Davita Lenexa Dialysis

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 50529 Based on observation, policy review, and staff interview, the End-Stage Renal Disease (ESRD) facility failed to ensure that direct care staff wore scrubs and closed-toe, slip-resistant shoes as required per facility policy. This deficient practice created a mode of cross-contamination, potentially spreading infection and poses a safety hazard to staff providing care. Findings Include: Review of a policy titled, “Personal Appearance Policy,” dated 01/09/25, showed that clinical teammates who work in dialysis facilities and who work in or around the treatment area are required to wear scrubs, whether company-branded or non-competitor scrubs, Sunday through Thursday. Teammates working in a facility, including facility administrators and support staff, must wear slip-resistant, closed-toe shoes. Observation of the treatment floor on 12/10/25 from 7:10 AM to 9:30 AM showed Staff H, Certified Clinical Hemodialysis Technician (CCHT), wore Adidas leggings, a Nike hoodie sweatshirt, and black Crocs with holes on the top and around the perimeter of the non-slip-resistant shoe. During an interview on 12/10/25, at 2:48 PM, Staff J, CCHT, stated that staff working on the treatment floor providing patient care should wear scrubs and refrain from wearing open-toed shoes. During an interview on 12/11/25 at 12:52 PM, Staff B, Manager of Clinical Services, stated that the expectation of patient care staff is to follow facility policy. Staff should be wearing scrubs and closed-toe shoes.”

“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: 50529 Based on observation, policy review, and interview, the End-Stage Renal Disease (ESRD) facility failed to ensure that staff disinfected all dialysis equipment and other surfaces that could be potentially contaminated with patients’ blood after a dialysis treatment. This deficient practice poses a potential mode of transmission for bloodborne pathogens, which could negatively impact the health and well-being of the 44 in-center patients who received dialysis treatment at the facility. Findings Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “ ...DISINFECTION ...Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area ...Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces ...Disinfection should be completed by using wiping motion with friction ...Sufficient disinfectant should be applied to surfaces are visibly wet ...Surfaces should be allowed to air dry in order to provide sufficient disinfection contact time ...At the end of each treatment, the dialysis station will be cleaned and disinfected ...Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g. control panel; top, front and sides of dialysis machine; touchscreens; countertops) ...The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system ...” An observation of the treatment floor on 12/10/25 at 8:41 AM showed Staff H, Certified Clinical Hemodialysis Technician (CCHT), performing the disinfection of the chair surface at station #1. Staff H failed to ensure the disinfection surface was visibly wet and free from all contaminants, as evidenced by a blood droplet on the footrest. Staff H failed to ensure sufficient disinfectant contact time by not allowing the surface to air dry and placed new patient supplies on the chair immediately after wiping with the disinfectant. During an interview on 12/10/25, at 2:35 PM, Staff J, Patient Care Technician (PCT), stated that staff are expected to clean the dialysis station by wiping it down with a 1:100 bleach rag that leaves disinfection surfaces visibly wet. All sides of the reclined chair, with both arms open, should be visibly wet from disinfectant and allowed to air dry. During an interview on 12/10/25 at 2:48 PM, Staff D, Registered Nurse (RN), stated that staff are expected to follow facility policy regarding the disinfection of dialysis stations. During an interview on December 11, 2025, at 12:52 PM, Staff B, Manager of Clinical Services, stated that care staff are expected to follow the facility’s policy, “Infection Control for Dialysis Facilities,” for instruction and guidance on the disinfection of dialysis stations, with monthly staff and patient audits being completed. During an interview on 12/11/25, at 1:09 PM, Staff A, Facility Administrator, stated that staff are expected to follow policy and procedures regarding the cleaning of patient stations. Due to changes in management, future staff meetings will incorporate more hands-on training and constructive criticism to ensure that policies and procedures are learned and understood by all staff.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 50529 Based on record review, facility policy review, and interview, nursing staff failed to assess and/or provide interventions to patients with abnormal blood pressure readings, out of parameter weights and blood flow rate (BFR) concerns. Nursing staff failed to assess patient treatments to ensure treatments were provided as ordered and that all assessments, findings, interventions, or variance in the prescribed treatment were documented in the medical record for 4 (Patient 1, 2, 3, and 6) of 4 sampled in-center hemodialysis patients and 2 (Patient 4 & 5) of 2 sampled peritoneal dialysis patients. This deficient practice increases the risk of changes in patient condition during dialysis treatments going unrecognized and unaddressed, which could negatively impact the health and well-being of the 50 patients who received treatment at this facility. Findings Include: 1. In-center Patients Review of a policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, showed that a licensed nurse must perform and document a nursing assessment that includes a verification of the patient’s blood flow rate (BFR) and review of documentation for accuracy and completion. The policy stated that the BFR must be monitored and documented every 30 minutes throughout the treatment and if the prescribed BFR is not being met the reason will be documented and the licensed nurse informed. The licensed nurse will assess the patient for any reported findings and document all findings, interventions, and patient response in the medical record. The policy went on to show the following requirements for blood pressure (BP) and fluid management monitoring and assessment: 1. Pre-treatment: Sitting and standing BP is required. If the patient is unable to stand the reason must be documented in the medical record or flowsheet. Any abnormal findings outside of parameters will be documented and immediately reported to the licensed nurse and the nurse will assess the patient prior to the initiation of dialysis. 2. Intradialytic (during treatment): Blood pressure will be monitored at a minimum of every 30 minutes. Abnormal findings will be documented and immediately reported to the licensed nurse. The nurse will assess the patient to determine if clinical interventions are needed. All findings, interventions, and patient responses will be documented in the medical record. 3. Post treatment: Any abnormal finds identified post treatment will be reported to the licensed nurse. The nurse will assess the patient prior to discharge. All findings, interventions, and patient responses will be documented in the medical record. The policy defined abnormal findings as: 1. Fluid status: any pre-treatment weight loss from last post weight; any post-treatment weight above or below 1 kilogram (kg) from the target weight. 2. Blood pressure: Pre-treatment and during treatment any systolic > 180 mm/Hg or < 90 mm/Hg and/or diastolic >/= 100 mm/Hg or < 50 mm/Hg. Post treatment systolic > 140 mm/Hg or < 90 mm/hg and/or diastolic > 90 mm/Hg or < 50 mm/Hg. Patient 1 A review of Patient 1’s orders revealed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min) and an estimated dry weight (EDW) of 74.6 kg. On 11/24/25 from 3:08 PM until 7:09 PM, Staff I, Certified Clinical Hemodialysis Technician (CCHT), Staff H, CCHT, and Staff G, Registered Nurse (RN), documented a BFR of 400 mL/min the entire treatment. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 11/26/25 at 1:31 PM until 4:56 PM, Staff G, RN, Staff D, RN, and Staff I, CCHT, documented a BFR of 350 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 11/26/25 at 6:08 PM, Staff D, RN, documented a “post dialysis weight” of 73.9 kg. Patient 1 left the clinic 1.5 kg under the prescribed target weight. Documentation failed to show evidence that the RN assessed and/or provide interventions to address out-of-parameter post weights and document them in the electronic medical record. On 11/28/25 at 2:02 PM until 3:02 PM, Staff G, RN, documented a BFR of 390 mL/min. From 3:32 PM until 5:50 PM, Staff H, CCHT, and Staff D, RN, documented a BFR of 390 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered On 12/01/25 at 1:52 PM until 5:50 PM, Staff D, RN, and Staff H, CCHT, documented a BFR of 400 mL/min the entire treatment. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 12/01/25 at 2:35 PM, Staff D, RN, documented BP as 84/58 and 126/102 at 4:35 PM. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. On 12/03/25 at 4:00 PM, Staff D, RN, documented a BFR of 400 mL/min. From 4:30 PM until the end of treatment at 7:41 PM, Staff D, RN, and Staff I, CCHT. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 12/03/25 at 6:31 PM, Staff D, RN, documented BP as 150/101. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. On 12/03/25 at 7:52 PM, Staff D, RN, documented a “post dialysis weight” of 73.5 kg. Patient 1 left the clinic 1.1 kg under the prescribed target weight. Documentation failed to show evidence that the RN assessed and/or provide interventions to address out-of-parameter post weights and document them in the electronic medical record. On 12/05/25 at 1:36 PM, Staff H, CCHT, documented a BFR of 400 mL/min. From 2:00 PM until the end of treatment at 5:37 PM, Staff D, RN, Staff G, RN, and Staff I, CCHT documented a BFR of 350 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 12/05/25 at 5:55 PM, Staff D, RN, documented a “post dialysis weight” of 72.8 kg. Patient 1 left the clinic 1.8 kg under the prescribed target weight. Documentation failed to show evidence that the RN failed to assess and/or provide interventions to address out-of-parameter post weights and document them in the electronic medical record. On 12/08/25 at 6:41 PM, Staff D, RN, documented a “post dialysis weight” of 73.2 kg. Patient 1 left the clinic 1.4 kg under the prescribed target weight. Documentation failed to show evidence that the RN assessed and/or provide interventions to address out-of-parameter post weights and document them in the electronic medical record. Patient 2 A review of Patient 2’s orders revealed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min) and an estimated dry weight (EDW) of 126.5 kg. On 11/24/25 at 2:02 PM, Staff K, PCT, documented a BFR of 0 mL/min. At 3:01 PM until the end of treatment at 4:46 PM, Staff K, PCT, Staff H, CCHT, and Staff G, RN documented a BFR of 300 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 11/26/25 at 11:30 AM, Staff D, RN, documented BP as 139/101. At 2:26 PM, Staff H, CCHT, documented BP as 161/138, 81/63 at 2:28 PM, 87/65 at 2:30 PM, and 124/102 at 2:52 PM. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. On 11/26/25 at 12:05 PM, Staff G, RN, documented a BFR of 305 mL/min. At 12:31 PM, Staff H, CCHT, documented a BFR of 250 mL/min. At 1:00 PM until 2:00 PM, Staff H, CCHT, documented a BFR of 280 mL/min. At 2:26 PM until the end of treatment at 2:52 PM, Staff H, CCHT, documented a BFR of 280 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered On 11/28/25 at 3:37 PM, Staff G, RN, documented BP as 144/113 and 183/131 at 3:38 PM. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. On 12/03/25 at 11:30 AM, Staff G, RN, documented BP as 136/110. At 4:01 PM, Staff D, RN, documented BP as 139/116. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. On 12/03/25 at 1:31 PM, Staff J, PCT, documented a BFR of 400 mL/min. At 2:31 PM, Staff G, RN, documented a BFR of 330 mL/min. At 3:01 PM until the end of treatment at 4:19 PM, Staff D, RN, and Staff I, CCHT, documented a BFR of 330 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 12/05/25 at 11:43 AM, Staff I, CCHT, documented a BFR of 400 mL/min. At 2:21 PM until the end of treatment at 3:13 PM, Staff G, RN, Staff J, PCT, and Staff D, RN, documented a BFR of 350 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 12/05/25 at 12:21 PM, Staff G, RN, documented BP as 157/101. At 2:40 PM, Staff G, RN, documented BP as 130/103. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. On 12/08/25 at 11:00 AM, Staff I, CCHT, documented a BFR of 300mL/min. At 11:20 AM, Staff D, RN, documented a BFR of 400 mL/min. At 11:40 AM, Staff D, RN, documented a BFR of 350 mL/min. At 12:01 PM until 12:20 PM, Staff I, CCHT, documented a BFR of 350 mL/min. At 12:41 PM until the end of treatment at 2:40 PM, Staff I, CCHT, documented a BFR of 300 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 12/08/25 at 11:31 AM, Staff D, RN, verified a documented pre-standing BP of 142/119. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. Patient 3 A review of Patient 3’s orders revealed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min), dialysate flow rate (DFR) of 600 mL/min, and an estimated dry weight (EDW) of 62.1 kg. On 11/24/25 at 3:01 PM, Staff G, RN, documented a BFR of 0 mL/min. At 3:30 PM, Staff G, RN, documented a BFR of 445 mL/min. At 4:00 PM until the end of treatment at 6:24 PM, Staff H, CCHT; Staff I, CCHT; and Staff G, RN documented a BFR of 350 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 11/24/25 at 2:56 PM, Staff G, RN, verified a documented pre-treatment standing BP as 209/113. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. On 11/24/25 at 6:34 PM, Staff G, RN, documented a “post dialysis weight” of 62.3 kg. Patient 3 left the clinic 1.1 kg over the prescribed target weight. Documentation failed to show evidence that the RN assessed and/or provide interventions to address out-of-parameter post weights and document them in the electronic medical record. On 11/26/25 at 2:39 PM until the end of treatment at 6:05 PM, Staff D, RN; Staff G, RN; and Staff I, CCHT documented a BFR of 400 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 11/26/25 at 3:01 PM, Staff G, RN, documented BP as 196/98. At 3:31 PM, Staff D, RN, documented BP as 209/96 and 187/116 at 4:01 PM. At 5:32 PM, Staff I, CCHT, documented BP as 179/106. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. On 12/05/25 at 2:48 PM until the end of treatment at 6:21 PM by Staff G, RN, and Staff I, CCHT, documented a DFR of 500 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 12/05/25 at 3:08 PM, Staff I, CCHT, documented BP as 107/27 and 85/75 at 5:37 PM. At 5:07 PM, Staff G, RN, documented BP as 89/22. At 5:18 PM, Staff I, CCHT, documented BP as 185/150, 215/142 at 5:37 PM, and 77/65 at 6:19 PM. Documentation failed to show evidence that the RN assessed and/or provided interventions to address the abnormal BP in the electronic medical record. The patient care staff failed to document that the RN was notified for the abnormal blood pressures in the electronic medical record, as per facility policy. On 12/08/25 at 2:49 PM, Staff K, PCT, documented a BFR of 215 mL/min. At 5:06 PM until 6:22 PM, Staff G, RN, and Staff J, PCT, documented a BFR of 415 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 12/08/25 at 3:08 PM, Staff K, PCT, documented BP as 175/102. At 5:06 PM, Staff J, PCT, documented BP as 183/89. At 5:36 PM, Staff G, RN, documented BP as 183/100. Documentation failed to show evidence that the RN assessed and/or provided interventions to address the abnormal BP in the electronic medical record. The patient care staff failed to document that the RN was contacted for the abnormal blood pressures in the electronic medical record, as per facility policy. On 12/08/25 at 6:34 PM, Staff G, RN, documented a “post dialysis weight” of 62.9 kg. Patient 3 left the clinic 1.7 kg over the prescribed target weight. Documentation failed to show evidence that the RN assessed and/or provided interventions to address out-of-parameter post weights and document them in the electronic medical record. Patient 6 Review of Patient 6’s orders showed a prescribed BFR of 450 mL/min and EDW of 101.5 kg. On 11/24/25 at 6:22 AM, Staff D, RN, verified a documented pre-treatment standing blood pressure as 160/127. Documentation failed to show evidence that the RN assessed and/or provided interventions to address BP in the electronic medical record. On 11/24/25 at 7:31 AM, Staff J, PCT, documented BP as 91/44. Documentation failed to show evidence that the RN assessed and/or provided interventions to address the abnormal BP in the electronic medical record. The patient care staff failed to document that the RN was notified of the abnormal blood pressures in the electronic medical record, as per facility policy. On 12/01/25 at 5:35 AM, Staff J, PCT, documented BP as 151/128. Documentation failed to show evidence that the RN assessed and/or provided interventions to address the abnormal BP in the electronic medical record. The patient care staff failed to document that the RN was notified of the abnormal blood pressures in the electronic medical record, as per facility policy. On 12/03/25 at 5:37 AM, Staff J, PCT, documented BP as 156/134. Documentation failed to show evidence that the RN assessed and/or provided interventions to address the abnormal BP in the electronic medical record. The patient care staff failed to document that the RN was notified of the abnormal blood pressures in the electronic medical record, as per facility policy. On 12/03/25 at 9:28 AM, Staff G, RN, verified the failure to document a post-treatment standing BP for an ambulatory patient as per facility policy. Documentation failed to show evidence that the RN assessed and/or provided interventions to address the abnormal BP in the electronic medical record. On 12/05/25 at 6:02 AM until the end of treatment at 9:09 AM, Staff I, CCHT, and Staff J, PCT, documented a BFR of 425 mL/min. Documentation failed to show evidence that an RN assessed and/or provided interventions to address BFR in the electronic medical record. The RN failed to document whether dialysis had been provided per the physician’s order and documented the rationale for not providing the prescribed BFR of 450 mL/min as ordered. On 12/05/25 at 8:32 AM, Staff J, PCT, documented BP as 68/44. Documentation failed to show evidence that the RN assessed and/or provided interventions to address the abnormal BP in the electronic medical record. The patient care staff failed to document that the RN was notified of the abnormal blood pressures in the electronic medical record, as per facility policy. On 12/08/25 at 5:34 AM, Staff J, PCT, documented BP as 146/102. Documentation failed to show evidence that the RN assessed and/or provided interventions to address the abnormal BP in the electronic medical record. The patient care staff failed to document that the RN was notified of the abnormal blood pressures in the electronic medical record, as per facility policy. On 12/08/25 9:20 AM, Staff D, RN, documented a “post dialysis weight” of 102.6 kg. Patient 6 left the clinic 1.1 kg over the prescribed target weight. Documentation failed to show evidence that the RN assessed and/or provided interventions to address out-of-parameter post weights and document them in the electronic medical record. 2. Peritoneal Patients Review of a peritoneal dialysis policy titled “Home Dialysis Monitoring and Ongoing Patient Education,” revised 10/20/23, showed that the facility will receive and review treatment information submitted by the patient and that the medical record will be updated to reflect any new information obtained. The facility team is responsible for monitoring the patient’s blood pressure and fluid management needs to identify and address any potential problems that may arise. Patient 4 A review of Patient 4’s orders revealed that Patient 4 was a patient undergoing peritoneal dialysis. On 11/25/25, Patient 4 documented a pre-treatment BP as 184/96. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. The patient failed to provide treatment records to the facility for review by an RN for treatments dated November 27, 2025, through November 29, 2025. On 11/30/25, Patient 4 documented a pre-treatment BP as 186/107. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/01/25, Patient 4 documented a pre-treatment sitting and standing BPs as 183/108 and 179/105. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/02/25, Patient 4 documented a pre-treatment BP as 193/123. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/03/25, Patient 4 documented a pre-treatment BP as 192/122. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/04/25, Patient 4 documented a pre-treatment BP as 189/117. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/05/25, Patient 4 documented a pre-treatment BP as 165/105. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/07/25, Patient 4 documented a pre-treatment BP as 156/105. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. Patient 5 A review of Patient 5’s orders revealed that Patient 5 was a patient undergoing peritoneal dialysis. On 12/02/25, Patient 5 documented a pre-treatment BP as 198/136. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/03/25, Patient 5 documented a pre-treatment BP as 174/114. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/06/25, Patient 5 documented a pre-treatment BP as 180/115. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/07/25, Patient 5 documented a pre-treatment BP as 182/119 and 177/115. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. On 12/09/25, Patient 5 documented a pre-treatment BP as 177/110. Documentation failed to show evidence that the RN reviewed treatment records when received to identify abnormal BP concerns, provide documentation re-education, and/or provide later interventions as per facility policy. During an interview on 12/10/25 at 2:35 PM, Staff J, PCT, stated that PCTs and CCHTs are to report nausea, vomiting, diarrhea, fever/chills, cramping, vitals outside of allowable parameters, changes made to treatment orders, behavior or baseline changes, and activities against medical advice (AMA). Staff J reports that the policy on patient monitoring and documentation was reviewed at a recent staff meeting. During an interview on 12/10/25 at 2:48 PM, Staff D, RN, stated that RNs are supposed to report any weight 1kg above or below the target weight, vitals outside of parameters, fluid gain, social issues, pain/falls, medication changes, and any changes in status or level of consciousness. All abnormal findings, changes, modifications to treatments, or orders should be reported to an RN or provider both verbally and documented electronically. During an interview on 12/11/25 at 12:52 PM, Staff B, Manager of Clinical Services, stated that it is the expectation of staff to follow facility policy regarding any vitals outside of parameters, changes to patient orders, notification of appropriate staff, and the reporting of any normal status changes.”