Greenfield Hs - Taylor

“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: 47976 Based on observation, record review, and interview, the facility failed to monitor a sanitary environment resulting in the potential for transmission of infectious agents to the 27 patients currently receiving dialysis services at this facility. Finding include: **Policy titled “Inventory Tracking and Supply Management” (revised 09/2022) stated, “On a regular basis and at least monthly, medical supplies will be checked to determine inventory levels and verify expiration dates. Expired items will be discarded appropriately.” During dialysis floor observation on 1/7/25 at 1045, a container of “Sani-Cloth” bleach wipes with an expiration date of 10/2024 was found on the counter across from station #11. Findings were reviewed with and acknowledged by the Clinical Nurse Manager (Staff A), the Coordinator of Quality and Compliance (Staff B), and Regional Administrator (Staff D) during an interview on 1/9/25 at 1230.”

“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: 47976 Based on observation and interview, the facility failed to ensure staff maintained aseptic technique when providing care to patients with central venous catheters for 4 of 4 patients observed with central venous catheters, resulting in the potential for increased risk of infection. Findings include: During dialysis floor observation on 1/7/25 at 1221, Registered Nurse (Staff H) was observed disconnecting a patient’s CVC access (a catheter placed into a large vein) from dialysis at station #3. Staff H was observed disconnecting the catheter lines and scrubbing the hub (open end) with an alcohol pad for 17 seconds before connecting the protective cap. Staff H was observed scrubbing the other hub for 7 seconds before connecting the protective cap. Upon completion of the procedure, Staff H was asked what the facility policy was for hub scrub time. Staff H stated the policy is 15 seconds. On 1/7/25 at 1355, Registered Nurse (Staff E) was observed preparing a patient’s CVC access to begin dialysis at station #25. Staff E was observed removing the protective end of the catheter and scrubbing the hub for 10 seconds before attaching the blood line. Staff E was then observed scrubbing the other hub for 10 seconds as well before attaching the other side. Upon completion of the procedure, Staff E was what the facility policy was for hub scrub time. Staff E stated the policy is 15 seconds. On 1/7/25 at 1428, Staff H was observed preparing a patient’s CVC access to begin dialysis at station #3. Staff H was observed removing the protective end of the catheter and scrubbing the hub for 16 seconds before attaching the blood line. Staff H was then observed scrubbing the other hub for 10 seconds before attaching the other side. On 1/8/25 at 1331, Patient Care Technician (Staff L) was observed disconnecting a patient’s CVC access from dialysis at station #10. Staff L stated during the procedure that she scrubs each hub for 15 seconds. However, during the observation, it was noted Staff L scrubbed 1 hub for 8 seconds and the other hub for 10 seconds. Upon review of the facility policies titled “Initiation of Dialysis with Central Venous Catheter” (revised 05/04/22) and “Discontinuation of Hemodialysis with Central Venous Catheter” (revised 07/12/24), it was noted the policies stated to “Scrub the sides (threads) and end of the hub thoroughly with friction ...”, however, it did not indicate a time. During an interview on 1/9/25 at 1600, the Clinical Education Manager (Staff K) was asked what “thoroughly” meant in regard to scrub hub time. Staff K acknowledged the policy was unclear and stated the staff are taught to scrub the hub for 15 seconds and that competency audit sheets supported that expectation. The findings were also reviewed with and acknowledged by the Clinical Manager (Staff A), the Coordinator of Quality and Compliance (Staff B), the Medical Director (Staff C), and the Regional Administrator (Staff D) at the time of the interview.”

“BACT CONTROL-SUPPLY LINE DISINFECTED CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: machine supply line disinfected Users should establish a procedure for regular disinfection of [the line between the outlet from the water distribution system and the back of the dialysis machine]. This Standard is not met as evidenced by: 37411 Based on observation and interview, the facility failed to ensure staff used unexpired test strips for testing disinfectant levels in all 8 hemodialysis machines in module 2 after the disinfection process of the machine water lines. This practice has the potential to result in undetected levels of a harmful disinfectant being distributed to all patients receiving hemodialysis in this module. Findings include: During a flash tour of the hemodialysis treatment floor on 1/7/25 at 1105, a bottle of Minncare HD residual test strips was found on the treatment counter in module 2 across from station 10. It was discovered that the expiration date was 2024-10-17. This finding was reviewed and acknowledged by the Coordinator of Quality and Compliance (Staff B) and Dialysis Nurse Manager (Staff A) during an interview on 1/9/25 at 1200.”

“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: 22050 Based on observation, interview, and record review the facility failed to maintain a safe environment resulting in the likelihood for cross-contamination, bacterial harborage, and decreased air quality. This deficient practice has the potential to affect all patients served by the facility. Findings include: On 01/07/25 at 11:43 A.M., An environmental flash tour of the facility Water Room was conducted with Technical Leader “J”. The following items were noted: 4 of 4 overhead light assembly plastic lens covers were observed with accumulated and encrusted dust, dirt, and rust discoloration. The yellow to orange rust discoloration appears to have been initiated by previous moisture exposure. Technical Leader “J” stated: “We had a water leak approximately three years ago.” The concrete flooring surface was observed chipped, cracked, and soiled with accumulated dust/dirt deposits. The wall/floor junctures and corners were also observed soiled with accumulated and encrusted dust/dirt deposits. The concrete flooring surface was additionally observed heavily soiled with a black watery substance directly beneath and adjacent to the Reverse Osmosis (RO) Unit catch basin. The concrete flooring surface was further observed chipped and cracked, adjacent to the sole floor drain. On 01/07/25 at 01:00 P.M., An interview was conducted with Technical Leader “J” regarding the facility housekeeping contractual service agreement. Technical Leader “J” stated: “We have Coverall for housekeeping services.” On 01/07/25 at 01:35 P.M., An environmental flash tour of the facility Treatment Floor was conducted with Technical Leader “J”. The following items were noted: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits, adjacent to the Peritoneal Dialysis (PD) Room. The soiled ventilation grill surface measured approximately 24-inches-wide by 24-inches-long. Janitor Closet: The mop sink basin was observed heavily soiled with accumulated and encrusted dust/dirt/grime deposits. The return-air-exhaust ventilation grill was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill surface measured approximately 12-inches-wide by 12-inches-long. The flooring surface and storage racks were additionally observed with multiple items resting in complete disarray. Treatment Room #18: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill surface measured approximately 12-inches-wide by 12-inches-long. Treatment Room #19: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill surface measured approximately 12-inches-wide by 12-inches-long. Module #3: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill surface measured approximately 24-inches-wide by 24-inches-long. Patient Restroom: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill surface measured approximately 12-inches-wide by 12-inches-long. On 01/07/25 at 02:00 P.M., An environmental flash tour of the facility was conducted with Technical Leader “J”. The following items were noted: Entrance Foyer: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill surface measured approximately 12-inches-wide by 24-inches-long. Patient Lobby Restroom: The overhead light plastic lens cover was observed soiled with accumulated dust, dirt, and debris (dead insect carcasses). Men’s Locker Room: 2 of 2 return-air-exhaust ventilation grills were observed heavily soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill surfaces measured approximately 12-inches-wide by 12-inches-long. On 01/07/25 at 02:45 P.M., Record review of the “Coverall Customized Service Plan and Proposal” dated 08/02/2018 revealed under Coverall Service Plan: “Dusting and Disinfecting: Included Tasks: High and Low Dusting: Clean items up to 12 feet from the floor (high dusting), such as ceiling vents, light fixtures, high window sills and corners not cleaned as part of normal wiping; and items near floor (low dusting), such as vents, corners, outlets, baseboards, etc.””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 47976 Based on observation, record review, and interview, the facility failed to ensure patient access sites were visible to staff at all times for 2 (#4, 16) of 56 patients currently receiving dialysis treatment, resulting in the potential for needle dislodgement or line disconnection to go undetected and for significant bleeding to occur. Findings include: **Policy titled “Patient Monitoring Guidelines” (revised 5/18/2023) stated under “III. Monitoring During Dialysis” that, “3. The vascular access site is visible and uncovered at all times. This must be documented during the hemodialysis treatment and if any changes occur to the vascular access.” During dialysis floor observation on 1/7/25 at 1130, it was noted the access site for the patient at station #4 was completely covered by a blanket. At 1134, Licensed Practical Nurse (Staff F) was observed sitting at the computer station directly in front of station #4. At 1144, Staff F was asked if she could see the access site on the patient at station #4. Staff F stated she could not and went to station #4 to uncover the patient. At 1155, it was noted the access site for the patient at station #4 was completely covered again. Registered Nurse (Staff D) was observed sitting at the computer station directly in front of station #4. At 1215, Staff D was asked if she could see the access site on the patient at station #4. Staff D stated the patient must have covered herself up and returned to station #4 to uncover the patient. On 1/8/25 at 1030, it was noted the access site for the patient at station #16 was completely covered by a blanket. At 1044, Patient Care Technician (Staff I) was asked if she could see the access site on the patient at station #16. Staff I stated she could not and went to station #16 to uncover the patient. Findings were reviewed with and acknowledged by the Clinical Nurse Manager (Staff A), the Coordinator of Quality and Compliance (Staff B), and Regional Administrator (Staff D) during an interview on 1/9/25 at 1230.”

“PR-PRIVACY & CONFIDENTIALITY-RECORDS CFR(s): 494.70(a)(4) The patient has the right to- (4) Privacy and confidentiality in personal medical records; This Standard is not met as evidenced by: 47976 Based on observation, interview, and record review, the facility failed to ensure confidentiality of protected medical information for all 103 patients currently receiving in-center hemodialysis at this facility. Findings include: **Policy titled “Privacy and Confidentiality” (dated 06/2021) stated, “Employees will observe and preserve the rights of the patient by providing for privacy and maintaining confidentiality.” During dialysis floor observation on 1/7/25 from 1015 to 1530, the following was noted: At 1035, a computer station across from station #11 was left unattended with patient information visible. At 1044, Certified Clinical Hemodialysis Technician (Staff D) was observed at the computer station, however, he walked away without closing the screen. At 1208, it was noted the same computer was again left unattended with patient information visible. At 1415, a computer screen located at the nurse station across from station #25 was left unattended with patient information visible. Two patients were observed walking through the area at the time the computer was left unattended. A sticker that stated, “Please minimize screen before walking away from the computer” was seen attached to the top of the computer screen. At 1430, a small bin containing discarded patient prescriptions was observed on the counter of dirty sink near station #23. The papers were left face up with patient first and last names visible to anyone who walked by. Findings were reviewed with and acknowledged by the Clinical Nurse Manager (Staff A), the Coordinator of Quality and Compliance (Staff B), and Regional Administrator (Staff D) during an interview on 1/9/25 at 1230.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 47976 Based on record review and interview, the facility failed to ensure a comprehensive reassessment and revision of the plan of care was completed monthly for 1 (P-3) of 10 patients reviewed, resulting in the potential for unmet patient needs and less than optimal outcomes. Findings include: **Policy titled “Patient Assessment and Care Planning” (revised 07/12/2024) stated, “A comprehensive IDT reassessment of each patient and a review of the plan of care will be conducted: ...(2) At least monthly for unstable patients. Unstable patients are identified using the following criteria: (a) Extended or frequent hospitalizations; (b) Marked deterioration in health status; ....” P-3: This 55-year-old patient was admitted to this dialysis facility on 6/5/09 with the diagnosis of end stage renal disease. During record review on 1/8/25, it was noted he had been hospitalized 28 times in 2024 for a total of at least 176 days. Upon review of the last comprehensive assessment dated 11/13/24 following re-admission to the facility after an extended hospitalization, it was noted the patient was identified as unstable on the note. However, the plan indicated the next plan of care meeting would be in 90 days. It was also noted the patient was not included on the facility’s unstable patient list. During an interview with the Medical Director (Staff C) on 1/9/25 at 0950, Staff C was asked why P-3 had not received a follow-up comprehensive assessment since 11/13/24. Staff C stated the patient had multiple hospitalizations causing him to miss multiple visits, so it was likely the monthly follow-ups was not able to be done on time. Staff C stated he told staff to evaluate him whenever he comes to treatment so the comprehensive assessment could be updated. Staff C was asked if there would ever be a reason for a patient who meets the unstable criteria to not be included on the unstable list. Staff C stated that although a patient could be identified as “chronically unstable”, he does not feel this is appropriate as it could lead to the patient being forgotten. Staff C was informed the patient was not included on the unstable list, therefore, was not scheduled for a monthly follow-up. According to the record, the patient had been to the facility on 12/11/24, 12/18/24, 12/21/24, and 12/24/24 with no follow-up completed. Staff C stated he did not agree with the patient being left off the unstable list and would be talking to the staff. During an interview on 1/9/25 at 1230, the Clinical Nurse Manager (Staff A) was asked why P-3 was not on the facility’s unstable list. Staff A stated the patient may have been deemed “chronically unstable”, therefore, he did not require a monthly follow-up. Staff A was asked how a patient would be deemed chronically unstable and if the facility had a policy regarding this. Staff A was unsure. The Clinical Education Manager (Staff K) was also present during the interview and stated there was not a specific policy that she knew of, but all members of the IDT team would have to agree, at minimum. Staff A and Staff K were unable to provide a policy that explained the procedure for deeming a patient chronically unstable. They were also unable to provide any documentation of this being discussed and agreed upon during an IDT meeting. They acknowledged the findings. Findings were also reviewed with and acknowledged by the Coordinator of Quality and Compliance (Staff B) and the Regional Administrator (Staff D) during the interview on 1/9/25 at 1230.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 38304 Based on record review and interview, the Facility failed to deliver the prescribed blood flow rate (BFR) and dialysate flow rate (DFR) for 4 (P-1, P-2, P-4, and P-8) of 8 in-center patient records reviewed, out of a total sample of 10 records reviewed, resulting in failure to achieve optimal effectiveness of dialysis treatments provided and poor patient care outcomes. Findings include: P-8: This 52-year-old male was admitted to the Facility on 1/6/21, with diagnoses which included end stage renal disease, hypertension, and anemia. On 1/8/25, record review of P-8’s six most recent in-center dialysis treatments (12/23/24 through 1/7/25) noted the following concerns: The treatment flow sheet dated 12/23/24, documented the physician ordered BFR and DFR were to be delivered at 400-450 milliliters/minute (mL/min) and 800 mL/min respectively throughout treatment. However, the 12/23/24 treatment sheet documented that 7 of 12 BFR entries had been delivered at 300 mL/min and 7 of 12 DFR entries had been delivered at 600 mL/min. Additional record review found no documented evidence why P-8’s BFR and DFR were run at a rate less than prescribed for a majority of the treatment. The treatment flow sheet dated 1/2/25, documented the physician ordered BFR and DFR were to be delivered at 400-450 mL/min and 800 mL/min respectively throughout treatment. Further review of the 1/2/25 treatment sheet documented that 9 of 9 BFR entries had been delivered at 350 mL/min and 9 of 9 DFR entries had been delivered at 700 mL/min. Additional record review found no documented evidence why P-8’s BFR and DFR were run at a rate less than prescribed for the entire treatment. These findings were reviewed and acknowledged by the Coordinator of Quality and Compliance (Staff B) and Dialysis Nurse Manager (Staff A) during interview on 1/9/25 at 1210. Staff B noted the failure to document the reason for changing the ordered dialysis prescriptions above did not meet Facility expectations or its policy referenced below. Facility Policy: “Patient Monitoring Guidelines” (revised 5/18/2023) stated under “III. Monitoring During Dialysis” No. 7 that “Interventions and responses are recorded as necessary. Interventions may include but are not limited to adjustment of blood flow based on arterial and venous pressures, ultrafiltration rate, adjustment of needle placement... when applicable.” 46476 P-1: This 61-year-old was admitted to facility on 2/25/16 with diagnoses including end stage kidney disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 1/9/25 and included the last 6 hemodialysis treatment flowsheets with dates between 12/24/24 through 1/6/25. During review, it was noted that the active physician order for the hemodialysis blood flow rate (BFR) was 400 milliliters/minute (mL/min), and dialysate flow rate (DFR) was 800 mL/min each treatment. There was also a “unique order” dated 12/23/19 which stated that BFR could range from 450-500 mL/min and DFR would be 2 times the BFR rate (not to exceed 800 mL/min). During review of the hemodialysis flowsheets, the following were noted: On the treatment flowsheet dated 12/24/24, the duration of treatment was 4 hours and 2 minutes. The BFR was set at 400 mL/min (30 mL/min less than active order and 50 mL/min less than unique order) for the entire treatment. There was no documentation which explained why the BFR ran at a lower than prescribed rate for this treatment. On the treatment flowsheet dated 12/29/24, the duration of the treatment was 4 hours and 3 minutes. The BFR was set at 400 mL/min for the entire treatment. There was no documentation which explained why the BFR ran at a lower than prescribed rate for this treatment. On 1/9/25 at 1430, the above findings were reviewed and acknowledged with the Clinical Nurse Manager (Staff A), Coordinator of Quality and Compliance (Staff B), and the Clinical Education Manager (Staff K). Staff B stated that unique orders give flexibility for the type of access and needle size being used but in P-1’s case, could not determine why P-1’s treatments had a lower than prescribed BFR on the dates indicated above and agreed that changing the prescription affects the quality of dialysis. P-2: This 52-year-old was admitted to facility on 2/29/24 with diagnoses including end stage kidney disease; type 2 Diabetes; and liver failure. The medical record was reviewed on 1/8/25 and included the last 6 hemodialysis treatment flowsheets with dates between 12/23/24 through 1/7/25. During review, it was noted that the active physician order for the hemodialysis BFR was 450 mL/min, and DFR was 800 mL/min each treatment. There was also a “unique order” dated 2/27/24 which stated that BFR could range from 350-450 mL/min and DFR would be 2 times the BFR rate (not to exceed 800 mL/min). During review of the hemodialysis flowsheets, the following were noted: On the treatment flowsheet dated 12/23/24, the duration of the treatment was 3 hours and 16 minutes. The BFR was set at 250 mL/min (200 mL/min less than prescribed) for the entire treatment. The DFR was at 500 mL/min for the entire treatment. Although the “unique” order states that DFR should run 2 times the BFR (and 500 is 2 times 250), the lowest BFR order was for 350 and would have included a DFR rate of 700 mL/min. This DFR was 200 mL/min less than the lowest prescribed dose. On the treatment flowsheet dated 12/28/24, the treatment was started at 1101 and ended at 1416 (3 hours and 15 minutes). The BFR was ran at the prescribed rate of 450 for 2 hours and 6 minutes. At 1307, the BFR was increased to 500 mL/min (50 mL/min higher than ordered) and continued for the remainder of the treatment (1 hour and 9 minutes). There was no documentation explaining why the BFR was increased above the prescribed rate. On the treatment flowsheet dated 1/7/25, the treatment was started at 1105 and ended at 1427 (3 hours and 22 minutes). The BFR was 400 mL/min at 1105. At 1134, the BFR was increased to 500 mL/min and stayed at that rate for the rest of the treatment (2 hours and 48 minutes). There was no documentation explaining why the BFR was increased above the prescribed rate. During interview on 1/9/25 at 1430, the above findings were reviewed with Staff A, Staff B, and Staff K. Staff B stated that the BFR on 12/23/24 was likely due to the acceptable rate for needle size used to cannulate the access site however, acknowledged that there was no documented evidence that the physician was made aware of the need to run the BFR/DFR at this lower than prescribed rate and acknowledged that changing the prescription does affect the quality of the dialysis. Staff B was not able to provide evidence for why the BFR was increased above prescribed rates on 12/28/24 and 1/7/25. 47976 **Policy titled “Patient Monitoring Guidelines” (revised 5/18/2023) stated under “III. Monitoring During Dialysis” that, “1. The blood pressure, pulse, hemodialysis machine parameters, and patient response to treatment are assessed, documented at least every half hour (inpatient setting) and hourly (outpatient setting) on the hemodialysis flowsheet. If the patient condition warrants, vital signs will be monitored more frequently.” P-4: This 76-year-old patient was admitted to this dialysis facility on 3/28/23 with the diagnosis of end stage renal disease. During record review on 1/8/25, it was noted the treatment order dated 12/4/24 ordered the blood flow rate (BFR) to be run at 350 milliliters/minute (mL/min) and the dialysate flow rate (DFR) to be run at 800 mL/min. The orders also included an “Unique Order” dated 3/23/23 that stated, “BFR from 300 to 350” and one dated 3/28/23 that stated, “DFR 2x BFR to 800 max.” During review of the last 6 treatment sheets, it was noted the BFR was run at 350 mL/min and the DFR was run at 700 mL/min for the entire treatment on 1/2/25, 1/4/25 and 1/7/25. There was no documentation of why the DFR was run at 700 mL/min instead of the prescribed 800 mL/min, however, it is within the parameters of the unique orders. It is unclear which order staff should be following for daily treatments. During an interview with the Medical Director (Staff C) on 1/9/25 at 0950, Staff C was asked which order he expected the staff to follow. Staff C stated the staff should follow the orders as written originally, unless there is a documented reason to use the parameters included in the unique orders. During an interview on 1/9/25 at 1230, the Clinical Nurse Manager (Staff A), the Coordinator of Quality Compliance (Staff B), and the Clinical Education Manager (Staff K) were shown the treatment sheets for the dates above and were asked why the original order was not followed. Staff K stated 700 mL/min falls within the “DFR 2x BFR to 800 max” unique order, however, was unable to provide documentation for the reason for the change from the original order. Staff A, Staff B, and Staff K were informed of the interview with Staff C. They were also asked how staff were supposed to know which orders to follow. Staff A, Staff B, and Staff K agreed it is unclear and acknowledged the findings at the time of interview.”

“POC-OUTCOME NOT ACHIEVED-ADJUST POC CFR(s): 494.90(b)(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient’s current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section. This Standard is not met as evidenced by: 47976 Based on record review and interview, the facility failed to ensure the interdisciplinary team (IDT) adjusted the plan of care to meet fluid management needs in 1 (P-4) of 10 records reviewed, resulting in the potential for unmet patient needs and poor patient outcomes. Findings include: P-3: This 55-year-old patient was admitted to this dialysis facility on 6/5/09 with the diagnosis of end stage renal disease. During record review on 1/8/25, the following was noted: On the comprehensive assessment dated 9/9/24, it was noted under “Fluid Management” that the registered dietician (Staff M) indicated the patient’s goal was “Met”. Upon further review of the record, it was noted the patient’s estimated dry weight (EDW, goal weight the patient is expected to be after dialysis treatment) was 55 kilograms (kg). According to the data collected under the “Fluid Management” section, the patient did not meet the EDW goal of 55 kg for any of the 6 visits noted. During an interview on 1/9/25 at 1300, Staff M was asked how she determines a fluid management goal is met if the patient has not met the goal in the time frame referenced. Staff M stated it looked like the patient’s EDW needed to be adjusted to a higher number due to the patient consistently not meeting the goal, however, she was unable to provide documentation of this being communicated with the physician. Staff M acknowledged the goal does not appear to be met at this time. The findings were also reviewed with and acknowledged by the Clinical Manager (Staff A), the Coordinator of Quality and Compliance (Staff B), the Medical Director (Staff C), and the Regional Administrator (Staff D) at the time of the interview.”

“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: 38304 Based on observation, interview, and record review, the Medical Director failed to ensure staff follow policy for removal of expired supplies, securing medications, and documenting medication administration for 1 (P-8) of 8 in-center records reviewed, resulting in the potential for less-than-optimal outcomes for all patients. Findings include: On 1/8/25 at 1024, an inspection of patient care supplies located in the home PD (peritoneal dialysis) training room noted the following supplies had expired beyond the manufacturer’s safety for use date: Micropore medical tape (box one), expired on 10/2022. Micropore medical tape (box two), expired on 8/15/2023. Baxter Ultraset “CAPD Disposable Disconnect Y-Set” expired on 12/20/2024. Alcavis 50-High Level Disinfectant bottle had an expiration date of 5/12/2022. At the time of discovery, the home PD nurse (Staff N) was interviewed concerning the expired supplies. Staff N was noted that she did not have a routine which verified all patient care supplies located in the home PD training room were non-expired. On 1/9/25 at 0945, the above findings were reviewed with and acknowledged by the Medical Director (Staff C) during an interview on 1/9/25 at 0945. Staff C noted this did not meet Facility expectations of following its policy referenced below. Facility Policy: “Inventory Tracking and Supply Management” Section 4/V-4.1.1 (revised 09/2022) stated, “On a regular basis and at least monthly, medical supplies will be checked to determine inventory levels and verify expiration dates. Expired items will be discarded appropriately.” P-8: This 52-year-old male was admitted to the Facility on 1/6/21, with diagnoses which included end stage renal disease, hypertension, and anemia. On 1/8/25, record review of P-8’s treatment flow sheet dated 1/2/25, noted the treatment ran from 1231 to 1552. Further review found that registered nurse (Staff O) had documented “Labetalol (blood pressure medication) given” at 1501. The previous recorded blood pressure (190/116) was 2 hours earlier at 1302. No documentation was evidenced in the medical record of Staff O administering a dosage of Labetalol to P-8. This finding was reviewed and acknowledged by the Coordinator of Quality and Compliance (Staff B) and Dialysis Nurse Manager (Staff A) during interview on 1/9/25 at 1215. Staff B noted this did not meet Facility expectations or its policy referenced below. Facility Policy: “Storage and Preparation of Medications” (revised December/2023) Section 17 stated, “Documentation of medication administration in the medical record should occur as soon as possible after administration.” 37411 Facility Policy: “Storage and Preparation of Medications” (revised December/2023) Procedure stated, “3. Medications will be secured/locked when unattended by staff.” During a flash tour of the hemodialysis treatment floor on 1/7/25, it was noted the medication cart in the walkway connecting the first half of the treatment floor to the second half was unlocked at 1140. The following medications were noted within the med cart: Catapres, Labetalol, Nitroglycerin, and Clonidine. Additionally, another drawer contained a prescription bottle with 2 pills of Hydrocodone/Acetaminophen tab 7.5mg/325mg. The bottle was given to Clinical Nurse Manager (Staff A) when observed. Staff A returned them to the patient who stated she lost the bottle a few months ago. Observed 6 patients walk by med cart unattended by staff. During dialysis floor observation and tour on 1/8/25 at 1035, it was noted that the Pneumococcal 13-valent conjugate vaccine box expired 2024 December. The Electrode Pack for the AED was opened and dated and initialed with “Exp 4/22/24”. Notified Clinical Education Manager (Staff K) and confirmed they were indeed expired. These findings were reviewed and acknowledged by the Coordinator of Quality and Compliance (Staff B) and Dialysis Nurse Manager (Staff A) during interview on 1/9/25 at 1200.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 47976 Based on record review and interview, the facility failed to ensure the medical record was complete and accurate in 3 (P-3, 4, 5) of 10 records reviewed, resulting in the potential for poor patient outcomes. Findings include: P-3: This 55-year-old patient was admitted to this dialysis facility on 6/5/09 with the diagnosis of end stage renal disease. During record review on 1/8/25, it was noted the treatment order dated 3/16/24 ordered a maintenance dose of heparin (a medication used to prevent blood clotting) to be given at 500 units per hour. Upon review of the treatment sheet dated 12/24/24, it was noted the column showing the running heparin dosage was recorded as “0” for the entire treatment. Upon further review of this treatment sheet, it was noted the patient was given a total of 900 units of heparin for maintenance. It is unclear which value is true. P-4: This 76-year-old patient was admitted to this dialysis facility on 3/28/23 with the diagnosis of end stage renal disease. During record review on 1/8/25, it was noted the treatment order dated 12/4/24 ordered a maintenance dose of heparin to be given at 500 units per hour. Upon review of the treatment sheet dated 1/2/25, it was noted the column showing the running heparin dosage was recorded as “0” for the entire treatment. Upon further review of this treatment sheet, it was noted the patient was given a total of 1800 units of heparin for maintenance. It is unclear which value is true. During an interview on 1/9/25 at 1230, the Coordinator of Quality and Compliance (Staff B) was asked about the column showing “0” units of heparin had been given on those days. Staff B stated he hadn’t noticed that column before and thought it may be due to an electronic medical record error. Staff B acknowledged it is unclear how much heparin was delivered in the examples above and stated he will look into it. Findings were also reviewed with the Clinical Nurse Manager (Staff A), the Regional Administrator (Staff D), and the Clinical Education Manager (Staff K) at the time of the interview. 37411 P-5: This 46-year-old patient was admitted to this dialysis facility on 9/20/22 with the diagnoses of end stage renal disease and Diabetes Type 2. During record review on 1/8/25, it was noted the treatment dated 1/4/25 contained no “Hemodialysis Session Data” which notes BFR (Blood Flow Rate), VP (Venous Pressure), -AP (Arterial Pressure), TMP (Temperature), UFR (Ultrafiltration Rate), and DFR (Dialysate Flow Rate). This finding was reviewed and acknowledged by the Coordinator of Quality and Compliance (Staff B) and Dialysis Nurse Manager (Staff A) during interview on 1/9/25 at 1200.”