Fmc - Griffith

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility failed to evidence exercises were conducted to test the emergency plan, annually at minimum, in 1 of 1 dialysis facility. Findings include: A revised policy, dated 07/03/2023, titled “Guidelines for Emergency Preparedness”, indicated that annually, the dialysis facility must participate in a community-based disaster drill as well as a table-top drill for an event of high likelihood. Clinic documents provided for a review included a flood tabletop exercise dated 03/13/2024, a blizzard tabletop exercise dated 10/03/2024, and a water interruption exercise dated 04/15/2025. During an interview on 07/17/2025, beginning at 10:00 am, the Facility Administrator [FA] indicated that these three trainings were the only training exercises completed in the last two years. The FA indicated that no community-based or full-scale exercise has been completed in the last two years, and that the Director of Operations is coordinating for a full scale exercise to occur in the future.”

“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: 41135 Based on observation, record review, and interview, the dialysis facility failed to ensure that staff performed hand hygiene in 1 of 2 observations of a RN before administering medication (RN 1) and in 1 of 2 observations of discontinuation and post dialysis access care for arteriovenous fistula (AVF, dialysis access) (PCT 3). The findings include: 1. A revised policy, dated 11/06/2023, titled “Hand Hygiene”, indicated hand hygiene should be performed before and after direct contact with patients, before performing vascular access, and after contact with inanimate objects near the patient. 2. During an observation, on 07/15/2025 beginning at 11:47 AM, while in station 16, RN 1 readjusted Patients’ blankets, then without hand hygiene, she touched the dressing of Patients AVF access site. 3. During an observation, on 07/14/2025 beginning at 10:59 AM, while in station 11, PCT 3 was discontinuing hemodialysis (HD) (a process to filter the blood in a patient whose kidneys do not work normally) for Patient #8. PCT 3 reinfused the HD machine, touched the computer screen next to the Patient, and failed to perform hand hygiene and don new gloves prior to removing the needles from Patient #8. 4. On 07/17/2025 at 11:23 AM, the FA indicated hand hygiene should take place after touching the patient’s fistula site.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 41135 Based on record review and interview, the facility failed to offer the Hepatitis B (a contagious viral infection) vaccine in 1 of 1 clinical record review for a patient with a diagnosis of Acute Kidney Injury (AKI, a sudden decrease in kidney function) in a total sample of 6 clinical records reviewed. (Patient #6) The findings include: A policy dated 02/07/2022 titled “Patient Vaccination for Hepatitis B” indicated the Hepatitis B vaccine would be offered to all susceptible patients, and a declination form would be signed by the patient if the Hepatitis B vaccine was declined. The policy indicated the patient did not have protection against Hepatitis B if the antibody titer levels were less than 10 milliinternational untis (mIU) per milliliter (ml, a unit of measure). A clinical record review for Patient #1evidenced the Patient’s diagnosis was AKI and evidenced a Hepatitis B antibody test dated 07/03/2025 which indicated the Hepatitis B antibodies were less than 10 mIU/ml. The record failed to evidence the agency offered the Hepatitis B vaccine and failed to evidence a signed declination form by the Patient. On 07/16/2025, at 12:55 PM, the FA indicated the Patient was not offered the Hepatitis B vaccine and indicated the facility typically did not offer the Hepatitis B vaccine to patients with AKI since the patients would not be receiving dialysis long enough to finish the vaccination series.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 41135 Based on record review and interview, the facility failed to ensure the chlorine testing was performed by a staff tested to be able to distinguish between colors in 1 of 2 personnel records reviewed of a RN. (RN 4) The findings include: A policy dated 01/23/2019 indicated staff that interpret or distinguish color when performing water and/or other quality tests are required to take a color blindness test to ensure the ability to perform the functions of the job. The chlorine tests completed on 07/04/2025 at 8:52 AM and 11:55 AM indicated RN 4 was the staff member that confirmed the test results and was the staff member that completed the test at 2:58 PM. A personnel record review for RN 4 failed to evidence a color blindness test. On 07/17/2025, at 11:38 AM, the Director of Operations indicated RN 4 did complete the chlorine testing on 07/04/2025 and could not find a color blindness test completed by RN 4.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 41135 Based on record review and interview, the facility failed to offer the pneumococcal (a contagious bacterial infection) vaccine in 1 of 1 clinical record review for a patient with a diagnosis of Acute Kidney Injury (AKI, a sudden decrease in kidney function) in a total sample of 6 clinical records reviewed. (Patient #6) The findings include: A policy dated 07/03/2025 titled “Pneumococcal Vaccine for Adults” indicated the vaccination status for all new patients should be reviewed, and the facility should offer the pneumococcal vaccine on an annual basis and obtain a declination statement for any patient that declines the pneumococcal vaccine. A clinical record review for Patient #1 indicated the Patient was admitted on 07/03/2025 and failed to evidence the facility offered the pneumococcal vaccine to the Patient and failed to evidence a declination form signed by the Patient. On 07/16/2025, at 12:55 PM, the FA indicated the facility didn’t offer the Patient the pneumococcal vaccine, because “there was a lot going on.” On 07/17/2025, at 10:43 PM, the FA indicated she thought the Patient was offered the pneumococcal vaccine but no declination form was obtained.”

“POC-OUTCOME NOT ACHIEVED-ADJUST POC CFR(s): 494.90(b)(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient’s current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section. This Standard is not met as evidenced by: 41135 Based on record review and interview, the facility failed to ensure the interdisciplinary team adjusted the plan of care when the expected outcome was not achieved and failed to identify and document the potential causes of patient non-adherence and efforts to address those causes in 1 of 3 clinical records reviewed for patients receiving in-center hemodialysis (HD, the process to filter the blood when the kidneys do not function properly) through a central venous catheter (CVC, dialysis access by way of inserting a tube through a large vein) greater than 90 days in a total sample of 6 clinical records reviewed. (Patient #2) The findings include: A policy dated 07/03/2023 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” indicated if the patient did not achieve expected outcomes in the POC, the interdisciplinary team must adjust the POC, implement the changes to address the identified issues, and document the changes made to the POC. A policy dated 11/04/2024 titled “Managing Treatment Adherence or Prolonged Hospitalization or Vacation” indicated a Patient who is non-adherent to treatment schedule should be referred to social work who can utilize the Root Cause Analysis and Intervention Tool for Patients Not Meeting Quality Goals to assess the reason for the missed treatment. A clinical record review for Patient #2 evidenced a POC dated 06/24/2025 which indicated the Patient had 6 missed treatments in the past 90 days, and the MSW was to continue education with the Patient. The POC also indicated the MSW would identify and address barriers to permanent access and utilize focused interventions as needed. The Provider Rounding Note dated 04/17/2025 indicated the Patient’s access for in-center HD was a CVC which was placed 12/02/2024. The Treatment Sheets indicated the Patient ended treatment early on 06/24/2025 and was absent on 07/08/2025 and 07/12/2025. A Psychosocial Progress Note dated 07/09/2025 failed to address the progress to goals related to adherence to treatment and permanent access. On 07/26/2025, beginning at 11:37 AM, the MSW indicated it would be helpful to know what the reason was for why the Patient was not compliant with showing up for treatment but was not sure why the Patient missed treatment. The MSW indicated it would be more effective to meet with the Patient in person, but it was difficult to meet with the Patient in-person due to the MSW’s schedule and oversight at 2 facilities. The MSW indicated she knew the Patient was refusing permanent access but had not yet had not yet talked to the Patient to determine barriers and utilized any focused interventions related to permanent access.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 41135 Based on record review and interview, the facility failed to evidence the Quality Assurance Performance Improvement (QAPI) program reviewed the tuberculosis (TB) (a contagious disease mostly affecting the lungs) risk assessment and failed to evidence performance improvement actions for the incidence of central venous catheters (CVC) (a plastic tube inserted into a large vein) greater than 90 days. The findings included: A policy dated 04/05/2021 titled “Facility Tuberculosis Risk Assessment” indicated an annual risk assessment would be determine the facility’s risk classification and would be presented and reviewed at QAPI. A review of the facility’s QAPI program evidenced a QAPI meeting dated 12/16/2024 which indicated the facility had an increase in the incidence of patients with a CVC greater than 90 days and did not meet the goal of a 5% reduction. The QAPI program failed to evidence the performance improvement actions put in place to address the unmet goal. The QAPI program failed to evidence a review of the facility’s TB risk assessment. On 07/16/2025 beginning at 3:27 PM, the FA indicated there was no information in the QAPI program regarding TB and indicated there were no new performance improvement actions implemented to address the increased incidence of CVC greater than 90 days.”

“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: 51199 Based on record review and interview, the dialysis facility failed to follow policies and procedures relative to adverse event reporting in 1 of 1 clinical record review [Patient 5] of patients who required use of Emergency Medical Services [EMS] and failed to follow their policies and procedures relative to administering the correct hemodialysis [HD] (a process to clean the blood of a patient whose kidney’s do not work normally) prescription in 1 of 1 clinical record review [Patient 3] of a patient who had a central venous catheter [CVC] (catheter into vein) greater than 90 days. Findings include: 1. The policy dated 02/06/2023 and titled “Patient Safety Event Reporting and Documentation,” indicated that staff are required to report serious safety events, including hypotension, tachycardia, and pain to dialysis access sites to the facility Patient Safety Data Entry Site. 2. The policy dated 02/06/2023 and titled “Pre-Treatment Safety Checks Procedure,” indicated that patient care staff should verify the prescribed dialysate flow rate [DFR] matches the patient. 3. A policy dated 05/01/2023 and titled “Patient Assessment and Monitoring,” indicated that prescribed blood flow rate [BFR] should be achieved, or documented otherwise. The policy also indicated that DFR settings should be checked to ensure the prescribed flow is being delivered. 4. A review of the clinical record for Patient 5, included a note by RN 1, that on 05/13/2025, Patient 5 was experiencing persistent hypotension, tachycardia, and complained of throbbing pain to the arteriovenous fistula [AVF] (dialysis access). RN 1’s notes further indicated that EMS was called to the facility and Patient 5 was transported to the hospital at 1:03 PM. 5. During a review of Patient Safety and Adverse Events for the last 6 months on 07/15/2025, no adverse event for Patient 5 for the 05/13/2025 event was provided to surveyors. 6. During an interview, on 07/15/2025 beginning at 1:00 PM, the FA indicated that no adverse event report was available for Patient 5 from the date of 05/13/2025. The FA indicated that an adverse event report should be completed and reported when EMS is called to the facility for a patient. 7. During an interview, on 07/15/2025 beginning at 1:30 PM, RN 1 indicated that she did not create an Adverse Event Report and did not realize that an Adverse Event Report needed to be completed for this event. 8. A review of the clinical record for Patient 3, noted the following: A. A dialysis prescription, with a start date of 06/17/2025 and stop date of 06/16/2026, indicated a DFR of 800 and a BFR of 350. B. A Treatment Sheet, dated 06/21/2025, indicated the BFR administered to Patient 3 was initiated at a rate of 400. C. Treatment Sheets, dated 07/05/2025, 07/08/2025, and 07/12/2025, indicated the DFR administered to Patient 3 was at a rate of 500. D. During an interview, on 07/16/2025 beginning at 2:19 PM, RN 2 indicated that the DFR and BFR should be administered at the prescribed rate, and MD should be notified if administered differently. E. During an interview, on 07/15/2025 beginning at 1:30 PM, RN 1 indicated that DFR and BFR should be run at the prescribed rates, and any different rate should be accompanied by MD notification and new prescription order.”