Davita Wyandotte County Dialysis

“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: 50873 Based on observation, policy review, and interview, the facility failed to ensure that patients washed their hands and/or access sites (point of needle entry into the bloodstream) before and after dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to perform these functions naturally) treatment on 3 of 4 observation days. This deficient practice provided a mode for contamination with the potential spread of infectious pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 59 patients that received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” revised 4/2023, showed, “ ...Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis b. Perform hand hygiene after treatment before leaving treatment area...” Review of a policy titled, “Post Dialysis Vascular Access Care: Fistula/Graft using Safety Fistula Needles,” revised 04/2023, showed, “ ...When the patient holds their cannulation sites, the patient will be offered gloves and perform hand hygiene when completed ...Gloves and hand hygiene protects patient and family members from cross contamination ...” During an observation on 07/07/25 at 11:46 AM at station #18, Patient Care Technician (PCT) 7, failed to ensure hand hygiene was performed after the patient held sites and removed glove. During an observation on 07/09/25 at 10:36 AM at station #16, Registered Nurse (RN) 5 failed to enforce or encourage the patient to wash his/her access upon arrival to clinic and prior to being escorted to the dialysis station. During an observation on 07/09/25 at 12:45 PM at station #21, RN 3 and RN 5, failed to ensure that Patient #2 performed hand hygiene post treatment after holding the access sites. During an observation on 07/10/25 at 9:08 AM at station #3, Staff N, PCT, failed to ensure the patient performed hand hygiene after holding access sites. During an interview on 07/09/25 at 12:25 PM, RN 3 confirmed that staff had not encouraged patients to wash their access site prior to dialysis treatment and did not provide or encourage hand hygiene post treatment after holding access sites. Staff H stated that policy requires staff to ensure or encourage patients to perform hand and access hygiene and failure to do so could potentially lead to cross contamination. During an interview on 07/10/25 at 10:33 AM, the Facility Administrator stated that it is the expectation of staff to ensure that patients wash their access sites upon arrival and prior to the initiation of dialysis, but also to perform hand hygiene after holding sites. Failure to follow policy and procedure could potentially lead to cross contamination. During an interview on 07/10/25 at 11:10 AM, the Medical Director confirmed that patients should be washing access sites upon arrival on to the treatment floor and performing hand hygiene after holding sites. The expectation is for staff to follow facility policy for infection control and hand hygiene.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 50873 Based on observation, policy review, and interview, the facility failed to store gloves in a manner to ensure the prevention of cross contamination from blood products or other bodily fluids on 3 of 4 observation days. This deficient practice provided a mode for contamination with the potential spread of infectious pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 59 patients that received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed that if dialysis delivery systems have computer/keyboards mounted on top, the computer and keyboard are considered “dirty” (possibly contaminated with infectious organisms) and that disposable gloves and alcohol-based hand sanitizer containers may not be stored on counters where terminals are mounted. During an observation on 07/07/25 at 12:09 PM, two boxes of opened gloves were stored on the wall counter behind stations # 4,12, 17, and 18. During an observation on 07/08/25 at 2:43 PM, three open boxes of gloves were stored on the wall counter behind station #14. During an observation on 07/09/25 at 12:25 PM, three open boxes of gloves were stored on the wall counter behind station #14. During an interview on 07/09/25 at 12:25 PM, Registered Nurse (RN) 3 confirmed that there were three open boxes of gloves being stored on the counter in dialysis station #14 and that this is not the expectation. It is facility policy to not store things in the patient station due to the possibility of contamination. During an interview on 07/10/25 at 10:33 AM, the Facility Administrator (FA), stated it is the expectation of staff to follow infection control policies to prevent cross-contamination. Clean supplies should not be stored in the dialysis station on the wall behind the machine. During an interview on 07/10/25 at 11:10 AM, the Medical Director (MD), confirmed that it is the expectation that staff follow facility policy to prevent cross-contamination and the potential spread of infectious bacteria.”

“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: 50873 Based on interview, record review, and facility policy review, the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 5 (Patients #1, #2, #3, #4, and #5) of 7 sampled patients. Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 59 patients who received dialysis treatments at the facility. Findings include: A facility policy titled, “Medication Policy,” revised 10/2023, showed, “...9. Medications are administered as prescribed and then documented in the patient’s medical record...10. Prior to administration of medication, verify physician or NPP [non-physician provider] order...” A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised in 04/2024, showed, “...3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation or as allowable by state law. Prescription components include but are not necessarily limited to...d. UFR [ultrafiltration rate] and Max UFR...f. Blood flow rate [BFR]...j. Heparinization (intradialytic infusion setting)...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT [patient care technician] or licensed nurse includes: a. Vital signs monitoring... are completed at least every thirty (30) minutes...b. At a minimum, obtain and document the following:..blood and dialysate flows, arterial and venous pressures...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed...” 1. Patient #1’s “Treatment Details Report,” dated 06/25/25, showed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min). Patient #1’s BFR was documented as 400 mL/min from 1:58 PM until 5:02 PM. There was no rationale documented regarding why the prescribed BFR was not achieved. Patient #1’s “Treatment Details Report,” dated 06/27/25, showed a prescribed BFR of 450 mL/min. Patient #1’s BFR was documented as 400 mL/min from 2:02 PM until 5:02 PM. There was no rationale documented regarding why the prescribed BFR was not achieved. During an interview on 07/09/25 at 10:06 AM, the Facility Administrator confirmed the expectation that a rationale would be documented if the treatment BFR deviated from the ordered BFR. During an interview on 07/10/25 at 11:54 AM, Patient Care Technician (PCT) #6, confirmed Patient #1 received the dose of heparin charted, and it was charted based on the dose the machine indicated. PCT #6 stated she was not sure why the patient received more heparin than ordered. PCT #6 stated she meant to notify the registered nurse but forgot because it was busy as the issue occurred during shift change. 2. Patient #2’s “Treatment Details Report,” dated 06/24/25, showed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #2’s BFR was documented as 450 mL/min from 6:00 AM until 8:02 AM. There was no rationale documented regarding why the treatment deviated from the prescription. Patient #2’s “Treatment Details Report,” dated 06/26/25, showed a prescribed BFR of 400 mL/min. Patient #2’s BFR was documented as 450 mL/min from 6:19 AM until 10:31 AM. There was no rationale documented regarding why the treatment deviated from the prescription. Patient #2’s “Treatment Details Report,” dated 06/26/25, showed a prescribed maximum ultrafiltration rate (UFR) of 13 milliliters per kilogram per hour (mL/kg/hr). Patient #2’s UFR was documented as 13.8 mL/kg/hr. There was no rationale documented regarding why the treatment deviated from the prescription. Patient #2’s “Treatment Details Report,” dated 07/01/25, showed a prescribed BFR of 400 mL/min. Patient #2’s BFR was documented as 450 mL/min from 5:41 AM until 9:31 AM. There was no rationale documented regarding why the treatment deviated from the prescription. Patient #2’s undated “Patient Summary Report” showed an active order for intravenous (IV) heparin 600 units per hour (units/hr) at every dialysis treatment, with a stop time of 60 minutes before the end of dialysis. Patient #2’s “Treatment Details Report,” dated 07/03/25, showed a heparin infusion started at 6:55 AM and ended at 9:03 AM, a period of two hours and eight minutes, with a total dose infused of 1,650 units. During an interview on 07/09/25 at 11:10 AM, the Facility Administrator (FA) confirmed Patient #2 should have received 1200 units of heparin instead of 1650 units as documented, based on the ordered infusion rate and run time. The FA stated Patient #2 arrived late for treatment, the heparin pump was not adjusted for the shortened treatment time, and the documentation showed the patient received too much heparin. During an interview on 07/10/2025 at 11:54 AM, Patient Care Technician (PCT) #6 acknowledged she missed that Patient #2’s BFR was running incorrectly on 07/01/2025 at 7:32 AM and 8:02 AM. 3. Patient #3’s undated “Patient Summary Report” showed an active order for intravenous (IV) heparin 600 units per hour (units/hr) at every dialysis treatment, to run for the entire treatment. Patient #3’s “Treatment Details Report,” dated 06/25/25, showed a heparin infusion started at 6:45 AM, ended at 9:14 AM, and the patient’s dialysis treatment continued until 10:16 AM. Patient #3’s “Treatment Details Report,” dated 06/26/25 showed a heparin infusion started at 6:03 AM, ended at 7:14 AM, and the patient’s dialysis treatment continued until 8:04 AM. The report showed the patient’s prescribed maximum ultrafiltration rate (UFR) was 13 milliliters per kilogram per hour (mL/kg/hr) but the actual treatment UFR was 14.6 mL/kg/hr. There was no documentation to explain the deviation from the prescribed maximum UFR. Patient #3’s “Treatment Details Report,” dated 06/27/25, showed a heparin infusion started at 7:16 AM and ended at 9:44 AM, with a total dose given of 1,200 units. The “Intradialytic Vitals Stat Line” section of the report showed the heparin pump was stopped at 8:46 AM and the treatment ended at 9:44 AM. Patient #3’s “Treatment Details Report,” dated 06/30/2025, showed a heparin infusion started at 7:53 AM, ended at 10:29 AM, and the patient’s dialysis treatment continued until 11:30 AM. The report showed the total dose of heparin given was 2,100 units. Patient #3’s “Treatment Details Report,” dated 07/02/25, showed heparin infusion was not given, due to, “Reason: Missed Administration.” The “Intradialytic Vitals Stat Line” section of the report showed the patient’s dialysis treatment started at 7:38 AM, ended at 10:10 AM, and the heparin pump was stopped at 9:32 AM. During an interview on 07/08/25 at 2:03 PM, the Facility Administrator (FA) confirmed the following in 06/25/25 and 06/26/25, Patient #3’s heparin infusion was stopped before the end of treatment and it was ordered for the entire treatment, so the infusions were stopped early. The FA confirmed on 06/27/2025, documentation was conflicting regarding the actual time Patient #3’s heparin pump was stopped. The FA stated if the patient’s heparin infusion ran for the entire two hours and 28 minutes of the treatment, the total dose given should have been about 1,500 units based on the ordered rate, and the 2,100 units documented was more than the patient should have received. The FA confirmed on 06/30/20205, Patient #3’s heparin pump was stopped earlier than prescribed, and if the heparin ran for two hours and 36 minutes, the total dose should have been about 1,500 units based on the ordered rate, and the 2,100 units documented was more than the patient should have received. The FA confirmed on 07/02/2025, documentation was conflicting, and it was unclear whether Patient #3’s heparin was given. 4. Patient #4’s undated “Patient Summary Report,” showed an active order for intravenous (IV) heparin 600 units per hour (units/hr) at every dialysis treatment, with a stop time of 60 minutes before the end of dialysis. Patient #4’s “Treatment Details Report,” dated 06/23/25, showed a heparin infusion started at 12:19 PM and ended at 1:49 PM, a period of one hour and 30 minutes. The report showed the total dose of heparin given was 1,300 units. Patient #4’s “Treatment Details Report,” dated 06/25/25, showed a heparin infusion started at 1:51 PM and ended at 5:12 PM. The “Intradialytic Vitals Stat Line” section of the report showed that the heparin pump was stopped at 4:45 PM, and the treatment ended at 5:12 PM. Patient #4’s “Treatment Details Report,” dated 07/04/25, showed a heparin infusion started at 6:11 AM and ended at 9:38 AM. The “Intradialytic Vitals State Line” section of the report showed the heparin pump was stopped at 8:30 AM, and the treatment ended at 9:37 AM. During an interview on 07/09/25 at 2:12 PM, the Facility Administrator (FA) confirmed the following on 06/23/25, based on the prescribed heparin infusion rate and time it ran, Patient #3 should have received a total dose of 900 units, not 1,300 as documented. The FA confirmed on 06/25/25, based on the prescribed heparin infusion rate and time it ran, Patient #3 should have received closer to 1,800 units, not the 1,500 units documented. The FA confirmed on 07/04/25, documentation was conflicting and made it difficult to determine if Patient #3 received heparin as ordered. 5. Patient #5’s undated “Patient Summary Report,” showed an active order for intravenous (IV) heparin 600 units per hour (units/hr) at every dialysis treatment, with a stop time of 60 minutes before the end of dialysis. Patient #5’s “Treatment Details Report,” dated 06/24/25, showed the patient’s prescribed maximum ultrafiltration rate (UFR) was 16 milliliters per kilogram per hour (mL/kg/hr) but the actual treatment UFR was 16.8 mL/kg/hr. There was no documentation to explain this deviation from the prescribed maximum UFR. Patient #5’s “Treatment Details Report,” dated 06/26/25, showed the patient’s prescribed maximum UFR was 16 mL/kg/hr but the actual treatment UFR was 17.4 mL/kg/hr. There was no documentation to explain this deviation from the prescribed maximum UFR. Patient #5’s “Treatment Details Report,” dated 07/03/25, showed the patient’s treatment time was three hours and 15 minutes and a heparin infusion started at 5:46 AM and ended at 7:59 AM, with a total dose given of 1,700 units. During an interview on 07/08/25 at 2:03 PM, the Facility Administrator (FA) stated that staff were following the protocol for heparin administration, not the orders. The FA stated the facility’s expectation was that staff confirm and follow the orders when administering medication. During an interview on 07/09/25 at 2:12 PM, the Facility Administrator (FA) confirmed that on 07/03/2025, Patient #5 should have received heparin at 600 units per hour for two hours and 15 minutes, for a total dose of 1,350 units. The FA confirmed documentation showed the total dose given was 1700 units, which was more than the ordered amount. During an interview on 07/10/25 at 11:11 AM, the Medical Director confirmed the facility’s expectation for dialysis treatments was staff should follow the dialysis prescription including the BFR, maximum UFR, and heparin administration, including heparin pumps, and that documentation should be per protocol. During an interview on 07/10/25 at 11:54 AM, Patient Care Technician (PCT) #6 stated BFRs were checked every 30 minutes with patients’ vital signs. PCT #6 stated if a BFR was at the incorrect value, a PCT would first check the chart to see if anyone changed the rate, and if not, the PCT would find the staff member who entered the value incorrectly so they could chart what they did. PCT #6 stated changes to the BFR needed to be documented. PCT #6 stated staff were trained to stop all heparin pumps one hour before the end of treatment if a patient had a fistula. PCT #6 confirmed she was taught to check heparin orders prior to administration.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 50873 Based on interview, record review, and facility policy review, the facility failed to adequately respond to adverse patient events for 5 (Patients #2, 3, 4, 6, and 7) of 7 sampled patients. Findings include: A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, showed, “Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record...Blood Pressure-Intradialytic: Systolic [the top number of the blood pressure reading] greater than 180 mm/Hg or less than 90 mm/Hg [millimeter of mercury] Diastolic [the bottom number of the blood pressure reading] greater than or equal to 100 mm/Hg or less than 50 mm/Hg...” An undated, untitled document showed that any interdialytic (during dialysis treatment) findings that are out of parameter will be communicated to the RN and the RN will notify the provider. Examples given were a systolic blood pressure >180 or < 90; a diastolic blood pressure > 100 or < 50; a heart rate > 100 or < 60; and signs and symptoms of low blood pressure, nausea, vomiting, cold and clammy skin, rapid breathing, and/or yawning. 1. Patient #2’s “Treatment Details Report” dated 07/05/25 at 9:01 AM, showed that Patient Care Technician (PCT) #10 documented, “the patient stated they were feeling pain under their arm and the RN was notified.” Further review failed to show documented evidence that an RN assessed the patient’s complaint of pain. The “Treatment Nurse Assessment” documented by RN #3 showed, “patient left in stable condition; voiced no complaints or concerns upon leaving tx [treatment] floor.” There was no documented evidence RN #3 addressed the patient’s complaint of pain under their arm. During an interview on 07/09/25 at 11:10 AM, the Facility Administrator (FA) confirmed there was no evidence of any RN follow up of Patient #2’s complaint of pain. The FA stated the facility expectation was for the RN to follow up and assess the patient for any complaints. Patient #2’s “Treatment Details Report” dated 06/28/25, showed PCT #7 documented the patient’s blood pressure (BP) at 111/45 mmHg at 6:08 AM, and 102/47 mmHg at 6:32 AM, and PCT #6 documented the patient’s BP at 101/48 mmHg at 7:02 AM. Further review failed to show evidence of RN notification of the low diastolic BP readings. During an interview on 07/10/25 at 11:54 AM, PCT #6 stated that if there were vital sign readings out of range, they should notify the RN and document the notification. PCT #6 confirmed she did not notify the RN of out-of-range vital signs for Patient #2 on 06/28/2025. 2. Patient #3’s “Treatment Details Report” dated 06/25/25 at 7:02 AM, showed that Patient Care Technician (PCT) #8 documented a blood pressure (BP) reading of 139/105 millimeters of mercury (mmHg). Further review failed to show evidence of registered nurse (RN) notification of the elevated diastolic BP reading. Patient #3’s “Treatment Details Report” dated 06/27/25 at 9:01 AM, showed that an RN was notified of a BP 89/49 mmHg. Further review failed to show evidence that the RN notificed the provider of the low BP reading. Patient #3’s “Treatment Details Report” dated 07/02/25 at 9:32 AM, showed that PCT #7 documented the patient’s BP reading at 72/43 mmHg. An additional note was documented by RN #3 at 9:34 AM that indicated the PCT notified the nurse of the low BP and the RN had completed an assessment. Further review failed to show documented evidence that the RN notified the provider of the low BP reading. 3. Patient #4’s “Treatment Details Report” dated 06/25/25, showed that PCT #11 documented the patient’s BP at 85/49 mmHg at 4:34 PM, and 91/30 mmHg at 5:12 PM, and PCT #8 documented the patient’s BP at 80/52 mmHg at 4:45 PM. Further review failed to show documented evidence of registered RN notification of the low BP readings. Patient #4’s “Treatment Details Report” dated 06/27/25 rat 2:52 PM, showed that PCT #10 documented the patient’s BP at 129/110 mmHg with a heart rate of 49 beats per minute (BPM). Further review failed to show documented evidence of RN notification of the elevated diastolic BP and low heart rate. Patient #4’s “Treatment Details Report” dated 07/02/25 at 1:20 PM, showed that PCT #11 documented the patient’s BP at 200/80 mmHg. Further review failed to show documented evidence of RN notification of the elevated systolic BP. Further review showed that RN #3 documented the patient’s BP at 190/97 mmHg at 12:34 PM and failed to show documented evidence of provider notification of the elevated systolic BP. Patient #4’s “Treatment Details Report” dated 07/04/25 rat 9:00 AM, showed that PCT #8 documented the patient’s heart rate at 48 BPM. Further review failed to show documented evidence of RN notification of the low heart rate. 4. Patient #6’s “Treatment Details Report” dated 06/23/25, showed Patient Care Technician (PCT) #8 documented the patient’s BP at 85/54 mmHg at 10:34 AM, 79/52 mmHg at 10:41 AM, 82/52 mmHg at 10:51 AM, and 69/49 mmHg at 11:04 AM. Further review failed to show documented evidence of RN notification of the low BP. Patient #6’s “Treatment Details Report” dated 06/27/2025 at 10:34 AM, showed that revealed that RN #12 documented the patient’s BP at 69/40 mmHg with a complaint of lightheadedness. Further review showed that RN #12 turned the ultrafiltration off and gave the patient 100 milliliters (ml) of normal saline. At 10:37 AM, RN #12 documented Patient #6’s BP at 77/43 mmHg and noted that the ultrafiltration remained off but the patient refused any other interventions. At 10:51 AM, RN #12 documented the patient’s BP at 99/55 mmHg and noted that the patient was asymptomatic and the ultrafiltration remained off for “continued BP support.” At 11:05 AM, RN #12 documented the patient’s BP at 121/67 mmHg and indicated the BP was improved, the patient was asymptomatic, and that the ultrafiltration was discussed with the patient and turned back on. Further review failed to show documented evidence that RN #12 notified the provider of the low BP or of the patient complaints of lightheadedness. During an interview on 07/08/25 at 10:27 AM, the Facility Administrator confirmed that while the RN completed multiple interventions and the patient’s BP improved, the provider should have been notified of Patient #6’s BP per the facility’s reporting parameters. 5. Patient #7’s “Treatment Details Report” dated 06/25/25, showed that PCT #11 documented the patient’s blood pressure (BP) at 88/52 mmHg at 12:32 PM, 88/44 mmHg at 12:33 PM, 79/43 mmHg at 12:34 PM, 93/46 mmHg at 1:02 PM, 89/39 mmHg at 1:17 PM, 93/43 mmHg at 1:23 PM, 92/46 mmHg at 1:37 PM and 106/48 mmHg at 2:32 PM. Further review showed that PCT #8 documented the patient’s BP at 93/45 mmHg at 12:45 PM and 87/42 mmHg at 1:32 PM. Further review failed to show documented evidence of registered nurse (RN) notification of the low BP readings. Patient #7’s “Treatment Details Report” dated 06/27/25 at 12:33 PM showed that PCT #10 documented the patient’s BP at 101/40 mmHg. Further review failed to show documented evidence of RN notification of the low diastolic BP reading. Patient #7’s “Treatment Details Report” dated 06/30/25 at 1:05 PM showed that RN #3 documented the patient’s BP at 94/47 mmHg. Further review failed to show documented evidence RN #3 notified the provider of the low diastolic BP. Patient #7’s “Treatment Details Report” dated 07/02/25, showed that PCT #7 documented the patient’s BP at 100/34 mmHg at 1:02 PM, 100/46 mmHg at 2:13 PM, and 101/45 mmHg at 2:33 PM. Further review failed to show documented evidence of RN notification of the low diastolic BP readings. Patient #7’s “Treatment Details Report” dated 07/04/25, showed PCT #8 documented the patient’s BP at 89/47 mmHg at 12:02 PM, 101/45 mmHg at 12:03 PM, 100/46 mmHg at 12:32 PM, 102/48 mmHg at 1:02 PM, 99/45 mmHg at 2:02 PM, 125/42 mmHg at 2:32 PM, and 93/44 mmHg at 2:47 PM. Further review failed to show documented evidence of RN notification of the low diastolic BP readings. During an interview on 07/08/25 at 10:00 AM, the Facility Administrator (FA) stated that during dialysis treatments the patients’ vital signs were recorded every 30 minutes, prior to treatment, and after treatment to include sitting and standing BPs if the patient was able. Per the FA, PCTs were expected to report any systolic blood pressure (SBP) greater than 180 mmHg and diastolic blood pressure (DBP) less than 50 mmHg prior to initiating treatment to the RN. According to the FA, the registered nurse (RN) was then expected to do an assessment and contact the provider. The FA clarified that RNs were required to assess patient pre-treatment for SBP greater than 180 mmHg and less than 90 mmHg , DBP greater than 90 mmHg and less than 50 mmHg, and for heart rates above 100 mmHg or less than 60 mmHg. During an interview on 07/08/25 at 11:38 AM, the FA confirmed the facility expectation for the PCTs to notify RNs of diastolic BP readings below 50. During a follow-up interview on 07/08/25 at 1:05 PM, the FA confirmed the facility expectation was for RNs to notify the provider for BP readings that were outside the parameters per the facility’s reporting parameters. During an interview on 07/10/25 at 11:11 AM, the Medical Director confirmed the facility expectation that staff notify the RNs and providers of out-of-range vital signs per facility protocol and parameters.”