Davita Owensboro Dialysis Center

“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, interview, and facility policy review, the facility failed to perform hand hygiene per the facility policy during 4 of 8 observations of hemodialysis treatment. The findings include: A facility policy titled “Infection Control for Dialysis Facilities,” revised 04/2023, indicated, “Hand Hygiene 1. All teammates, Physicians and Non-Physician will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e. [id est, that is], plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” The policy indicated, “7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station, this will include patients and visitors assisting with procedures such as self-cannulation or holding access sites. a. Gloves should be changed when: i. When soiled with blood, dialysate or other body fluids ii. When going from a “dirty” area or task to a “clean” area or task iii. When moving from a contaminated body site to a clean body site of the same patient; and iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system.” A facility policy titled “Central Venous Catheter (CVC) with [brand name] HD [hemodialysis] Antimicrobial End Caps Procedure,” revised 04/2025, indicated, “Upon Completion of Dialysis 29. Remove gloves and discard, perform hand hygiene per procedure and re-glove. 30. Clamp arterial catheter limb and blood line. Aseptically disconnect arterial blood line from arterial CVC limb Attach a 10 ml [milliliter] syringe filled with normal saline to arterial catheter limb. Unclamp arterial catheter limb and push normal saline into arterial port and quickly clamp arterial catheter limb. Attach arterial blood line to saline infusion line and conclude dialysis rinse back per procedure: Termination of Dialysis applicable to the facility’s blood lines and dialysis delivery system. 31. Remove gloves and discard, perform hand hygiene per procedure and re-glove. 32. Clamp venous catheter limb and blood line. Aseptically disconnect venous blood line and connect 10 ml syringe with normal saline to the venous catheter limb. Unclamp venous catheter limb and push normal saline into venous port and quickly clamp venous catheter limb.” A facility policy titled “AV [arteriovenous] Fistula or Graft Cannulation with [brand name] or [brand name] Safety Fistula Needle (SFN) and Administration of Heparin Loading Dose,” revised 04/2025, indicated, “11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry.” The policy indicated, “13. Do not palpate the insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation. 14. If applicable: Anesthetize needle insertion area.” The policy specified, “16. Remove gloves, perform hand hygiene and put on clean gloves prior to cannulation.” During an observation on 05/20/2025 at 10:47 AM, Patient Care Technician (PCT) #8 performed treatment discontinuation for a patient with a CVC at Treatment Station 11A. PCT #8 disconnected the arterial bloodline, cleaned the arterial lumen with alcohol, flushed with normal saline (NS), and connected the arterial bloodline to the machine. PCT #8 then began to reinfuse the patient’s blood. PCT #8 removed her gloves, performed hand hygiene, and went to the computer between Stations 11A and 12A. When PCT #8 was finished at the computer she performed hand hygiene, donned clean gloves, touched the patient’s machine, opened supplies, raised the feet of the patient’s chair, disconnected the bloodlines from the patient’s venous lumen, cleaned the venous lumen and flushed with NS, attached the venous bloodline to the machine, administered dwelling solution into both lumens, and then cleaned the lumens prior to applying caps. PCT #8 did not perform hand hygiene or change her gloves when she went from the patient’s machine and other objects in the treatment station to accessing the patient’s CVC. During an observation on 05/20/2025 at 12:00 PM, PCT #6 discontinued a dialysis treatment at Treatment Station 4B for a patient with an arteriovenous fistula (AVF)/arteriovenous graft (AVG). PCT #6 changed his gloves and performed hand hygiene while the patient’s blood was reinfusing. PCT #6 then assisted the patient don a glove for holding their cannulation site, touched the machine, disconnected the bloodline from the venous needle, attached the bloodline to the machine, placed tape on the back of one of their gloves, removed the blood pressure cuff from the patient, set the legs of the patient’s chair down, and then removed the first cannulation needle. The patient held the site of the first needle while PCT #6 removed the second needle and placed a clamp to apply pressure to the second site. PCT #6 then removed his gloves and performed hand hygiene. PCT #6 did not perform hand hygiene or change his gloves after he touched the dialysis machine and multiple objects prior to the removal of the patient’s cannulation needles. During an observation on 05/20/2025 at 12:59 PM, PCT #12 initiated a dialysis treatment at Treatment Station 11B for a patient with an AVF. After preparation of the patient’s access for cannulation, PCT #12 removed her gloves, performed hand hygiene, left the treatment station, and returned at 1:05 PM with a white canister that contained a numbing spray. PCT #12 performed hand hygiene, donned clean gloves, sprayed the patient’s access, palpated the insertion site, and then cannulated. PCT #12 had difficulty cannulating the patient’s access/graft and called PCT #6 for assistance. PCT #6 performed hand hygiene, donned clean gloves, palpated the access, auscultated the access, reapplied the numbing spray to the access, palpated again after applying the spray, and then cannulated. PCT #6 and PCT #12 did not change their gloves or perform hand hygiene after they reapplied antiseptic after they touched the patient’s access and prior to cannulation. During an observation on 05/21/2025 at 10:44 AM, PCT #2 discontinued a dialysis treatment at Treatment Station 5A for a patient with an AVF. PCT #2 performed hand hygiene, donned gloves, clamped the arterial lines, disconnected the arterial bloodline, flushed the arterial line, and began to return the patient’s blood. PCT #2 removed her gloves, performed hand hygiene, and charted while the blood reinfused. PCT #2 performed hand hygiene, donned gloves, clamped the venous lines, disconnected the venous bloodline, attached the bloodline to the dialysis machine, and removed the first cannulation needle. PCT #2 did not perform hand hygiene or change her gloves when she went from the machine to the patient. During an interview on 05/20/2025 at 3:50 PM, PCT #12 stated the normal cannulation process was to perform hand hygiene, don gloves, assess the access, including palpating and auscultating for bruit and thrill, clean with alcohol and betadine, remove gloves, perform hand hygiene, complete charting, perform hand hygiene, don clean gloves, and then cannulate the access. PCT #12 stated it was not their normal practice to change gloves, perform hand hygiene, and reapply antiseptic if the access was palpated after the antiseptic had been applied, and confirmed those things had not been done when she cannulated the patient at Station 11B because her gloves were clean. During an interview on 05/20/2025 at 4:44 PM PCT #6 stated the normal cannulation process was to perform hand hygiene, don gloves, and perform an access check, including feeling the access, listening to the access, and raising the arm up to see if the access re-engorged. PCT #6 stated the access would then be cleaned with sanitizing wipes, washed with alcohol, scrubbed with betadine, and then the gloves would be removed and hand hygiene performed so charting could be completed while the betadine was drying. PCT #6 stated once dry he would perform hand hygiene, don clean gloves, attach 10 ml syringe to needle lines to aspirate, apply a tourniquet if the patient had an AVF, spray the access if being used, and then cannulate. PCT #6 stated that if the access was touched after the antiseptic was applied, he would change gloves and reapply antiseptic because the area had been contaminated. PCT #6 stated, when cannulating the patient at Station 11B, he felt the site palpated was sufficiently far from the insertion site and that their co-worker had already applied betadine, so he did not need to do it again. During an interview on 05/23/2025 at 1:30 PM, the Medical Director confirmed the facility expectation that hand hygiene be done in between touching the machine and the patient, especially the patient’s access. The Medical Director also confirmed that antiseptic should be reapplied if the access was touched after the antiseptic had been applied and prior to cannulation.”

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to ensure all environmental surfaces in the dialysis treatment stations were disinfected at the end of each hemodialysis treatment during 2 of 2 observations. The findings include: A facility policy titled “Infection Control for Dialysis Facilities,” revised 04/2023, indicated, “13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings and frequently contacted by healthcare personnel.” The policy indicated, “ii. Priming containers are to be emptied prior to disinfection.” During a concurrent n observation and interview on 05/20/2025 at 12:47 PM, Patient Care Technician (PCT) #6 disinfected the dialysis machine at Treatment Station 5B, and fluid was observed in the prime waste receptacle. PCT #6 told PCT #12 that the machine was cleaned and asked if they could set the machine up for the next treatment. PCT #6 confirmed he finished disinfecting the dialysis machine and forgot to clean the prime waste receptacle. PCT #6 stated he usually cleaned the prime waste receptacle but forgot due to being stressed. During a concurrent observation and interview on 05/21/2025 at 10:12 AM, PCT #9 set up the dialysis machine at Treatment Station 9B, and fluid was observed in the prime waste receptacle. PCT #9 confirmed she completed disinfection, and when shown the fluid in the prime waste receptacle, she stated she had not emptied or disinfected the container. PCT #9 stated, “I usually do. I just forgot.” During an interview on 05/22/2025 at 4:45 PM, Registered Nurse #15 confirmed the facility staff were trained to empty and clean the prime waste receptacles after every treatment, and that was their usual practice. During an interview on 05/23/2025 at 1:30 PM the Medical Director confirmed the facility expectation was for the dialysis station to be cleaned per the facility protocol, and that would include the prime waste receptacle.”

“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 4 (Patients #1, #2, #3, and #4) of 5 sampled patients. The findings include: A facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, indicated, “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 05/07/2025 revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #1’s BFR was documented as 360 mL/min from 8:39 AM until the treatment was terminated at 10:33 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s “Treatment Details Report,” dated 05/14/2025 revealed a prescribed BFR of 400 mL/min. Patient #1’s BFR was documented as 450 mL/min from 7:22 AM until the treatment was terminated at 9:52 AM. There was no rationale documented why the prescribed BFR was not achieved. 2. Patient #2’s “Treatment Details Report,” dated 05/06/2025 revealed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min). Patient #2’s BFR was documented as 350 mL/min from 12:29 PM until the treatment was terminated at 3:05 PM. There was no rationale documented why the prescribed BFR was not achieved. 3. Patient #3’s “Treatment Details Report,” dated 05/12/2025 revealed a prescribed blood flow rate (BFR) of 350 milliliters per minute (mL/min). Patient #3’s BFR was documented as 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. 4. Patient #4’s “Treatment Details Report,” dated 05/13/2025 revealed a prescribed blood flow rate (BFR) of 250 milliliters per minute (mL/min). Patient #4’s BFR was documented as 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. During an interview on 05/21/2205 at 12:30 PM, the Manager of Clinical Services and Clinical Coordinator stated the staff were expected to note on the treatment sheet the rationale as to why the BFR was changed. During an interview on 05/23/2025 at 1:30 PM, the Medical Director stated that BFR changes should be documented including a rationale, and the registered nurse should be notified.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 50873 Based on interview, record review, and facility policy review, the facility failed to notify the licensed nurse and/or medical doctor (MD) of abnormal vital signs for 3 (Patients #2, #4, and #7) of 7 sampled patients. The findings include: A facility policy titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, indicated “Pre-Treatment Data Collection/Assessment 4. Any abnormal findings or finding outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse.” According to the section titled “Intradialytic Data Collection/Assessment,” “11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately.” 1. Patient #2’s physician’s orders, dated 02/11/2025, indicated notify the medical doctor (MD) when during dialysis the patient’s systolic blood pressure (SBP) was less than 80 millimeters of mercury (mmHg), greater than 200 mmHg, or their heart rate (HR) was greater than 100 beats per minute (BPM). Patient #2’s “Treatment Details Report,” dated 05/10/2025 indicated during dialysis on 05/10/2025 at 2:44 PM, the patient’s blood pressure (BP) was 166/119 mm/Hg and at 3:16 PM the patient’s HR was 103 BPM. The Treatment Details Report revealed no evidence that the licensed nurse or MD was notified of the out-of-range vital signs. Patient #2’s “Treatment Details Report,” dated 05/13/2025 indicated during dialysis on 05/13/2025 at 11:07 AM, the patient’s HR was 110 BPM. The Treatment Details Report revealed no evidence that the licensed nurse or MD was notified of the out-of-range vital signs. Patient #2’s “Treatment Details Report,” dated 05/15/2025 indicated during dialysis on 05/15/2025 at 11:25 AM, the patient’s HR was 174 BPM and at 2:26 PM their BP was 251/215 mm/Hg. The Treatment Details Report revealed no evidence that the licensed nurse or MD was notified of the out-of-range vital signs. During an interview on 05/21/2025 at 1:25, the Clinical Coordinator confirmed the findings for Patient #2 and stated the facility expected staff to recheck and confirm out-of-range vital signs, but there was no evidence that was done. 2. Patient #4’s physician’s orders, dated 02/11/2025, indicated notify the medical doctor (MD) when the patient’s pre-treatment systolic blood pressure (SBP) was less than 90 millimeters of mercury (mmHg), greater than 180 mmHg, or their diastolic blood pressure was greater than 110 mmHg or their heart rate (HR) was greater than 100 beats per minute (BPM). The order also specified to notify the MD if during dialysis the patient’s SBP was less than 80 mmHg, greater than 200 mmHg, or their HR was greater than 100 BPM. Patient #4’s “Treatment Details Report,” dated 05/01/2025 indicated before dialysis on 05/01/2025, the patient’s standing blood pressure (BP) was 187/108 mm/Hg, their HR was 102 BPM, and their sitting BP was 190/111 mm/Hg. The Treatment Details Report indicated during dialysis at 12:28 PM, the patient’s HR was 104 BPM. The Treatment Details Report revealed no evidence that the licensed nurse or MD was notified of the out-of-range vital signs. Patient #4’s “Treatment Details Report,” dated 05/08/2025 indicated before dialysis on 05/08/2025, the patient’s HR was 120 BPM. The Treatment Details Report indicated during dialysis, the patient’s HR was 120 BPM at 1:35 PM, 114 BPM at 3:35 PM, and 120 BPM at 3:51 PM. The Treatment Details Report revealed no evidence that the licensed nurse or MD was notified of the out-of-range vital signs. Patient #4’s “Treatment Details Report,” dated 05/13/2025, indicated during dialysis on 05/13/2025 at 1:56 PM, the patient’s HR was 104 BPM at 1:56 PM and 107 BPM at 2:56 PM. The Treatment Details Report revealed no evidence that the licensed nurse or MD was notified of the out-of-range vital signs. 3. Patient #7’s physician’s orders, dated 02/11/2025, indicated notify the medical doctor (MD) when the patient’s pre-treatment systolic blood pressure (SBP) was less than 90 millimeters of mercury (mmHg), greater than 180 mmHg, or their diastolic blood pressure was greater than 110 mmHg or their heart rate was greater than 100 beats per minute (BPM). The order also specified to notify the MD if during dialysis the patient’s SBP was less than 80 mmHg, greater than 200 mmHg, or heart rate was greater than 100 BPM. The order further indicated to notify the MD if after treatment, the patient’s SBP was less than 90 mmHg or greater than 180 mmHg. Patient #7’s “Treatment Details Report,” dated 04/28/2025, indicated before dialysis on 04/28/2025, the patient’s sitting blood pressure (BP) was 195/112 mmHg. The Treatment Details Report indicated after dialysis the patient’s standing HR was 110 BPM. The Treatment Details Report revealed no evidence that the licensed nurse or MD was notified of the out-of-range vital signs. Patient #7’s “Treatment Details Report,” dated 05/02/2025, indicated before dialysis on 05/02/2025, the patient’s sitting BP was 164/123 mm/Hg. The Treatment Details Report revealed no evidence that the licensed nurse or MD was notified of the out-of-range vital signs. During an interview on 05/22/2025 at 10:35 AM, the Clinical Coordinator confirmed there was no evidence the MD was notified of Patient #7’s out-of-range vital signs. During an interview on 05/23/2025 at 1:30 PM, the Medical Director confirmed that reporting parameters should be followed by the individual patient orders. The Medical Director confirmed the facility expectation for staff was to document any notifications.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 50873 Based on interview, facility document review, and facility policy review, the facility QAPI (Quality Assurance and Performance Improvement) Committee failed to measure, analyze, and track quality indicators for mortality and infections. This failure had the potential to affect all 96 patients who received care at the facility. The findings include: A policy titled “Continuous Quality Improvement Program,” revised 04/2021, indicated, “7. The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not be limited to, the following: - Patient Safety, including - Review of sentinel events - Review of trends of adverse patient occurrences including falls and blood loss - Review of product, equipment, or medication notices or recalls -Infection Control, including -Incidence of infections,” and “- Mortality - review of deaths.” The policy indicated, “8. Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track this change in performance over time to verify improvements are sustained.” A facility electronic record titled “Mortality Improvement Plans- January 2025” indicated there was no data available for cardiac death for the timeframe from 03/2024 through 12/2024. During an interview with the Facility Administrator and Manager of Clinical Services on 05/23/2025 at 10:30 AM, the Facility Administrator stated there was no evidence of analysis of mortality data in QAPI. The Facility Administrator stated an investigation was done on each infection event in the Risk Event Management (REM) system and presented during the QAPI meetings. The Facility Administrator stated the facility identified a trend of an increase in the number of COVID-19 cases, which resulted in an action plan, but this was not documented in QAPI. The Facility Administrator stated there were notes in a weekly interdisciplinary team (IDT) meeting that there was an increase in COVID-19 cases, and an action plan to reinstitute masking was approved in a Governing Body meeting, but the facility failed to catch it when putting data into QAPI. The Manager of Clinical Services stated there was no trending of potentially contributing factors for mortality in QAPI. The Manager of Clinical Services stated the facility tracked COVID-19 infections and influenza infections in the Risk Event Management (REM) system. The Manager of Clinical Services stated in QAPI COVID-19 cases were tracked under the tab labeled “Other” and flu cases were tracked under the “Infection” tab. The Manager of Clinical Services stated there was no evidence of investigation of these infections, analysis, identification of trends, or any action plans in QAPI. During an interview on 05/23/2025 at 1:30 PM, the Medical Director confirmed the facility expectation that QAPI included analysis, tracking, and trending documentation.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 50873 Based on interview, record review, and facility policy review, the facility failed to clarify a medication order for 1 (Patient #2) of 7 sampled patients. The findings include: A facility policy titled “Physician Orders for Patient Care,” revised 10/2024, indicated, “7. Unclear or incomplete orders must be clarified with the physician by the licensed nurse teammate or Registered Dietitian prior to implementation.” Patient #2’s “Patient Summary Report,” included active treatment orders that specified the patient received in-center hemodialysis treatment for four hours three times a week. Per the Patient Summary Report, the patient was to receive a loading dose of heparin at 1000 units and an hourly dose at 400 unit with the hourly dose to be discontinued 60 minutes before the end of dialysis. Patient #2’s “Treatment Details Report,” dated 05/06/2025, indicated the patient began dialysis at 10:59 AM and treatment ended at 2:00 PM. Per the Treatment Details Report, the patient was administered 1000 units of heparin. However, the patient’s order indicated that the patient should receive a loading dose of 1000 unit at 10:59 AM and 400 units at 11:59 AM and 12:59 PM. Patient #2’s “Treatment Details Report,” dated 05/08/2025, indicated the patient began dialysis at 10:48 AM and treatment ended at 1:48 PM. Per the Treatment Details Report, the patient was administered 1000 units of heparin. However, the patient’s order indicated that the patient should receive a loading dose of 1000 unit at 10:48 AM and 400 units at 11:48 AM. Patient #2’s “Treatment Details Report,” dated 05/10/2025, indicated the patient began dialysis at 11:13 AM and treatment ended at 2:13 PM. Per the Treatment Details Report, the patient was administered 1200 units of heparin. However, the patient’s order indicated that the patient should receive a loading dose of 1000 unit at 11:13 AM and 400 units at 12:13 PM. Patient #2’s “Treatment Details Report,” dated 05/13/2025, indicated the patient began dialysis at 11:05 AM and treatment ended at 2:07 PM. Per the Treatment Details Report, the patient was administered 1000 units of heparin. However, the patient’s order indicated that the patient should receive a loading dose of 1000 unit at 11:05 AM and 400 units at 12:05 PM. Patient #2’s “Treatment Details Report,” dated 05/15/2025, indicated the patient began dialysis at 10:51 AM and treatment ended at 1:54 PM Per the Treatment Details Report, the patient was administered 1000 units of heparin. However, the patient’s order indicated that the patient should receive a loading dose of 1000 unit at 10:51 AM and 400 units at 11:51 AM During a concurrent interview on 05/21/2025 at 1:25 PM, the Clinical Coordinator (CC) stated that based on Patient #2’s orders the total dose of heparin indicated would be 1,200 units. The CC stated the volumes documented as being delivered were correct for the rate and time of the order but did not match the total volume ordered. The CC stated the heparin order did not make sense and should have been clarified and updated. During an interview on 05/21/2025 at 1:25 PM, the Manager of Clinical Services stated there was no evidence the orders were clarified. During an interview on 05/23/2025 at 1:30 PM, the Medical Director stated the medication dose should match the rate and time of the orders. The Medical Director stated the order must be followed, and if the order did not make sense the staff should review it with the nurse manager, who would then review with the doctor to clarify or correct the order.”