Davita Dialysis Center of Hutchinson

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 43397 Based on observation, policy review, and interview, the facility failed to ensure staff followed the Conditions for Coverage (CfC) requirement for infection control in a dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) facility. Failure to follow infection control CfC provided a mode of cross contamination with the potential spread of pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 86 patients who received dialysis treatments at the facility. Findings Include: 1. The facility failed to ensure staff provided a sanitary environment to minimize the transmission of infectious agents. (Refer to Tag V0111) 2. The facility failed to ensure staff wore disposable gloves when caring for a patient or touching a patient’s equipment and that staff failed to perform appropriate hand hygiene before and after glove removal. (Refer to Tag V0113) 3. The facility failed to ensure that a hand washing sink on the treatment floor was in working order for the availability of patients and staff. (Refer to Tag V0114) 4. The facility failed to ensure staff wore face shields while performing procedures during which contact with blood might occur. (Refer to Tag V0115) 5. The facility failed to ensure that bio-hazardous medical waste (blood or other bodily fluids) was contained in a manner to prevent spills/leaks before transporting waste across the dialysis treatment floor. (Refer to Tag V0121) 6. The facility failed to ensure staff followed facility policy and procedure for the cleaning and disinfecting of surfaces and equipment to prevent transmission of infectious pathogens. (Refer to Tag V0122) 7. The facility failed to ensure staff followed facility policy and procedure for the care of a Central Venous Catheter (CVC) access to prevent transmission of infection. (Refer to Tag V0147)”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 43397 Based on observation, policy review, and interview, the facility failed to provide a sanitary environment that meets the Standard Precautions as required to prevent transmission of infectious agents in a dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) setting in which blood, bodily fluids, secretions, and excretions pose a risk for infection to patients and staff. The failure to maintain a sanitary environment provided a mode of cross contamination with the potential spread of pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 86 patients who received dialysis treatments at the facility. Findings Include: Review of a facility policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “ ...All teammates ...will perform hand hygiene ...prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, after interacting with wall boxes ....between patients even if the contact is casual, before touching clean areas such as supplies, supply cart and chairside keyboard/mouse ...Patients and caregivers will be encouraged to wash their hands and access extremity upon entering the treatment area prior to initiation of dialysis ...Perform hand hygiene after treatment before leaving treatment area ...Hand washing will be performed if hands are visibly contaminated with blood ...Appropriate PPE [personal protective equipment] will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces ...unused supplies or medication taken into the station should be used only for that patient and should not be returned to a common clean area or used on other patients ...Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood ...Prior to routine disinfection, remove all visible blood ...Cleaning of visible blood should be performed when first observed ...At the end of each treatment, the dialysis station will be cleaned and disinfected ...Sinks should be easily accessible and readily available in the treatment area ...Sinks must be plumbed with both hot and cold water ...Clean supplies or equipment will not be placed adjacent to a sink unless a splash guard is in place ...” Observation of the treatment floor on 01/14/25 between 10:15 AM and 11:20 AM showed the following: 1. Staff G, Certified Clinical Hemodialysis Technician (CCHT), was observed multiple times at different dialysis stations, touching machines with a glove wrapped around his finger. Staff G failed to don gloves or perform hand hygiene before or after glove use. During an interview on 01/14/25 at 2:15 PM, Staff G, CCHT, acknowledged this practice and stated he did not feel that applying gloves was necessary “just to touch a machine.” 2. At 10:40 AM, Staff C, Registered Nurse (RN), removed bloody gloves from his hands and applied hand sanitizer. Staff C failed to wash hands with soap and water as required per facility policy after contamination with visible blood. 3. Multiple staff were observed providing patient care during initiation/discontinuation of treatments without wearing face shields/safety glasses as required per facility policy. During an interview on 01/15/25 at 9:10 AM, Staff I, RN, stated that getting staff to wear face shields was challenging and stated, “Staff just don’t like wearing them.” 4. Dialysis stations were not equipped with biohazard waste bags/containers. Staff were observed carrying used dialyzers and tubing containing blood product across the dialysis treatment area to a centralized biohazard bin without being contained in a manner to prevent leaks/spills. 5. Opened containers of dialysis acid concentrate used at patient stations were identified and stored in a clean area at the nurses’ station. During an interview on 01/16/25, Staff L, CCHT, stated that opened containers of acid concentrate are wiped down with disinfectant and stored for later use. Staff L confirmed that the containers are not labeled and used on different patients. 6. Observation of the nurses’ station and medication preparation station showed face shields laying on the counter and counters were covered in dust and water spots. A sink adjacent to a medication station failed to have splash guards installed. 7. Station 3 was vacant and set up for an incoming patient. Dried blood was observed on the floor, on front of dialysis machine, and on the wall behind the dialysis chair. At time of observation, Staff B, Manager of Clinical Services, was notified and confirmed the findings appeared to be dried blood. 8. A hand washing sink on the dialysis treatment floor was inoperable at the time of survey. When observed, Staff A, Facility Administrator, acknowledged the sink as inoperable. During an interview on 01/15/25 at 2:55 PM, Staff A, Facility Administrator, stated that failure of the facility to maintain a sanitary environment poses a safety and infection control risk to staff and patients.”

“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: 43397 Based on observation, policy review, and interview, the facility failed to ensure staff were following infection control policies for glove use and hand hygiene. Failure to use gloves and perform hand hygiene posed potential spread of pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 86 patients who received dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatments at the facility. Findings include: Review of a facility policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “ ...All teammates ...will perform hand hygiene ...prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, after interacting with wall boxes ....between patients even if the contact is casual, before touching clean areas such as supplies, supply cart and chairside keyboard/mouse ...Patients and caregivers will be encouraged to wash their hands and access extremity upon entering the treatment area prior to initiation of dialysis ...Perform hand hygiene after treatment before leaving treatment area ...Hand washing will be performed if hands are visibly contaminated with blood ...”. Observation of the treatment floor on 01/14/25 between 10:15 AM and 11:20 AM showed patients entering the treatment floor were not washing their access prior to treatment and were not performing hand hygiene/hand washing after holding sites and glove removal post treatment. During an interview on 01/15/25 at 10:45 AM, Staff E, Certified Clinical Hemodialysis Technician (CCHT), confirmed that patients are expected to wash their hands and access site prior to initiation of treatment and provided hand sanitizer or encouraged to wash hands after treatment when removing gloves. Observation of the treatment floor on 01/14/25 at 10:40 AM showed Staff C, Registered Nurse (RN), assisted a patient at Station 9 with an active bleeding incident. Staff C removed gloves, left the station, and failed to wash hands with soap and water after direct blood contact as required per facility policy. Observation of the treatment floor on 01/14/25 at 10:43 AM showed Staff E, CCHT, discharged a patient at Station 5. The patient exited the facility without washing hands. At the time of observation Staff E stated that the patient was not offered hand sanitizer and was not asked to wash hands prior to exiting the facility. Staff E confirmed it is policy to request patients wash hands prior to leaving treatment area. Observation of the treatment floor on 01/14/25 at 10:10 AM showed Staff G, CCHT, provided direct patient care at Station 10 without performing hand hygiene or applying gloves. Observation of the treatment floor on 01/14/25 from 10:30 AM - 11:00 AM showed Staff G, CCHT, at multiple stations and touched dialysis machines multiple times with a glove wrapped around his finger. Staff G failed to don gloves or perform hand hygiene before or after glove use. During an interview on 01/14/25 at 2:15 PM, Staff G, CCHT, acknowledged this practice and stated he did not feel that applying gloves was necessary “just to touch a machine”. During an interview on 01/15/25 at 1:55 PM, Staff A, Facility Administrator, stated that expectations for glove use and hand hygiene is to follow policy and failure to do so is a safety concern that could lead to infections.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 43397 Based on observation, policy review, and interview, the facility failed to ensure a sink in the treatment area for hand washing was in working order. Failure to ensure that available sinks are in working order poses a risk for patients and/or staff from being able to perform hand hygiene thus increasing risk of infection for all 86 patients receiving care in this facility. Findings Include: Review of a facility policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “ ...Sinks should be easily accessible and readily available in the treatment area ...Sinks must be plumbed with both hot and cold water ...” Observation of the treatment floor on 01/15/25 at 8:45 AM showed a hand washing sink between Pods 1 & 2 was inoperable. Staff E, Certified Clinical Hemodialysis Technician (CCHT), stated that the sink “works when it wants”. The sink was inoperable on each day survey. During an interview on 01/15/25 at 9:37 AM, Staff A, Facility Administrator, was asked about the non-functioning sink and if a work order had been submitted. Staff A stated that the facility was aware of the sink issue but a work order had not yet been submitted.”

“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: 43397 Based on observation, policy review, and interview, the facility failed to ensure staff wore face shields/safety glasses and/or face masks as required per facility policy. Failure to wear face shields/safety glasses increase risk of blood exposure with the potential for the spread of infectious pathogens (organisms that may cause disease or infection) which could negatively impact the staff and the 86 patients that received treatment in this facility. Findings Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “ ...appropriate PPE [personal protective equipment] will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces...”. Review of a policy titled, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure,” revised 10/2024, showed that face masks must cover the nose and mouth during treatment initiation to prevent the exposure of the catheter and exit site to nasal drops and infectious bacteria. Observation of the treatment floor on 01/14/25 from 10:08 AM to 11:45 AM showed a visitor at Station 5 was not offered a face mask during a central venous catheter (CVC) treatment initiation. The failure to use face masks near a CVC site during treatment initiation poses a risk for the exposure to infectious bacteria. Observation of the treatment floor on 01/15/25 at 10:10 AM, showed Staff G, Certified Clinical Hemodialysis Technician (CCHT), terminated a treatment at Station 10 without wearing a face shield. During an interview on 01/14/25 at 10:53 AM, Staff B, Manager of Clinical Services, stated that the expectation for staff is to wear face shields whenever there is the possibility of splashing of blood or body fluids. Staff B stated that a face shield/safety glasses must be worn at all times during the initiation/discontinuation of a dialysis treatment. During an interview on 01/15/25 at 2:55 PM, Staff A, Facility Administrator, stated that face shields are for patient and staff protection and must be worn and that failure to do so increases infection risk. During an interview on 01/16/25 at 3:14 PM, the Medical Director stated that staff should be wearing face shields any time there is potential for exposure to blood or body fluids.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 43397 Based on observation, policy review, and interview, the facility failed to contain biohazardous medical waste (blood or other bodily fluids) in a manner to prevent spills/leaks prior to transporting such waste across the dialysis treatment floor. Failure to contain medical waste prior to transport provided a potential spread of pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 86 patients who received dialysis treatments at the facility. Findings Include: Review of a facility policy titled, “Medical Waste Management Plan,” revised 10/2023, showed, “Medical waste is healthcare waste that may be contaminated by blood, body fluids or other potentially infectious materials ...it includes but is not limited to ...blood lines ...used hemodialyzers ...gauze sponges, underpads or any other item contaminated with blood ...” Review of a facility policy titled, “Segregation of Medical Waste,” revised 10/2023, showed, “ ...bags are secured, tied with a center knot ...double bagged and placed in the designated medical waste receptacles ...” Observation of the treatment floor on 01/14/25 from 10:15 AM to 11:20 AM showed that dialysis stations failed to have individual biohazardous containers for the disposal of medical waste, including gloves, gauze, underpads, dialyzers, and bloodlines. Staff were observed carrying used dialyzers containing blood/blood products from the dialysis stations across the treatment floor to centralized biohazard containers without being contained in a manner to prevent spills/leaks. During an interview on 11/15/25 at 11:18 AM, Staff A, Facility Administrator, confirmed that carrying non-contained biohazardous waste across the treatment floor posed an infection control risk with the potential to spread bloodborne pathogens to staff and patients.”

“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: 43397 Based on observation, policy review, and interview, the facility failed to ensure staff disinfected all dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) equipment and other surfaces that could be potentially contaminated with patients’ blood after a dialysis treatment. Failure to ensure all surfaces of the dialysis machine or other objects that could come in contact with a patient are appropriately disinfected provided a mode of potential transmission of bloodborne pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 86 patients who received dialysis treatments at the facility. Findings Include: Review of a facility policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “ ...At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but are not limited to: all surfaces in contact with the patient or their belongings ...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 ...” Observation of the treatment floor on 01/14/25 at 10:28 AM, showed Staff G, Certified Clinical Hemodialysis Technician (CCHT), performed disinfection of the dialysis station at Station 8 and failed to wipe down the TV/TV arm, wall box, back counter, or water supply lines. At the time of observation, Staff G confirmed that facility policy requires everything in the dialysis station that may come in contact patients or their belongings or any item that could come in contact with blood or bodily fluids must be disinfected. “I should have wiped those things down.” Observation of the treatment floor on 01/14/25 at 11:03 AM showed Station 23 had been set up for a new dialysis patient. Blood was observed on the floor, front of the dialysis machine, and on the wall behind the dialysis chair. Staff B, Manager of Clinic Services was immediately notified of findings and confirmed the presence of blood on the dialysis machine, floor, and wall. Observation of the treatment floor on 01/15/25 at 10:17 AM showed an unidentified staff performed disinfection of a dialysis station and failed to extend and disinfect the footrest, the dialysis machine side bucket, TV/TV arm, wall box, water lines, or back counter where patient belongings had been stored. During an interview on 01/15/25 at 2:55 PM, Staff A, Facility Administrator, stated that disinfection of the dialysis station must be completed per facility policy and failure to do so increases the risk of infection to patients. Staff A confirmed that the back counters where patient belongings may be stored is considered part of the dialysis station and must be disinfected after each treatment.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 43397 Based on observation, policy review, and interview, the facility failed to ensure staff followed policy and procedure to reduce infection risk in patients with a Central Venous Catheter (CVC) access (a thin, flexible tube that is inserted into a vein to access the bloodstream) during 3 of 3 CVC care observations. Failure to ensure appropriate infection control practices when caring for a patient with a CVC catheter provided a potential spread of pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of any CVC catheter patients who received dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatments at the facility. Findings Include: Review of a facility policy titled, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure,” revised 10/2024, showed that face masks and face shields must be worn during initiation and discontinuation of treatment for patients with a CVC catheter to prevent the exposure of the catheter and exit site to infectious bacteria. Staff must set up a new clean field with a new clean moisture proof barrier upon initiation of treatment and again upon discontinuation of treatment to minimize opportunities for cross contamination. When accessing the CVC insertion site or when connecting/disconnecting blood lines, staff should instruct the patient to turn head to the opposite side of the CVC exit site to decrease the risk of bacteria contaminating the site. These measures are vital to preventing the exposure of the catheter and exit site to nasal droplets and infectious bacteria. During initiation and discontinuation of treatment the patient should be placed in a supine [reclined] position to decrease the risk of an air embolism [a possible life-threatening incident in which air enters a vein or artery and disrupts the passage of blood to the heart or lungs]...” Observation of the treatment floor on 01/14/25 at 10:30 AM, showed Staff G, Certified Clinical Hemodialysis Technician (CCHT), discontinued a dialysis treatment at Station 8 for a patient with a CVC. Staff G was not wearing a face shield, failed to place the patient in a supine position, did not request that patient turn head away from CVC site, and failed to replace the old moisture proof barrier with a clean barrier to prevent cross contamination of bacteria. During an interview on 01/14/25 at 2:15 PM, Staff G, CCHT, confirmed that facility policy requires use of a face shield when initiating or discontinuing treatment but stated he didn’t use one because he didn’t like how it feels when wearing. Staff G stated he was unaware that policy required a new and clean moisture proof barrier when discontinuing treatment but was aware that the patient should be placed in a supine position before discontinuing treatment and said, “I forgot to do that.” Observation of the treatment floor on 01/14/25 at 11:12 AM, showed Staff E, CCHT, discontinued a dialysis treatment at Station 7 for a patient with a CVC. Staff E was not wearing a face shield, failed to place the patient in a supine position, did not request that patient turn head away from CVC site, and failed to replace the old moisture proof barrier with a clean barrier to prevent cross contamination of bacteria. At time of observation, Staff E confirmed that a face shield or safety glasses are required to be worn by staff for initiation or discontinuation of dialysis treatments. Observation of the treatment floor on 01/15/25 at 10:08 AM, showed Staff J, CCHT, discontinued a dialysis treatment for a patient with a CVC. Staff J failed to place the patient in a supine position, did not request that patient turn head away from CVC site, and failed to replace the old moisture proof barrier with a clean barrier to prevent cross contamination of bacteria. During an interview on 01/15/25 at 9:10 AM, Staff I, Registered Nurse (RN), stated that it was challenging to get staff to wear face shields and stated that staff “don’t like wearing them”. During an interview on 01/15/25 at 2:55 PM, Staff A, Facility Administrator, stated that face shields or approved safety glasses are considered Personal Protective Equipment (PPE) and are required when initiating or discontinuing dialysis treatments. Staff A stated that the expectation is that staff follow all policy and procedures for safety and infection control when caring for patients.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 43397 Based on observation, policy review, and interview, the facility failed to ensure a safe environment free of hazards which would present risks for trips and falls and failed to ensure that fire drills were completed as required to prepare patients and staff in case of a fire emergency. The failure to provide a safe environment placed patients at risk of being unable and/or unprepared to evacuate the facility safely in case of an emergency and could negatively impact the health and well-being of the 86 patients who received dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatments at the facility. Findings Include: Review of a document titled, “Facility Emergency Management Plan,” revised 10/2024, showed that fire safety drills are required on a quarterly basis and must have the following: be conducted for each shift of patients, utilize the “Emergency Exercise Template”, include patient emergency takeoff procedure, documentation of training for both teammates and patients, exercise evaluation, and teammate attendance sheet. Observation of the treatment floor on 01/14/25 at 10:15 AM showed trash cans and biohazard containers in the middle of the treatment area, obstructing egress from the facility in case of an emergency and posing a fall/trip hazard to patients and staff. Staff B, Manager of Clinical Services, was notified immediately of the hazard. Staff B immediately instructed staff to move the trash cans and biohazard containers from the path of egress to the individual dialysis stations. Observation of the treatment floor on 01/15/25 at 8:30 AM showed the trash cans and biohazard containers had been placed back into the middle of the treatment floor, obstructing the path of egress and posing a fall/trip hazard for patients and staff. During an interview on 01/15/25 at 2:55 PM, Staff A, Facility Administrator, confirmed that having items in the middle of the treatment floor posed a safety risk and that the concern would be addressed. Review of the facility’s Emergency Preparedness Plan failed to show documented evidence that Fire Safety Drills were completed for the first (1st) and fourth (4th) quarter of 2024. During an interview on 01/16/25 at 11:18 AM, Staff A, Facility Administrator stated that the facility did not have documentation for two (2) quarterly fire drills and could only provide documentation for April and August.”

“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: 43397 Based on record review, policy review, and interview, the facility failed to ensure that a Registered Nurse (RN) assessed and monitored fluid status and management needs and failed to notify a physician of fluid status concerns for 3 of 3 sampled patients (Patient 2, 6, and 7). The failure to address and monitor fluid status places patients at risk for adverse effects such as hypertension (high blood pressure), intradialytic hypotension (low blood pressure during dialysis treatment), difficulty breathing, heart failure, increased hospitalizations, increased mortality rates, and could negatively impact the health and well-being of the 86 patients who received dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatments at the facility. Findings Include: Review of a facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, showed, “ ...The Nursing assessment will be performed and documented by a licensed nurse ...The assessment includes the following components: ...Auscultation of the lungs ...Evaluation of volume status including edema ...The prescription components are confirmed by a licensed nurse ...Prescription components include ...UFR [ultrafiltration rate] and Max [maximum] UFR ...Post Treatment Assessment: ...If an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge ...Abnormal Findings ...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ...Post-treatment: If a patient is above or below 1 [one] kg [kilogram] from the target weight ...” Observation of the dialysis treatment floor on 01/15/25 between 10:25 AM and 10:35 AM showed three unidentified patients weighed themselves without staff present. The patients printed their weight from the scale and placed the printed result in a basket and left the treatment area. Staff failed to assess patient weights prior to patients leaving. During an interview on 01/15/25 at 9:10 AM, Staff I, RN, stated that patients weigh themselves after dialysis treatments and place their printed weight in a basket for staff to document at a later time. Staff I stated that patient post weights are not being assessed and documented after treatment prior to patient discharge and that staff would be unaware of abnormal weight findings and would have to wait to address until the patient’s next scheduled treatment. During an interview on 01/15/25 at 10:45 AM, Staff E, Certified Clinical Hemodialysis Technician (CCHT), stated that patient weights are not obtained by staff after treatment and that patients obtain their own weights and leave a print-out in a basket for staff to document at a later time. Patient 2 Review of Patient 2’s hemodialysis orders dated 01/07/25, showed a maximum UFR of 13 milliliters/kilogram/hour (mL/kg/hr). Review of a document titled, “Patient Summary Report,” showed the facility exceeded the ordered maximum UFR of 13 mL/kg/hr for 4 of 6 treatments on the following dates: On 12/31/24 the average UFR was documented at 23.9 mL/kg/hr. On 01/02/25 the average UFR was documented at 35 mL/kg/hr. On 01/04/25 the average UFR was documented at 39.5 mL/kg/hr. On 01/09/25 the average UFR was documented at 30.4 mL/kg/hr. Review of Patient 2’s medical record failed to show documented evidence that a physician was notified of the UFR frequently exceeding the maximum or interventions provided to prevent excessive UFR such as longer or more frequently scheduled dialysis treatments or increased patient education on fluid management and risks of fluid overload and/or risks of excessive fluid removal. During an interview on 01/21/25 at 2:20 PM, Staff B, Manager of Clinical Services, confirmed that Patient 2’s UFR exceeded the maximum as specified in the facility policy and physician order. Staff B stated the UFR exceeded the maximum due to shortened treatment times and the amount of fluid removal needed to reach target dry weight in less time. Patient 6 Review of Patient 6’s hemodialysis orders dated 12/14/24, showed an estimated dry weight (EDW) of 127 kg. On 12/30/24 the post dialysis weight was documented as 128.5 kg (1.5 kg over EDW). Review of the treatment flowsheet failed to show documented evidence of interventions or physician notification as required for a post treatment weight >1 kg over EDW. Patient 7 Review of Patient 7’s hemodialysis orders dated 01/03/25, showed an estimated dry weight (EDW) of 113.1kg. On 01/04/25 the post dialysis weight was documented at 114.1 kg (1 kg over EDW). Review of the treatment flowsheet failed to show documented evidence of interventions or physician notification as required for a post treatment weight >1 kg over EDW. On 01/09/25 the post dialysis weight was documented at 114.1 kg (1 kg over EDW). Review of the treatment flowsheet failed to show documented evidence of interventions or physician notification as required for a post treatment weight >1 kg over EDW.”