Renal Care Group - Liberal

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 22198 Based on observation, interview, and review of the March 2024 Emergency Crash Cart checklist, the facility failed to ensure all supplies ready for medical emergencies were not expired. This failure to have only viable emergency supplies on the crash cart has the potential to negatively affect all 10 Home Training patients at this facility. Findings Include: During an observation with the Home Training Registered Nurse Manager (HTRNM) on 03/04/24 at 2:45 PM the suction canister attached to the emergency suction machine on the top of the crash cart expired on 06/2017 and was available for immediate use. In the bottom section of the crash cart were four additional suction canisters that expired on 06/2017. A 1000 milliliter (ml) bag of normal saline expired on 01/2024. A review of the “Emergency Crash Cart Checklist” signed off as completed for the month of March, revealed there was no entry for intravenous fluids on the emergency crash cart checklist, and the suction canister had been checked off “yes” it had been checked on 03/02/24. During an interview on 03/04/24 at 2:45 PM with HTRNM confirmed the suction canisters and the IV fluid had expired and should have been removed. HTRNM confirmed that the emergency crash cart is checked off monthly and no one had checked the expiration date on the suction canisters, and the IV fluids should have been removed and replaced in January. During an interview on 03/06/24 at 11:00 AM the Facility Administrator confirmed the facility did not have a specific policy for outdates specific to emergency supplies, but the expectation is that like all supplies with an expiration date, they are removed from immediate use.”

“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: 22198 Based on observations, interviews, and policy review, the facility failed to ensure staff (Registered Nurse (RN) 2) wore gloves when touching supplies that were removed from a used dialysis station and ensure patient performed hand hygiene after assisting with holding their access site and removing their glove two of two patients (Patient (P)1) and P8) holding their access site. This has the potential to affect all 45 patients currently receiving dialysis at this facility. Findings Include: A review of the facility’s policy titled “Hand Hygiene” dated 11/06/23 revealed, “All staff, patients, ...must follow the same requirements for hand hygiene. ... Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids, such as when self-cannulating or holding access sites post-treatment to achieve hemostasis. To help ensure the prevention of cross-contamination to their family members or other patients, hand hygiene must be performed.” A review of the facility’s policy titled, “Dialysis Precautions” dated 01/04/12, revealed, “All employees will be educated regarding Dialysis Precautions, Standard Precautions, and bloodborne pathogens transmission, as mandated by OSHA [Occupational Safety and Health Administration] and recommended by the CDC [Centers for Disease Control and Prevention].” A review of the facility’s policy titled “Cleaning and Disinfecting the Dialysis Station” dated 09/05/23, revealed, “The dialysis station could become contaminated with blood and other body fluids during treatment.” 1. During an observation on 03/04/24 at 9:43 AM of Patient Care Technician (PCT) 2 discontinuing dialysis at Station 15 for P1, PCT2 donned a glove on P1’s hand to allow P1 to assist with achieving hemostasis. After hemostasis was achieved, P1 removed the glove, and without a reminder to wash hands and/or offering hand sanitizer, P1 left the dialysis unit without performing hand hygiene. During an interview on 03/04/24 at 10:12 AM PCT2 confirmed he/she had not offered hand sanitizer or reminded P1 to wash his/her hands after P1 removed a glove and before P1 left the dialysis unit. 2. During an observation of the breakdown before disinfecting the dialysis station on 03/04/24 at 10:15 AM, PCT2 removed a zip lock containing one yellow top test tube from the dialysis station’s Intravenous (IV) pole and walked over to Registered Nurse (RN) 2 at the nurse station. PCT2 handed the potentially contaminated bag to RN2 who took the potentially contaminated bag from the used dialysis station with his/her bare hands. During an interview on 03/04/24 at 10:15 AM, PCT2 stated the bag had been hanging on the IV pole of the dialysis station for the duration of the dialysis treatment. PCT2 stated the patient’s blood was supposed to be collected by him/her but he/she forgot to get the sample before removing the lines. During an interview on 03/04/24 at 10:20 AM RN2 was asked if he/she knew what the facility’s policy was related to wearing gloves when handling used equipment or supplies out of a used dialysis station, RN2 responded, “I am not sure of what our policy says”. During an interview on 03/04/24 at 10:30 AM the Facility Administrator confirmed the policy requires gloves should be worn when handling equipment or supplies from a used dialysis station. 3. During an observation on 03/04/24 at 10:50 AM of RN2 discontinuing dialysis at Station 12 for P8, RN2 donned a glove on P8’s hand to allow P8 to assist with achieving hemostasis. After hemostasis was achieved, P8 removed the glove, and without a reminder to wash hands and/or offering P8 hand sanitizer, P8 left the dialysis unit without performing hand hygiene. During an interview on 03/04/24 at 11:10 AM, RN2 confirmed he/she had not offered hand sanitizer or reminded P8 to wash his/her hands after P8 removed glove and before P8 left the dialysis unit. RN2 stated, “I knew he/she should have but he/she was in a hurry and gets upset”.”

“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: 22198 Based on observation, interviews, and policy review, the facility failed to ensure that each dialysis station was completely cleaned before starting the setup for new patients on two of two observation days. This had the potential to affect all 45 current incenter patients in this facility. Findings Include: Review of the facility’s policy titled, “Cleaning and Disinfecting the Dialysis Station”, dated 09/05/23, revealed, “All work surfaces shall be cleaned and disinfected with l:100 bleach solution after completion of procedures. Make the surface glisteningly wet and let air dry unless otherwise specified by the manufacturer. For patients dialyzing in a treatment area where multiple patients dialyze, the patient must completely vacate the dialysis station before the dialysis machine can be externally disinfected, allowed to dry, and set up for the next treatment.” 1. During an observation of the dialysis treatment floor on 03/04/24 at 10:15 AM during the process of cleaning and disinfecting dialysis Patient Care Technician (PCT) 2 failed to clean the television (TV), TV arm, or the countertop behind the dialysis chair and machine at Station 15. PCT2 went to the clean supply area to retrieve the supplies to set up dialysis Station 15. During an interview on 03/04/24 at 10:15 AM PCT2 confirmed he/she had not cleaned the dialysis wall box, the TV, the TV arm, or the countertop behind the dialysis chair and machine. PCT2 stated that he/she was going to clean them but needed to set up the dialysis station for the next patient. 2. During an observation of the dialysis treatment floor on 03/05/24 at 10:17 AM during the process of cleaning and disinfecting dialysis Station 3, PCT4 started setting up the cleaned dialysis machine with a bleach wipe on the arm of the dialysis station chair. PCT4 had not cleaned the dialysis chair, the blood pressure cuff, TV, the TV arm, or the countertop behind the dialysis chair and machine. During an interview on 03/04/24 at 10:17 AM PCT4 confirmed he/she had not cleaned the dialysis chair, wall box, the blood pressure cuff, the TV, the TV arm, or the countertop behind the dialysis chair and machine. PCT4 stated when he/she needs the station set up for another patient he/she usually cleans them later. When asked if he/she knew what their facility policy stated, PCT4 replied, “The cleaning should be done before setting up the machine.” During an interview on 03/06/24 at 9:00 AM the Facility Administrator confirmed the entire dialysis station should be cleaned before it is set up for the next patient”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 22198 Based on observation, interview, and policy review, the facility failed to ensure that one of two dialysis areas (Home Training Department) discarded medication that had removed expired medication from immediate use and discarded it. This had the potential to affect all 10 current Home Training patients at this facility. Findings Include: A review of the facility’s policy titled, “Medication Preparation and Administration” dated 06/02/23 revealed, “When preparing medications if the vial is not used immediately ...writing the date and time the vial was opened. ... Label any open multidose vial that is not used immediately and store the vial accordingly. ... Any open multi-dose vials must be discarded 28 days after opening or per manufacturer’s expiration date.” During an observation of the locked medication cupboard in the Home Training Department with the Home Training Registered Nurse Manager (HTRNM) on 03/04/24 at 2:45 PM a 30 milliliter vial of Heparin (medication used to prevent blood from clotting), was labeled as it was opened as 01/22/24. The date the bottle would expire after opening was 02/22/24. During an interview on 03/04/24 at 2:45 PM the HTRNM confirmed that was based on the manufacturer’s directions for use, or the facility policy, the medication expired 28 or 30 days after opening and should have been discarded from the available medication cupboard when it expired.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 22198 Based on observations, interviews, manufacturer’s directions for use (DFU), and policy review, the facility failed to 1) ensure equipment that two of four centrifuges had preventative maintenance (PM) or removed from service; 2) ensure the biohazardous storage was secured, and 3) ensure that expired supplies were taken out of immediate use areas for two of two observation days. This had the potential to affect all 45 incenter patients and the 10 home-training patients currently receiving dialysis services at this facility. Findings Include: A review of the facility’s policy titled, “Equipment Installation - Operation - Maintenance - Repair - And Disposal,” dated 07/06/21, revealed, “Intentional or accidental exclusion of equipment or systems from Fresenius’ approved electronic documentation system does not remove the requirement to maintain the equipment/system in accordance with this policy. ... Equipment that is removed from service for repair or maintenance must be tagged in accordance with Use of Hemodialysis and Ancillary Machine Repair/Return Tag Policy.” 1. a. Observation during the facility flash tour 03/04/24 from 8:00 AM to 8:30 AM revealed two centrifuges (a machine used to spin blood), one of the centrifuges, labeled “755,” in the laboratory room did not have a current PM sticker. During an interview on 03/04/24 at 8:15 AM Registered Nurse (RN)1 confirmed that the centrifuge (755) did not have a current PM sticker on it and would check with Biomedical to see if there was more paperwork on the PM. During an interview on 03/05/24 at 8:00 AM the Area Technical Operations Manager (ATOM) confirmed that the centrifuge in the laboratory room was not working and should have been removed from the laboratory room and sent back to the company. The ATOM confirmed failure to remove the centrifuge could lead to it being potentially used. b. Observation on 03/05/24 at 11:00 AM of the Isolation (ISO) Room (Station 17) revealed there was a dedicated centrifuge that indicated the last PM was completed on 03/31/22. The label indicated the next PM was due on 03/31/23. There was no other sticker to indicate that the PM had been done on 03/31/23. During an interview on 03/05/24, the Facility Administrator confirmed that the sticker indicated that the PM was due in 2023 but would check with Biomedical. During an interview on 03/06/24 at 8:00 AM the ATOM confirmed that the centrifuge was due for a PM on 03/31/23 and it had not been completed. The ATOM confirmed that the ISO room has not been used in over a year and the equipment maintenance was an oversight. 2. Observation during the facility flash on 03/04/24 from 8:00 AM to 8:30 AM revealed in the clean and sterile supply storage room there was an adjoining room with a biohazardous sticker on the door that was propped open with a wedge. Both clean biohazardous bins and used and sealed biohazardous bins were identified in the room. The biohazardous room door had a keypad lock. During an interview on 03/04/24 at 8:05 AM, RN1 confirmed that the biohazardous room should have been locked and was not. 3. a. Observation during the facility flash tour on 03/04/24 from 8:00 AM to 8:30 AM, revealed in the laboratory room in a cupboard filled with clean laboratory supplies ready for use there were five blood culture tubes. Four of the blood culture tubes expired on 07/22/23 and one expired on 07/19/23. During an interview on 03/04/24 at 8:15 AM RN1 confirmed that the five blood culture tubes had expired and should not be in the cabinet available for use. b. During an observation of the Water Treatment room on 03/04/24 at 12:31 PM, revealed an opened bottle of “Steri-Chek” reagent testing strips (for hard water testing) with no date as to when the bottle was opened. During an interview on 03/04/24 at 12:31 PM Patient Care Technician (PCT) 1 confirmed the bottle was opened and not labeled with the date it was opened. A review of the manufacturer’s DFU revealed that the product is no longer stable and is to be discarded “six months after opening.” c. During an observation on 03/05/24 at 10:56 AM on the dialysis treatment floor an opened bottle of “EXSEPT PLUS” (an antimicrobial skin cleanser) had no label as to when the “EXSEPT PLUS” had been opened. During an interview on 03/05/24 at 10:56 AM, PCT1 confirmed that the opened bottle of EXSEPT PLUS did not have a label to indicate the date it was opened. The manufacturer’s DFU on the label indicated; “Stable for 6[six] months after first opening.” d. During an observation on 03/05/24 at 11:10 AM in the medication prep room there were three opened bottles of a nutritional supplement called “Liqua-Cel” (concentrated protein) that were opened and not dated when the protein supplements were opened. There was a 100 milliliters (ml) bag of normal saline that expired on 02/2024 and was out of its original packaging. During an interview on 03/05/24 at 11:10 AM the Facility Administrator confirmed that the Liqua-Cel expires three months after opening per the manufacturer’s DFU on the Liqua-Cel label. The Facility Administrator confirmed there was no way to identify when the bottles had been opened to know the integrity of the three bottles of Liqua-Cel. The Facility Administrator confirmed that the 100 ml bag of normal saline expired on 2/24 but was not aware of the manufacturer’s change or limit in product stability if the original package had been opened. A review of the manufacturer’s DFU on the Liqua-Cel label revealed, “Use within 3 [sic] months of opening.” e. During an observation on 03/05/24 at 11:20 AM in the laboratory room on the counter and in a lower cabinet were six bottles of machine testing and calibrating solutions that were expired as follows: i. Two bottles of MesaLab Standard buffer Solution 7.00 pH (used for the calibration of conductivity meters) expired 01/25/24. ii. Two bottles of MyronLCompany TDS/Conductivity Standard solution, expired 09/02/23. iii. Two bottles of MesaLab Conductivity Standard Solution 14.0 M S/CM 25degrees Celsius expired on 11/5/23 and 12/13/23. During an interview on 03/05/24 at 11:20 AM, the Facility Administrator confirmed that the six bottles of solution were expired and should not be available for testing or calibrating.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 22198 Based on medical record reviews, interview, and policy reviews, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for 5 of 5 sampled in-center dialysis patients’ (Patient (P)1, P2, P3, P4, and P5). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 45 patients receiving in-center dialysis treatments at this facility. Findings Include: A review of the facility’s policy titled, “Patient Assessment and Monitoring,” dated 05/01/23, revealed, “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and that the prescribed flow is being delivered. A review of the facility’s policy titled, “Nursing Supervision and Delegation,” dated 11/06/23, revealed “Right Supervision and Evaluation” ... The RN [Registered Nurse] is able to monitor and follow up with the delegate at the completion of the task or activity. ... The RN is ready and available to intervene, as necessary to complete the task. ... Appropriate documentation of the task is completed. ... The registered nurse must evaluate each patient preferably within an hour or according to state requirements ... to: Review the accuracy and completeness of treatment and patient data. Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. ... The record must be reviewed for: Correct dialysate prescription was delivered.” Patient 1 A review of P1’s electronic medical record (EMR) “Order Summary Report”, revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (ml/min) and a Dialysate Flow Rate (DFR) rate of 800 ml/min. A review of two of six d “Treatment Sheet for Facility: Liberal” from 02/19/24 through 03/04/24 revealed the following: a. On 02/21/24 from 5:58 AM until 6:35 AM the BFR was documented as 300 ml/min. From 6:35 AM for the remainder of the treatment the BFR was documented as 350 ml/min without a documented rationale for the changes to the physician prescribed BFR. b. On 03/01/24 from 6:09 AM until 8:06 AM the BFR was documented at 350 ml/min, and again at 9:05 AM for the remainder of the treatment the BFR was documented at 350 ml/min, without a documented rationale for the changes to the physician prescribed BFR. Patient 2 A review of P2’s EMR “Order Summary Report,” revealed a prescribed BFR rate of 400 ml/min and a DFR rate of 800 ml/min. A review of one of six “Treatment Sheet for Facility: Liberal” from 02/05/24 through 03/04/24 revealed the following: On 03/04/24 from 10:39 AM until the end of treatment at 3:06 PM the BFR was documented at 350 ml/min without a documented rationale for the changes to the physician prescribed BFR. During an interview on 03/05/24 at 1:00 PM during medical record review, the Facility Administrator confirmed that the BFR’s were not run as prescribed by the physician and there was no additional documentation to justify or provide a rationale for the change in P1 and P2’s BFR. Patient 3 A review of P3’s EMR “Order Summary Report”, revealed a prescribed BFR rate of 400 ml/min and a DFR rate of auto 1.5 (600 ml/min). A review of two of six “Treatment Sheet for Facility: Liberal” from 02/05/24 through 03/04/24 revealed the following: a. On 02/27/24 from 10:47 AM until 12:00 PM, the BFR was documented as 410 ml/min DFR was 740 ml/min. From 12:00 PM until 1:03 PM, the BFR was 410 ml/min and the DFR was 740 ml/min. At 1:03 PM until the end of treatment at 2:15 PM, the DFR was run at 800 ml/min, without a documented rationale for the changes to the physician prescribed BFR or DFR. b. On 02/29/24 at 9:13 AM, the DFR was documented as 800 ml/min for a BFR of 400 ml/min. At 9:37 AM, the BFR was documented at 350 ml/min until 10:35 AM. At 10:35 AM, the BFR was documented as 300 ml/min and DFR at 500 ml/min until 9:12 AM, without a documented rationale for the changes to the physician’s prescribed BFR or DFR. Patient 4 A review of P4’s EMR “Order Summary Report”, revealed a prescribed BFR rate of 400 ml/min and a DFR of 600 ml/min. A review of six of the six “Treatment Sheet for Facility: Liberal” from 02/20/24 through 03/04/24 revealed the following: a. On 02/20/24 from 11:04 AM until 12:03 PM, the BFR was 300 ml/min and the DFR was 800 ml/min. At 11:04 AM the PCT documented “BFR at 400 as prescribed.” From 12:03 PM until 2:02 PM (end of treatment), the BFR was 350 ml/min and the DFR was 800 ml/min without a documented rationale for the changes to the physician’s prescribed BFR or DFR. b. On 02/22/24 from 10:58 AM for the entire dialysis treatment at 2:06 PM, the BFR was 300 ml/min without a documented rationale for the changes to the physician’s prescribed BFR. c. On 02/24/24 from 11:16 AM for the entire dialysis treatment until 2:31, PM the BFR was 300 ml/min without a documented rationale for the changes to the physician’s prescribed BFR. d. On 02/27/24 from 11:32 AM until 12:04 PM, the BFR was documented as 350 ml/min. From 12:34 PM until 2:06 PM, the end of dialysis treatment, the BFR was documented as 350 ml/min without a documented rationale for the changes to the physician’s prescribed BFR. e. On 02/29/24 from 11:07 AM until 12:04 PM, the DFR was documented as 800 ml/min. At 12:04 PM, the BFR was changed to 350 ml/min and the DFR remained at 800 ml/min until 12:30 PM. From 12:30 PM until 2:18 PM the end of the dialysis treatment, the BFR was 300 and the DFR was 800, without a documented rationale for the changes to the physician’s prescribed BFR or DFR. f. On 03/03/24 from 11:18 AM until the end of dialysis treatment at 2:21 PM, the BFR was documented as 300 ml/min. Patient 5 A review of P5’s EMR “Order Summary Report”, revealed a prescribed BFR rate of 350 ml/min and a DFR of 700 ml/min. A review of two of six “Treatment Sheet for Facility: Liberal” from 02/20/24 through 03/02/24 revealed the following: a. On 03/01/24 from 6:16 AM until the end of the dialysis treatment at 9:06 AM, the DFR was documented at 800 ml/min without a documented rationale for the changes to the physician’s prescribed DFR. b. On 03/02/24 from 9:30 Am until 9:47 AM, the BFR was documented as 300 ml/min. At 9:47 AM, the BFR was lowered to 200 ml/min without a documented rationale for the changes to the physician’s prescribed BFR. During an interview on 03/06/24 at 7:45 AM during a review of the medical record review findings for P3, P4, and P5, the Facility Administrator confirmed that the BFRs and DFRs were not run as prescribed by the physician and there was no additional documentation to justify or provide a rationale for the change in P3, P4 or P5’s BFR or DFR.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 22198 Based on interview, medical record review, and policy review, the facility failed to ensure 5 of 5 in-center sampled patients (Patient (P)1, P2, P3, P4, and P5) had blood pressures (BPs) monitored every 30 minutes as required and failed to follow policy when Patient Care Technician (PCT’s) failed to notify the Registered Nurse (RN) of BPs that fell outside of defined parameters in a total universe of eight. The failure to monitor patients’ BPs could potentially negatively affect a timely manner and could prevent all 45 in-center hemodialysis patients from receiving timely assessments for BP management. Findings Include: A review of the facility’s policy titled “Patient Assessment and Monitoring” dated 05/01/23 revealed, “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Recheck blood pressures after a drop that requires interventions such as administering normal saline. Reposition the electronic cuff or use a manual cuff for aberrant blood pressure readings. ‘Report to the nurse;’ Systolic blood pressures greater than 180 mm/Hg; Diastolic blood pressure greater than 100 mm/Hg; Blood Pressure less than or equal to 100 mm/Hg systolic.” Patient 1 A review of P1’s electronic medical record (EMR) revealed that P1 was admitted on 07/03/23 with a diagnosis of End State Renal Disease (ESRD). A review of the “Treatment Sheet for Facility: Liberal” from 02/19/24 through 03/04/24 revealed the following: a. On 02/19/24 at 7:33 AM, P1’s BP was 98/59 mm/Hg (millimeters of mercury), documented by the PCT, no documentation was found that the RN was notified. Thirty minutes later at 8:03 AM P1’s BP remained low at 91/53 mm/Hg and no documentation was found of the RN being notified. Thirty minutes later at 8:33 AM, P1’s BP remained low at 98/56 mm/Hg and no documentation was found of the RN being notified. b. On 02/21/24 at 5:58 AM, P1’s BP was 141/75 mm/Hg, and at 6:35 AM the next BP was a drop in systolic blood pressure (of 26 mm/Hg) recording the BP at 115/65. At 8:35 AM, P1’s BP dropped to 93/59 no documentation was found that the RN was notified. c. On 02/23/24 at 11:02 AM, P1’s BP was 96/52 mm/Hg. After the low BP between 11:02 AM and 11:43 AM (41 minutes), no BP was taken. d. On 02/26/24 at 7:33 AM, P1 had a BP taken by the RN of 97/56 mm/Hg. At 8:05 AM, the PCT documented the BP 81/56 mm/Hg and no documentation was found that the RN was notified. At 9:32 AM, P1’s BP was 92/44 mm/Hg and no documentation was found that the RN was notified. e. On 02/28/24 at 8:02 AM, P1 had a BP of 97/55 mm/Hg, by the PCT, and no documentation was found that the RN was notified. f. On 03/01/24 at 6:02 AM, P1’s BP was 157/89 and at 6:32 AM P1’s BP had a systolic drop of 31 mm/Hg at 7:32 AM and no documentation was found that the RN was notified. Patient 2 A review of P2’s EMR revealed that P2 was admitted on 02/18/23 with a diagnosis of ESRD. A review of the “Treatment Sheet for Facility: Liberal” from 02/05/24 through 03/04/24 revealed the following: a. On 02/05/24 at 11:32 AM, P2’s BP was 96/55 mm/Hg. At 12:32 PM P2’s BP remained low at 96/43. No documentation was found that the RN was notified of the low BPs. b. On 02/28/24 from 11:06 AM until 12:01 PM (55 minutes), no BP was recorded. There was no documentation for why the BP was not recorded every 30 minutes or that the RN was notified. c. On 03/04/24 at 10:39 AM, P2’s BP was 111/51 and 30 minutes later P2’s BP elevated 44 mmHg systolic and 20 mmHg diastolic recorded at 11:07 AM as 156/71 mm/Hg. At 11:30 AM, P2’s BP was 156/82 mm/Hg and at 12:12 PM, P2 had a drop in systolic pressure of 50 mm/Hg and a diastolic pressure of 39 mm/Hg recorded as 106/43 mm/Hg. At 12:53 PM, BP was 99/54 mm/Hg. At 1:00 PM, BP was 90/52 mm/Hg. At 1:33 PM, BP was 98/48 mm/Hg. At 1:48 PM, BP was 98/43 and at 2:03 PM BP was 97/53 mm/Hg and there was no documentation found that the RN was notified of the abnormal BP findings. Patient 3 A review of P3’s EMR revealed that P3 was admitted on 01/20/24 with a diagnosis of End State Renal Disease (ESRD). A review of the “Treatment Sheet for Facility: Liberal” from 02/20/24 through 03/02/24 revealed the following: a. On 02/20/24 for 48 minutes between 8:52 AM and 9:40 AM, no BP was taken. There was no justification or explanation for why the BP was not documented every 30 minutes per policy. b. On 02/27/24 at 10:01 AM, P3’s BP was 118/66 mm/Hg. Thirty minutes later the BP was elevated by 20 mm/Hg, reading 140/68 mm/Hg. At 2:02 PM, BP was recorded at 116/70 mm/Hg and at 2:15 PM there was a systolic elevation of 24 mm/Hg recorded at 140/72. No documentation was found that the RN was notified of the abnormal BP findings. c. On 02/29/24 between 9:37 AM and 10:35 AM (58 minutes), there was no BP recorded for P3. There was no justification or explanation for why the BP was not documented every 30 minutes per policy. Patient 4 A review of P4’s EMR revealed that P4 was admitted on 07/19/23 with a diagnosis of ESRD. A review of the “Treatment Sheet or Facility: Liberal” from 02/20/24 through 03/03/24 revealed the following: a. On 02/20/24 at 11:04 AM, P4’s BP was 158/69 mm/Hg. At 11:37 AM, P4 had a 23 mm/Hg systolic drop in blood pressure that was documented at 135/52. No documentation was found that the RN was notified of the abnormal BP findings. b. On 02/22/24 at 10:58 AM, P4’s BP was 119/51 and at 11:38 AM had a systolic drop of 31 mm/Hg recorded as 88/38 mm/Hg. No documentation was found that the RN was notified of the abnormal BP findings. c. On 02/24/24 at 11:16 PM, P4’s BP was 149/61 and at 11:36 AM had a 25 mm/Hg systolic drop in blood pressure recorded as 124/45. Between 11:36 AM and 12:02 PM, had a systolic increase of 22 mm/Hg and a diastolic increase of 23 mm/Hg recorded as 146/68 mm/Hg. Between 1:04 PM and 1:43 PM, P4 had a systolic increase of 23 mm/Hg going from 159/68 mm/Hg to 182/83 mm/Hg. No documentation was found that the RN was notified of the abnormal BP findings. d. On 02/27/24 between 12:34 PM and 1:04 PM, P4 had a 41 mm/Hg increase in systolic pressure and a 21 mm/Hg increase in diastolic pressure recorded as 144/65 mm/Hg and 185/86 mm/Hg. At 2:02 PM, P4’s BP was 205/77 mm/Hg, and the end-of-treatment pressure was recorded as 209/78 mm/Hg. No documentation was found that the RN was notified of the abnormal BP findings. Patient 5 A review of P5’s EMR revealed that P5 was admitted on 07/04/22 with a diagnosis of ESRD. A review of the “Treatment Sheet for Facility: Liberal” from 02/20/24 through 03/02/24 revealed the following: a. On 02/20/24 at 7:06 AM, P5’s BP was 158/75 mm/Hg at 7:33 AM had a 22 mm/Hg systolic drop to 136/67, and 30 minutes later at 8:09 AM had a systolic increase of 29 mm/Hg reading 165/71 mm/Hg. At 8:32 AM, BP was 160/76 and had a systolic drop of 22 mm/Hg at 9:04 AM to 138/75. No documentation was found that the RN was notified of the abnormal BP findings. b. On 02/22/24 at 7:31 AM, P5’s BP was 140/69 mm/Hg and had a systolic drop of 24 mm/Hg and a diastolic drop of 20 mm/HG at 8:03 AM recorded at 116/49 mm/Hg. At 8:03 AM, BP was 116/69 mm/Hg, and a systolic increase of 23 mm/Hg was recorded at 8:38 AM as 139/72 mm/Hg. No documentation was found that the RN was notified of the abnormal BP findings. c. On 02/24/24 at 7:03 AM, P5’s BP was 177/78 mm/Hg and had a systolic drop of 29 mm/Hg at 7:36 AM recorded as 148/74 mm/Hg. d. On 02/27/24 at 9:02 AM, P5’s BP was 116/58 mm/Hg and 30 minutes later had a 33 mm/Hg increase at 9:32 AM recorded as 149/75 mm/Hg. e. On 03/01/24 at 8:37 AM, P5’s BP was 152/77 mm/Hg and 29 minutes later had a 21 mm/Hg drop in systolic pressure at 9:06 AM recorded as 131/62 mm/Hg. No documentation was found that the RN was notified of the abnormal BP findings. During an interview on 03/06/24 at 7:45 AM and reviewing the findings for P3, P4, and P5, the Facility Administrator confirmed the above findings and stated that policy requires 30-minute BP checks not to exceed 45 minutes between checks. The Facility Administrator confirmed that abnormal readings below 100 or greater than 180 mm/Hg systolic must be reported to the RN, and the PCT did not document it in the records.”

“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: 22198 Based on observation, interviews, and policy review, the facility failed to ensure Registered Nurse (RN) 2 changed an access site dressing to assess hemostasis and provide a clean dry dressing before allowing the patient (P) 8 to leave during one of three survey days. This has the potential to affect all 45 current incenter patients receiving care at this facility. Findings Include: A review of the facility’s policy titled, “Post-treatment Fistula Needle Removal” dated 07/06/21 revealed, “ Once hemostasis is achieved: Remove the gauze, ... Place Band-Aid, adhesive dressing or gauze dressing secured with clean tape. During an observation on 03/04/24 at 10:50 AM, RN2 discontinued dialysis at Station 12 for P8. After the needles were removed, P8 held his/her access site to help with achieving hemostasis (stop the bleeding). Without removing the pressure dressing or checking to ensure the bleeding stopped, RN2 applied more gauze and additional tape to the upper and lower needle sites and allowed P8 to leave. During an interview on 03/04/24 at 11:10 AM, RN2 confirmed he/she had not changed the pressure dressing or applied a clean dressing. RN2 stated, “I should have” but he/she was in a hurry and gets upset.””