Patient #7’s Treatment Detail Report dated 06/28/2024 evidenced a BFR of 350 at 1:36 PM, 2:06 PM, 2:36 PM, 3:06 PM, and 3:21 PM. The record failed to indicate a reason why the prescribed BFR was not achieved or maintained. During an interview on 07/29/2024 at 12:30 PM, the Manager of Clinical Services (MCS) stated the expectation was for staff to document why BFRs are not achieved or maintained and should follow up with the physician. During an interview on 07/30/2024 10:39 AM, the Medical Director stated that staff are expected to follow the facility policy and call the Physician if BFRs are not achieved. 4. A review of Patient #11’s Treatment Detail Report indicated a prescribed BFR of 450 mL/mm. Patient #11’s BFR was not achieved or maintained throughout the dialysis treatment on the following dates: A review of Patient #11’s Treatment Detail Report dated 07/15/2024 evidenced a BFR of 400 for the entire treatment. Patient #11’s BFR was not ran at the prescribed rate of 450 mL/mm and no documentation of why the patient did not receive the prescribed BFR. A review of Patient #11’s Treatment Detail Report dated 07/13/2024 evidenced a BFR of 400 at 5:36 AM, 6:06 AM, 6:36 AM, 7:06 AM, and a BFR of 300 at 7:36 AM and at 8:06 AM. Patient #11’s BFR was not achieved or maintained throughout the dialysis treatment. During an interview on 07/29/2024 at 12:30 PM, the MCS stated the expectation was for staff to document why BFRs are not achieved or maintained and should follow up with the physician. 48387 Based on record review and interview, the facility failed to ensure patient dialysis prescription orders were adhered to in order to achieve and sustain the prescribed dose of dialysis to meet the adequacy of dialysis for 3 of 5 in-center record reviews. (Patients #7, #10, #11) Findings include: 1. A policy titled ‘Blood Flow Problems’ indicated that any issues with blood flow should be reported to the nurse. The policy indicates that the nurse should then notify the Physician for further evaluation and intervention, and document the situation in the patient’s record. 3. A record review on Patient # 10 included a 07/24/2024 Treatment Details Report that indicated Dialysate Flow Rate (DFR) was ordered for 800 mL/min, A review of the Treatment Detail Report indicated Patient #10’s DFR ran at 600/ mL/min or 610/mL/min throughout treatment. The facility failed to provide treatment as ordered by the Physician. During an interview on 07/29/2024 at 11:55 AM, the Manager of Clinical Services (MCS) reviewed Patient #10’s treatment record for 07/24/2024; she indicated that the DFR was programmed into the machine incorrectly at the start of treatment.”

“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: 38262 Based on record review and interview, the facility failed to ensure staff followed Heparin (blood thinner medication) prescribed orders and record appropriately for 2 of 6 in-center record reviews. (Patients #2, #11) Findings include: 1. A policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” was provided by the Manager of Clinical Services on 07/29/2024. The policy indicated Heparin should be monitored every 60 minutes. The policy indicated that if the dialysis prescription was not followed or met the reason should be documented. All documentation should be reviewed for accuracy. 2. A review of Patient #2’s prescription order indicated Heparin was to stop 60 minutes before the end of treatment. A review of Patient #2’s Patient Summary Report indicated Heparin was not stopped 60 minutes before the end of treatment for the following dates: A review of Patient #2’s Treatment Details Report dated 07/24/2024 indicated in the medication administration section that Heparin pump was stopped at 2:35 PM; the treatment ended at 2:34 PM. The Heparin was not stopped at 1:34 PM, 60 minutes before 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 Patient #2’s Treatment Details Report dated 07/22/2024 indicated in the medication administration section that the Heparin pump was stopped at 1:37 PM; the treatment ended at 1:37 PM. The Heparin was not stopped at 12:37 PM, 60 minutes before 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 Patient #2’s Treatment Details Report dated 07/19/2024 indicated in the medication administration section that the Heparin pump was stopped at 2:06 PM; the treatment ended at 1:59 PM. The Heparin was not stopped at 12:59 PM, 60 minutes before 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. During an interview on 07/26/2024 at 8:55 AM, Registered Nurse (RN) 1 stated that to prevent errors and near misses he confirms the prescription was accurately entered into the dialysis machine before treatment. RN 1 stated staff are to monitor the patient every 30 minutes which includes Heparin pump delivery. RN 1 stated he completes a post nursing assessment and reviews the treatment record at that time. During an interview on 07/29/2024 at 12:00 PM, the Facility Administrator (FA) and MCS reviewed the patient’s record and stated that the Heparin was documented incorrectly. The MCS stated that the facility does not have a specific Heparin policy and staff are to follow the prescribed Heparin order. The MCS stated staff are to document when the Heparin stopped in the medication administration (Infusion start/end) section of the report. 3. A review of Patient #11’s prescription order indicated Heparin was to stop 60 minutes before the end of treatment. A review of Patient #11’s Patient Summary Report indicated Heparin was not stopped 60 minutes before the end of treatment for the following dates: A review of Patient #11’s Treatment Details Report dated 07/22/2024 indicated in the medication administration section that the Heparin pump was stopped at 2:00 PM; the treatment ended at 1:58 PM. The Heparin was not stopped at 12:58 PM, 60 minutes before 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 Patient #11’s Treatment Details Report dated 07/19/2024 indicated in the medication administration section that the Heparin pump was stopped at 1:52 PM; the treatment ended at 1:36 PM. The Heparin was not stopped at 12:36 PM, 60 minutes before 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 Patient #11’s Treatment Details Report dated 07/17/2024 indicated in the medication administration section that the Heparin pump was stopped at 1:59 PM; the treatment ended at 1:57 PM. . The Heparin was not stopped at 12:57 PM, 60 minutes before 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 Patient #11’s Treatment Details Report dated 07/15/2024 indicated in the medication administration section that the Heparin pump was stopped at 1:19 PM; the treatment ended at 1:17 PM. The Heparin was not stopped at 12:17 PM, 60 minutes before 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 Patient #11’s Treatment Details Report dated 07/5/2024 indicated in the medication administration section that the Heparin pump was stopped at 1:49 PM; the treatment ended at 1:47 PM. The Heparin was not stopped at 12:47 PM, 60 minutes before 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. During an interview on 07/26/2024 at 8:55 AM, Registered Nurse (RN) 1 stated that to prevent errors and near misses he confirms the prescription was accurately entered into the dialysis machine before treatment. RN 1 stated staff are to monitor the patient every 30 minutes which includes Heparin pump delivery. RN 1 stated he completes a post nursing assessment and reviews the treatment record at that time. During an interview on 07/26/2024 at 10:05 AM, Patient Care Technician (PCT) 1 stated she verifies the prescription, which includes Heparin, at the start of treatment. PCT 1 stated she records the prescription into the dialysis machine. PCT 1 stated she monitors the patient every 30 minutes and documents the assessment which includes Heparin pump delivery on the Treatment Details Report. PCT 1 stated she reports to the nurse when the patient prescription (Heparin) was not met or delivered. During an interview on 07/29/2024 at 12:00 PM, the Facility Administrator (FA) and MCS reviewed the patient’s record and stated that the Heparin was documented incorrectly. The MCS stated that the facility does not have a specific Heparin policy and staff are to follow the prescribed Heparin order. The MCS stated staff are to document when the Heparin stopped in the medication administration (Infusion start/end) section of the report that accurately reflects when Heparin stops.”