Greenfield Hs - Pontiac

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 47976 Based on observation, record review, and interview, the facility failed to ensure items taken into the dialysis station were cleaned or disinfected before being taken into a common area or used on another patient, resulting in the potential to spread infectious diseases to all 26 patients receiving in-center hemodialysis at this facility at the time of observation. Findings include: **Policy titled “Infection Prevention and Control Policy” (revised 10/2022) stated under “B. Infection Control Precautions for all patients:” that, “1. Items taken into a patient’s dialysis station, including those placed on top of dialysis machines, should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being returned to a common clean area or used on other patients.” During dialysis floor observation on 12/17/24 and 12/18/24, the following was noted: On 12/17/24 at 1028, Staff F (Certified Clinical Hemodialysis Technician) was observed taking the pH test strip container from the counter, bringing it into station #2 for testing, placing it on top of the dialysis machine, and then returning the container to the counter without disinfecting it first. On 12/17/24 at 1050, Staff F was observed getting the thermometer from the holder on the counter, taking it to station #2 to take the patient’s temperature, and returning it to the holder without disinfecting it first. On 12/17/24 at 1052, the staff were observed using the Hoyer lift (mechanical lift used for people who are unable to stand) on the patient at station #20. Afterwards, Staff E (Patient Care Technician) was observed rolling the Hoyer lift back to the corner for storage without disinfecting it first. Staff E was asked what the expectation was regarding cleaning the Hoyer lift after use. Staff E stated she wasn’t sure because she had “never been taught” about the Hoyer lift. On 12/18/24 at 0938, the staff were observed using a Hoyer lift on the patient at station #1. Afterward, another staff member (unidentified) was observed rolling the Hoyer lift back to the corner for storage without wiping it down first. On 12/18/24 at 1030, Staff H (Patient Care Technician) was observed taking the pH test strip container from counter, bringing it into station #19 for testing, placing it on top of the dialysis machine, and then returning the container to the counter without disinfecting it first. On 12/18/24 at 1155, Staff G (Patient Care Technician) was observed disinfecting the pH strip container after leaving a station. Staff G was asked what the expectation was for disinfecting items that enter the patient station. Staff G stated it is the expectation that any item that enters the patient’s station should be disinfected before returning it to another area. Findings were reviewed with and acknowledged by the Regional Administrator (Staff A) and Coordinator of Quality and Compliance (Staff C) during an interview on 12/19/24 at 1230.”

“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: 37411 Based on observation and interview, the facility failed to maintain a clean and safe environment, resulting in the potential for the spread of infectious agents and slipping hazard for the 28 patients receiving dialysis treatment at the time of observations. On 12/18/2024 at 0945, observation of the dialysis treatment floor across from station #22, noted an approximately 3-inch diameter of liquid on the floor, next to a gray bucket used to discard IV bags. At 1035 the same area was observed to additionally have liquid drops trailing across the floor, spanning approximately 1.5 feet into the pathway between sinks. The area was observed to be clear of liquid at 1145. Staff-A was interviewed on 12/19/24 at 1005 and stated, “Hourly rounds are expected to observe for potential safety hazards.” A policy was requested but not provided by the time of exit.”

“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 agency failed to ensure patient access sites were in view of staff during dialysis treatment of 4 patients, 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 12/17/24, the following was noted: At 0946, it was observed the access site for the patient at station #15 was completely covered by a blanket. At 0950, Staff H (Patient Care Technician) was observed cleaning the machine next to the patient. At 0956, another staff member (unidentified) was observed walking past the patient at station #15. At 1005, the patient’s access site was still covered. At 1010, the registered nurse (Staff D) was asked if she was able to see the access site for the patient at station #15. Staff D stated she could not and went to station #15 to uncover the patient’s access site. At 1143, it was observed the access site for the patient at station #6 was completely covered by blankets. From 1143-1153, Staff E (Patient Care Technician) was observed sitting at a computer facing station #6. Upon leaving the area, Staff E did not ask the patient to uncover the access site. At 1203, Staff E had not returned to the area, so Staff D was asked if she was able to see the access site for the patient at station #6. Staff D stated she could not and went to station #6 to uncover the patient’s access site. At 1320, it was observed the access site for the patient at station #22 was completely covered by a blanket. From 1320-1325, Staff I (Patient Care Technician) was observed documenting at a computer station directly in front of station #22. At 1325, Staff I was observed leaving the area and going into station #23 (isolation room). At 1355, it was noted Staff I had not returned to the area and the access site at station #22 was still completely covered. Staff D was asked if she was able to see the access site for the patient at station #22. Staff D stated she could not and went to station #22 to uncover the patient’s access site. At 1335, it was observed the access site for the patient at station #24 (isolation room) was completely covered by a blanket. From 1335-1350, Staff F (Certified Clinical Hemodialysis Technician) was observed sitting at a computer station facing station #24. At 1400, Staff F was asked if she could see the access site for the patient at station #24. Staff F stated she could not and that he “must have covered himself back up.” Findings were reviewed with and acknowledged by the Regional Administrator (Staff A) and Coordinator of Quality and Compliance (Staff C) during an interview on 12/19/24 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: 37411 Based on observation, interview, and record review, the facility failed to ensure confidentiality of protected medical information for the 98 patients scheduled to receive dialysis treatment on 12/17/2024 and 12/18/2024, resulting in the potential for unauthorized access to patient information. Findings include: On 12/17/2024 at 1100 through 1230 and on 12/18/2024 at 0930-1030, floor staff were observed to leave unattended daily patient schedules on the treatment carts. The patient’s names were visible while walking within the aisle to the treatment area. Review of Policy #4.1.5 “Privacy and Confidentiality” (Revised: 06/2021) stated, “Policy: Employees will observe and preserve the rights of the patient by providing for privacy and maintaining confidentiality.””

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 46476 Based on record review and interview, the facility failed to ensure the patient was informed about, and able to participate in treatment, in accordance with facility policy, regarding early termination of dialysis treatment by the patient for 1 (P-8) of 8 sampled in-center records reviewed resulting in the potential for the patient to be unaware of consequences for not receiving the full dialysis treatment. Findings include: Facility policy titled “Against Medical Advice”, Revised 02/2023, was reviewed on 12/19/24. On page 1-2., it stated “Policy ... When a patient chooses to refuse medical treatment, voluntarily shorten dialysis treatments ... and/or leave the unit AMA, it is the physician/Advanced Practitioner (APP)/ nurse’s responsibility to educate the patient on complications and document the discussion ... Once the patient’s decision to leave AMA is final, the physician/APP/nurse will complete the following documentation: The patient will be asked to sign and date on the AMA form.” P-8: This 45-year-old was admitted to the facility on 6/14/19 with end stage kidney disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 12/18/24 and included 6 in-center hemodialysis treatment sheets between the dates of 12/9/24 and 12/17/24. The active physician orders for dialysis included a treatment duration of 240 minutes each treatment, 4 times per week. It was also noted that P-8 had a “Unique Order” beginning on 10/23/24 which stated “extra treatment per dr due to fluid overload” [sic]. During review, the following shortened treatments were noted: On the treatment sheet dated 12/9/24, treatment started at 0536 and ended at 0737 (121 minutes). There were no clinical notes entered which explained why the treatment ended 119 minutes early, if education of possible complications was provided, or if an Against Medical Advice (AMA) form was signed. On the treatment sheet dated 12/12/24, treatment started at 0655 and ended at 1009 (194 minutes). There were no clinical notes entered which explained why treatment ended 46 minutes early, if education of possible complications was provided, or if an AMA form was signed. On the treatment sheet dated 12/17/24, treatment started at 0636 and ended at 1014 (218 minutes). There were no clinical notes entered which explained why treatment ended 22 minutes early, if education of possible complications was provided, or if an AMA was signed. These findings were reviewed with the Regional Administrator (Staff A) and the Coordinator of Quality and Compliance (Staff C) during interview on 12/19/24 at 1330. Staff C stated that at one point prior to the treatments noted above, a nurse entered a note that a 4th treatment could be shortened however, this was not transcribed on the physician orders sheet and not clear if it was meant only for a particular day or meant to be ongoing. None of the active physician orders for the period reviewed stated a time less than 240 minutes per treatment. This was acknowledged by Staff A and Staff C.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 38304 Based on record review and interview, the Facility failed to ensure the Initial Nursing Assessment (INA) was completed by a registered nurse prior to the start of the first treatment in 2 (P-1 and P-6) of 8 in-center records, out of a total sample of 10 records reviewed, resulting in the potential for poor patient outcomes. Findings include: P-1: This 34-year-old patient started dialysis treatment at this Facility on 12/2/24, with the diagnosis of which included end-stage renal failure, hypertension, and anemia. During record review on 12/18/24, it was determined that the INA did not have a time of completion documented by the registered nurse to determine whether it had taken place prior to initiation of the first dialysis treatment. This finding was reviewed with and acknowledged by the Regional Administrator (Staff A) during an interview on 12/18/24 at 11:35. Staff A verified the Facility was unable to determine if the INA had occurred prior to P-1’s first dialysis treatment as stipulated by Facility policy below. Agency Policy: “Patient Assessment and Care Planning” No. 4.2 (Revised 7/12/2024) stated, “A nursing evaluation/assessment must be completed before the first treatment is started... The note should be titled: “Initial Nursing Evaluation” and is an assessment the day the patient comes to first treatment which should be completed before the first treatment is started.” 46476 P-6: This 64-year-old was admitted to the facility on 8/15/24 with end stage kidney disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 12/18/24. During review, it was noted that P-6’s first hemodialysis treatment was started at 0607 on 8/15/24. The INA was documented at 0822 (2 hours 15 minutes later). This finding was reviewed with the Regional Administrator (Staff A) and the Coordinator of Quality and Compliance (Staff C) during interview on 12/19/24 at 1330. Staff C stated that a lot of times the nurse will complete the assessment before the dialysis treatment is started but not document it until later. Staff C was asked if the nurse did the assessment prior to the treatment in this case. Staff C acknowledged that it could not be determined from the documentation and appeared as if the assessment was not completed until after the treatment had already started.”

“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: 46476 Based on observation, record review and interview, the facility failed to deliver the prescribed blood flow rate (BFR) and dialysate flow rate (DFR) for 1 (P-4) of 8 in-center patient records reviewed; and failed to ensure patient treatments were delivered as prescribed by an emergency order of the Medical Director in 3 (P-5, 6 and P-8) of 8 sampled in-center patient records resulting in staff not being aware of what dialysate flow rate to use and the potential to poorly impact dialysis adequacy and/or facility supplies. Findings include: On 12/18/24, a request was made to review an emergency physician order written for DFR changes due to a prescription observation on the treatment floor earlier in the day. A handwritten document with a physician order written by the Medical Director (Staff B) and dated 11/30/24 was provided and reviewed. The order stated, “Dialysate flow to be set at 500 for all patients due to a 2 K shortage”. There was no end date, and no additional instructions on the order. P-6: This 64-year-old was admitted to the facility on 8/15/24 with end stage kidney disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 12/18/24 and included 6 in-center hemodialysis treatment sheets between the dates of 12/4/24 and 12/14/24. Recent dialysis adequacy (amount of dialysis delivered to the patient and measured in Kt/V where K=clearance; t=time; and V=volume) labs were also reviewed. P-6’s recent dialysis adequacy labs included a result on 11/6/24 of 1.69 Kt/V, and a result on 12/4/24 of 1.57 Kt/V. On the treatment sheet dated 12/6/24, the Dialysate Flow Rate (DFR) was run at 800 milliliters/minute (mL/min) for the duration of treatment (243 minutes). There were no clinical notes entered which explained the DFR being run at 800 mL/min (versus the emergency order for 500 mL/min). P-8: This 45-year-old was admitted to the facility on 6/14/19 with end stage kidney disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 12/18/24 and included 6 in-center hemodialysis treatment sheets between the dates of 12/9/24 and 12/17/24. Recent dialysis adequacy labs were also reviewed. P-8’s recent dialysis adequacy labs included a result on 11/7/24 of 1.54 Kt/V, and a result on 12/10/24 of 1.21 Kt/V. On the treatment dated 12/10/24, treatment started at 0655. The DFR was ran at 800 mL/min from 0655 to 0840 (105 minutes). At 0900, the DFR was changed to 500 mL/min (300 mL/min less), and continued at that rate until the end of treatment at 1057 (117 minutes). There were no clinical notes entered which explained the change in DFR. On 12/19/24 at 1005, interview was conducted with Staff B. Staff B was asked about the emergency order. Staff B stated the facility should be setting the DFR for hemodialysis to 500 mL/min due to a dialysate supply shortage. Staff B was asked if the facility intended for all in-center hemodialysis patient’s to have the DFR ran at 500 mL/min each treatment while the order was in effect, or whether there would be situations when the DFR would remain at a patient’s individually prescribed rate (if higher than the emergency order). Staff B stated consideration would be made if a patient was not meeting their dialysis adequacy goal. Staff B stated the minimum adequacy goal was 1.2 Kt/V for all hemodialysis patient’s and that this was measured by drawing labs at scheduled times for each patient. Staff B also stated if a patient was regularly meeting dialysis adequacy at 1.2 Kt/V with a DFR higher than 500 mL/min, the facility would not want to decrease the DFR to 500 mL/min for that patient due to the risk of reducing adequacy. Staff B was asked who determined if the DFR would be changed or maintained for patient’s each day. Staff B stated that the charge nurse on duty would make that determination and that it should be documented. On 12/19/24, two nurses were working on the hemodialysis treatment floor. The following interviews were conducted: At 1117, Staff K, a registered nurse (RN), was asked what she knew about an emergency order regarding DFR’s. Staff K explained that the emergency order stated the DFR was to be run at 500 mL/min. Staff K was asked if there would ever be a time that the DFR should be run at a rate different than 500 mL/min. Staff K stated no, all patients are to be run at 500 mL/min. At 1120, Staff J, an RN, was asked to explain what she knew about the emergency order regarding DFR’s. Staff J stated she did not know anything about an emergency order. Staff J was also asked if she had been told to run DFR’s at 500 mL/min. Staff J stated she has been running the DFR at whatever rate is on the prescription in the EMR. These findings were reviewed and acknowledged by the Regional Administrator (Staff A) and the Patient Care Technician Team Lead (Staff H) during interview on 12/19/24 at 1330. Staff H stated that each patient’s individual prescription was not changed in the EMR with the emergency order and auto populated when the patient was entered on the hemodialysis computer. Staff H stated that because of that, it was easy to overlook the DFR at the time of setting the dialysis up. 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 68-year-old patient was admitted to this dialysis facility on 10/16/24 with the diagnosis of end stage renal disease. During record review on 12/18/24, it was noted the treatment order (dated 11/15/24) ordered the blood flow rate (BFR) at 400 milliliters/minute (mL/min) and the dialysate flow rate (DFR) at 800 mL/min. Upon review of the daily treatment sheet dated 11/25/24, it was noted the BFR was run at 300 mL/min and the DFR was run at 600 mL/min for the entire treatment (214 minutes on this day). There was no documentation regarding the reason for the change in flow rates. Findings were reviewed with and acknowledged by the Regional Administrator (Staff A) and Coordinator of Quality and Compliance (Staff C) during an interview on 12/19/24 at 1230. During dialysis floor observation on 12/18/24 at 1000, Staff L (Patient Care Technician) was asked to verify the prescription was being run at the ordered rate at station #13. During the observation, it was noted the printed prescription ordered a blood flow rate (BFR) of 400 milliliters/minute (mL/min) and a dialysate flow rate (DFR) of 800 mL/min. Upon checking the machine, it was noted the DFR was being run at 500 mL/min. When asked why the DFR did not match the written prescription, Staff L stated she doesn’t usually work there, but “was told” to run it at 500 mL/min due to a “water problem or something.” After overhearing the conversation, Staff H (Patient Care Technician) reported the doctor wrote an order for the DFR to be run at 500 mL/min due to a supply shortage. Staff H was able to provide a written order dated 11/30/24 that stated, “Dialysate flow to be set at 500 for all patients due to a 2 K shortage.” There was no duration or additional instructions noted on the order. P-5: This 74-year-old patient was admitted to this facility on 7/8/22 with the diagnosis of end stage renal disease. During review of the last 6 treatment sheets on 12/18/24, it was noted the DFR was run at 500 mL/min on 12/6/24, 12/7/24, 12/10/24, and 12/12/24. The DFR was run at 800 mL/min on 12/14/24 and 12/17/24. There was no documentation explaining the reason for the change back to the original order. During an interview with the medical director on 12/19/24 at 0930, the Medical Director (Staff B) was asked about the emergency order. Staff B stated the DFR should be run at 500 mL/min at this time due to a supply shortage. Staff B was asked why a patient might be run at 800 mL/min based on record findings for P-5 above. Staff B stated if a patient is not meeting their adequacy goal, they may be run at a higher rate. Staff B was also asked who made that determination for daily treatments. Staff B stated the charge nurse would oversee that decision to instruct the staff on what the DFR should be run at for those patients. Staff B stated this should be documented in the record. During an interview on 12/19/24 at 1117, Staff K (Registered Nurse) was asked what she knew about an “Emergency Order.” Staff K reported the Emergency Order stated the dialysate flow rate (DFR) was to be run at 500 milliliters/minute (mL/min) for all patients. Staff K was asked if there would ever be a time that the DFR would be run at a rate other than 500 mL/min per the emergency order. Staff K stated no, all patients are to be run at 500 mL/min at this time. During an interview on 12/19/24 at 1120, Staff J (Registered Nurse) was asked to explain what she knew about the “Emergency Order.” Staff J was confused and stated she did not know anything about an emergency order. Staff J was also asked if she had been told to run the DFR at 500 mL/min for all patients. Staff J stated she runs the DFR at the rate on the individual patient prescription. Based on the findings and interviews above, there was confusion on the emergency order and a lack on communication regarding which orders staff should follow for daily dialysis treatment. Additionally, there was no documentation in the record for P-5 that indicated a decision to discontinue the emergency order and change the patient’s order back to the original presciption. Findings were reviewed with and acknowledged by the Regional Administrator (Staff A) and Coordinator of Quality and Compliance (Staff C) during an interview on 12/19/24 at 1230.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 47976 Based on record review and interview, the facility failed to ensure all members of the interdisciplinary team (IDT), including the patient or patient’s designee, signed the plan of care in 1 (P-4) of 10 records reviewed, resulting in the potential for lack of involvemnt of the IDT and poor patient outcomes. Findings include: **Policy titled “Patient Assessment and Care Planning” (revised 7/12/2024) stated under “Frequency of Assessment and Plan of Care” on page 2 stated, “The care plan should be dated to indicate when the plan was initiated, and all members of the IDT (interdisciplinary team) will sign the assessment and plan of care.” P-4: This 68-year-old patient was admitted to this dialysis facility on 10/16/24 with the diagnosis of end stage renal disease. During record review on 12/18/24, it was noted the signature page for the initial plan of care dated 11/1/24 was missing signatures from the patient and the physician. There was no documentation of the reason for the missing signatures. Findings were reviewed with and acknowledged by the Regional Administrator (Staff A) and Coordinator of Quality and Compliance (Staff C) during an interview on 12/19/24 at 1230.”

“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: 38304 Based on record review and interview, the Facility failed to document and maintain accurate records for 1 (P-2) of 2 home PD (peritoneal dialysis) patients, out of a total sample of 10 records reviewed, resulting in the potential for adverse patient outcomes for all 13 patients currently receiving services within the home dialysis program at this Facility. Findings include: P-2: This 68-year-old male was admitted to the Facility’s in-center dialysis program on 7/27/2022, with diagnoses which included chronic kidney disease, renal osteodystrophy, anemia, hypertension, and fluid overload-unspecified. P-2 had transitioned to the Facility’s dialysis home program on 6/25/24. On 12/18/24, review of P-2’s initial Plan of Care (POC) performed by the IDT (inter-disciplinary-team) on 7/16/24 noted the following inaccuracies and omissions: Under “Current Status” P-2 was listed as “Not Stable” which was found to be in error. Also, the POC section which addressed blood pressure (BP) management documented P-2’s goal were met but was void of any BP data/readings throughout the entire IDT evaluation. Further review of P-2’s subsequent POC performed by the IDT on 10/15/24 noted the following inaccuracies and omissions: The POC section which addressed BP management documented P-2’s goal were met but again was void of any BP data/readings throughout the entire IDT evaluation. The IDT member of Skilled Nursing documented, “He (P-2) has struggled recently with his diet, and he wants to lose weight. His wife, who is a nurse, has noted some swelling in his legs. These were discussed with him and the team.” However, the Dietician IDT member documented, “EDW: 120 kg (264 pounds) ... (P-2) states a desire for weight loss as he wants transplant... He has lost 27 kg. /59 pounds or 22% since starting PD. Current weight is 93 kg. (205 pounds). This significant finding was found to be in error as P-2 has maintained his of original weight of 264 pounds as of 12/18/24. This error failed to be noticed during IDT discussions pertaining to P-2’s current POC. In addition, the 10/15/24 POC was authenticated (handwritten date and signature) by each team member (Physician, Nurse, Dietician, Social Worker, Patient/Representative) as “9/15/24” or one month earlier than it should. The above findings were reviewed and acknowledged by the Regional Administrator (Staff A) during an interview on 12/19/24 at 12:25 PM. Staff A noted this did not meet Facility expectations or its policy referenced below. Facility Policy: “Clinical Documentation” ID No. 10453313 (Dated 2/23/2022) stated, “The primary purpose of complete and accurate patient record documentation is to foster quality and continuity of care. Clinicians are required to document in compliance with all federal, state, and local laws and Medical Staff Rules and Regulations.””

“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: 38304 Based on observation, interview, and policy review, the facility failed to monitor for a sanitary environment to minimize the transmission of infectious agents by failing to separate dirty/contaminated items from designated “clean areas” and failing to ensure cleaning supplies were not expired, potentially effecting all 94 in-center hemodialysis patients currently receiving treatment, resulting in an increased potential for infections. Findings include: On 1/8/24 at 1012 through 1018, it was observed during treatment floor observations, that all designated “CLEAN SINK” areas (4 of 4) had open garbage containers and red biohazard containers stored within 2 inches of all “CLEAN SINK” areas. The Facility Administrator (Staff A) acknowledged the findings on 1/8/24 at 1035. Staff A was noted this did not meet facility expectations or its policy referenced below. Facility Policy: “Infection Prevention and Control Policy”, No. I-3.1.1, (Revised 10/22) stated, “The hand hygiene sink is considered a “clean” area. The hand hygiene sink is a clean area, and no blood collection tubes, or other “dirty” items may be placed near it. Lab collection holders and lab specimens must be maintained in a “dirty” area.” 47976 **Policy titled, “Inventory Tracking and Supply Management” (revised 9/2019) 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. Items will be ordered so they can be received in time to replace or replenish the stock.” During dialysis floor observation on 1/8/24 at 1110, it was noted that a container of Sani-Cloth disinfectant wipes on the counter near station #20 had an expiration date of 12/2022. The Facility Administrator (Staff A) was made aware at the time of discovery. She acknowledged the findings.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 38304 Based on observation, interview, and policy review, the facility failed to ensure that expired medications were not available for patient use, resulting in the potential for less-than-optimal outcomes for the 15 patients being treated in the facility’s Home Program. Findings include: On 1/8/2024, it was observed during the tour of the facility’s Home Program at 1145, a medication refrigerator designated for patient use, contained an un-opened supply of 10 single dose 0.5 ml. syringes of Pneumococcal vaccine, which had an expiration date of 1/29/2023. Prior the time of discovery above at 1135, the Home Program’s nurse (Staff C) was queried when supply inventory was checked for expiration dates. Staff C replied, “At least every three months or quarterly.” The facility’s Administrator during an interview on 1/8/24 at 1310, acknowledged the finding and was noted this did not meet facility expectations or its policy referenced below. Facility Policy: “Inventory Tracking and Supply Management” No. V-4.1.1, (Revised 09/2019) 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. Items will be ordered so they can be received in time to replace or replenish the stock. Incoming supplies are received, inspected for any packaging issues and expiration dates. Supplies will be rotated when restocked (first in first out).””

“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 each patient’s vascular access site and blood line connections were in view of staff during dialysis treatment at 5 of 24 (#6, 11, 12, 15, 23) stations, 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 5/18/23) state, “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.” Policy titled, “Against Medical Advice (AMA)” (revised 2/2023) stated, “Safe practices as described in this policy include but are not limited to keeping access arm visible and keeping face visible during treatment.” During dialysis floor observation on 1/8/24 and 1/9/24, the following observations were made: 1)On 1/8/24 at 1107, it was noted the access site for the patient at stations #12 and #15 were completely covered. At 1122 after several staff members were observed walking past these stations, patient care technician (Staff M) was queried whether she was able to see the access site for the patient at station #12 and #15. Staff M reported she could not see it and went to uncover the patients. She reported the patients always cover themselves back up. 2) On 1/8/24 at 1120, it was noted the access site for the patient at station #11 was covered by his shirt and a blanket. At 1132, registered nursed (Staff O) was observed going to station #11 to turn off the machine alarm. Staff O returned to the nurse’s station without uncovering the patient. At 1135, Staff O was asked if he was able to see the access site on the patient at station #11. Staff O returned to station #11 to uncover the site and asked, “Like that? Is it supposed to be like that?” 3) On 1/8/24 at 1430, it was noted the access site for the patient at station #6 was completely covered by a blanket. His head was also completely covered. At 1438, patient care technician (Staff P) was observed going to station #6 to check the machine and the patient. Staff P then left the station without uncovering the patient. Another staff member was also seen walking by this station without uncovering the patient. At 1440, Staff P was made aware of the situation and uncovered the patient. 4) On 1/9/24 at 1130, it was noted the access site for the patient at station #6 was completely covered by a red blanket. From 1130 to 1145, 2 staff member were observed facing the patient at the medication counter, 1 staff member was observed walking by the station and another staff member (Staff O) was observed working at computer station directly in view/facing station #6. At 1145, Facility Administrator (Staff A) came onto the treatment floor, and she was asked what she thought about the access sites not being visible at station #6. Staff A went to the 2 staff members working near that station and pointed out the situation, which was then resolved. Staff A stated she just had a meeting that morning reminding staff to remember to always look for that. She stated it is her expectation that staff should be continually looking at the patients for this, even if it is not in their section. Findings were again reviewed with and acknowledged by Staff A during an interview on 1/10/24 at 1400. 46476 On 1/8/24 during incenter hemodialysis treatment floor flash tour at 1010, it was noted that station #23 was an isolation room and a patient was receiving hemodialysis treatment in the room. Station #23 was at one end of the treatment floor and had large viewing windows which faced the rest of the treatment floor and staff documentation area. The entrance door to station #23 was facing another isolation room (station #24) across from it. There was a large mirror near the entrance to station #23 facing into the room so that visualization of the patient could be made with the mirror from that angle. During the tour, it was noted that the privacy curtain in station #23 was pulled 90% of the way across the windows, obstructing staff view of the patient. Additionally, the light in the room was off and the room was dark which made viewing the patient’s face, vascular access, or blood line connections with the mirror, difficult from any area (the treatment floor or staff documentation area). Upon closer inspection, the patient in station #23 was resting quietly with eyes closed and was covered by a blanket (potentially sleeping and unaware of events occurring during treatment). This was brought to the attention of the Team Lead, Staff F at the time of the finding. Staff F stated that the patient had a call light in hand, and they (staff) only schedule patients that are alert and independent in this room. This patients face, vascular access, and blood line connections were not able to be seen by staff due to the curtain being pulled and light being off. This finding was reviewed and acknowledged during interview on 1/10/24 at 1030 with the Facility Administrator (Staff A) and the Covering Medical Director (Staff O).”

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 46476 Based on record review and interview, the facility failed to ensure the patient signed Against Medical Advice (AMA) documentation for early termination of hemodialysis treatments per facility policy in 4 (P #’s 1, 2, 5, and 7) of 8 sampled incenter records reviewed resulting in the potential for these patients being uninformed of their right to participate in their treatment and the consequences of early termination of treatments. Findings include: Facility policy titled “Against Medical Advice (AMA)”; Last revised 02/2023, was reviewed on 1/10/24. On page 1., it stated “The patient has the right to refuse medical treatment and/or leave the dialysis unit against medical advice (AMA). When a patient chooses to refuse medical treatment, voluntarily shorten dialysis treatments or refuses to follow safe, in unit, practices and/or leave the unit AMA, it is the physician/Advanced Practitioner (APP) /nurse’s responsibility to educate the patient on complications and document the discussion.” On page 2., it stated “Once the patient’s decision to leave AMA is final, the ... nurse will complete the following documentation: The patient will be asked to sign and date on the AMA form. If the patient refuses to sign, document on the form that the patient refused to sign and add to the medical record.” P-5: This 69-year-old was admitted to the facility on 6/24/19 with end stage kidney disease; high blood pressure; and type 2 Diabetes. The medical record was reviewed on 1/9/24 and included 6 hemodialysis flowsheets between the dates of 12/21/23 and 1/6/24. The active physician orders for the period reviewed included a hemodialysis treatment duration of 225 minutes each treatment. On the flowsheet dated 12/21/23, the total treatment duration was 129 minutes (96 minutes less than prescribed). There was no signed AMA form found for the date above which would have indicated that P-5 was informed of the health consequences associated with early termination or that doing so was against medical advice. P-7: This 78-year-old was admitted to the facility on 10/15/13 with end stage kidney disease and type 2 Diabetes. The medical record was reviewed on 1/9/24 and included 6 hemodialysis flowsheets between the dates of 12/30/23 and 1/8/24. The active physician orders for the period reviewed included a hemodialysis treatment duration of 255 minutes each treatment. On the flowsheet dated 1/3/24, the total treatment duration was 234 minutes (21 minutes less than prescribed). On the flowsheet dated 1/8/24, the total treatment duration was 183 minutes (72 minutes less than prescribed). There were no signed AMA forms found for those dates which would have indicated that P-7 was informed of the health consequences associated with early termination or that doing so was against medical advice. These findings were reviewed and acknowledged during interview on 1/10/24 at 1400 with the Facility Administrator (Staff A). 47976 P-1: This 60-year-old patient was admitted to this dialysis facility on 12/4/23 with the diagnosis of end stage renal disease and was receiving dialysis treatments 3 times per week. During record review of the last 6 treatment sheets on 1/9/24, it was noted the patient’s visit was shortened by 82 minutes on 12/23/23 and by 38 minutes on 12/31/23. During an interview on 1/10/24 at 1100, the Facility Administrator (Staff A) was queried regarding AMA sheets being filled out and signed for these dates or if there was any other documentation to show why the visit was shortened that may not require an AMA form per their policy (transportation, for example). Staff A was unable to provide filled out AMA forms or evidence of why the visit was shortened. She acknowledged the findings. P-2: This 75-year-old patient was admitted to this dialysis facility on 10/1/23 with the diagnosis of end stage renal disease due to diabetes and hypertension (high blood pressure). During record review of the last 6 treatment sheets on 1/9/24, it was noted the patient’s visit was shortened by 74 minutes. During an interview on 1/10/24 at 1100, the Facility Administrator (Staff A) was queried regarding AMA sheets being filled out and signed for these dates or if there was any other documentation to show why the visit was shortened that may not require an AMA form per their policy (transportation, for example). Staff A was unable to provide filled out AMA forms or evidence of why the visit was shortened. She acknowledged the findings.”

“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: 38304 Based on record review and interview, the facility failed to notify the physician of 2 patients (P-1, 8) post-dialysis weights significantly less than target weight, out of a total sample of 8 patients, resulting in the potential for less-than-optimal outcomes for all 94 patients currently receiving services at this facility. Findings include: Review of P-8’s medical record on 1/9/2024 revealed a 77-year-old male admitted to the in-center unit at this dialysis facility on 5/20/23, with a past medical history which included end-stage renal disease, bilateral below the knee amputation, anemia, and diabetes-type 2. P-8’s dialysis schedule was every Tuesday, Thursday, and Saturday. Review of P-8’s active treatment orders (effective 9/18/23) noted the prescribed target weight (TW) was 79.0 Kg. or 174 pounds. Review of P-8’s six most recent treatment sheets revealed the following: On 12/26/23; post-treatment weight of 78.9 Kg. On 12/28/23; post-treatment weight of 78.3 Kg. On 12/30/23; post-treatment weight of 78.6 Kg. On 01/02/24; post-treatment weight of 78.8 Kg. On 01/04/24; post-treatment weight of 75.2 Kg. On 01/06/24; post-treatment weight of 73.4 Kg. During an interview on 1/10/24 at 1220, the facility’s Administrator (Staff A) reviewed and acknowledged the above findings. Staff A was noted this represented a significant change in the patient’s baseline and that staff should have notified the physician per facility policy referenced below: Facility Policy: “Patient Monitoring Guidelines” (Revised 5/18/2023) stated, “Reporting Guidelines: Dialysis staff should report abnormal findings and/or vital signs that vary from the listed parameters and are not limited to the situations listed below. These must be reported to the patient’s nephrologist or advance practice provider (APP), unless otherwise directed by the supervising physician/APP. 1) Patient weight less than dry weight (target weight).” 47976 P-1: This 60-year-old patient was admitted to this dialysis facility on 12/4/23 with the diagnosis of end stage renal disease and was receiving dialysis treatments 3 times per week. During record review on 1/9/24, the most recent active orders (dated 9/25/23) showed the prescribed target weight (TW) to be 79.5 kilograms (kg). Review of P-1’s 6 most recent hemodialysis flowsheets revealed the following regarding weights pre-treatment and post-treatment: On 12/23/23: pre-treatment = 71.4 kg, post-treatment 71.2 kg On 12/24/23: pre-treatment =71.2 kg, poste-treatment 68.2 kg On 12/27/23: pre-treatment = 73.2 kg, post-treatment 72.0 kg On 12/31/23: pre-treatment = 67.6 kg, post-treatment 66.5 kg On 1/5/24: pre-treatment = 72.0 kg, post-treatment = 71.0 kg On 1/8/24: pre-treatment = 70.2 kg, post-treatment = 69.6 kg During an interview on 1/10/24 at 1100, the Facility Administrator (Staff A) was queried on how the facility determines when a target weight should be changed. Staff A reported that there are monthy checks done for all patients and the physician should be notified in signifcant changes above as per facility policy. She acknowledged the findings.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 47976 Based on record review and interview, the facility failed to ensure each patient new to dialysis had a comprehensive assessment completed within 30 days or 13 treatments of admission in 1 (Patient #1) of 10 records reviewed, resulting in the potential for poor patient outcomes. Findings include: P-1: This 60-year-old patient was admitted to this dialysis facility on 12/4/23 with the diagnosis of end stage renal disease and was receiving dialysis treatments 3 times per week. During record review on 1/9/24, it was noted the 30-day comprehensive assessment should have been completed by 1/3/24 and had not been completed yet. During an interview on 1/10/24 at 1100, the Facility Administrator (Staff A) was queried whether this assessment had been started or scheduled or if there was any documentation as to why it was not done yet. Staff A reported it has not been started or scheduled due to the Medical Director being on vacation in Pakistan until later this month. Staff A acknowledged the facility should have another physician or nurse practitioner stand in for the Medical Director to ensure care plans are completed in a timely manner.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) 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- (1) At least annually for stable patients; This Standard is not met as evidenced by: 46476 Based on record review and interview, the facility failed to complete an annual comprehensive reassessment in 2 (P #’s 6 and 3) of 8 sampled incenter records reviewed resulting in a lack of assessment findings for development of the plan of care and potential for current health status and treatment needs to go unrecognized. Findings include: Facility policy titled “Patient Assessment and Care Planning”; Revised: 08/2020, was reviewed on 1/10/24. On page 2., it stated: “A comprehensive IDT reassessment of each patient and a revision of the plan of care will be conducted (1) At least annually for stable patients ...” P-6: This 76-year-old was admitted to the facility on 5/27/21 with end stage kidney disease and diabetes. The medical record was reviewed on 1/9/24 and included the annual comprehensive reassessment for 2022 and 2023. During review it was noted that the comprehensive reassessment dated 8/23/22 was absent of all nursing and social worker assessment documentation including patient’s current status; complaints; physical assessment and vital signs; cardiopulmonary health; blood pressure and fluid management; anemia; dialysis adequacy; dialysis access; infection; psychosocial; modality options; disaster review; dialysis experience; medication review; falls review; and check point (timing of assessment). The annual comprehensive reassessment dated 8/23/22 was not completed. During interview with the Facility Administrator (Staff A) on 1/9/24 at 1345, Staff A stated that the reassessment was overlooked at the time due to the patient schedule and acknowledged that it was never completed. 47976 P-3: This 44-year-old patient was admitted to this dialysis facility on 6/14/19 with the diagnosis of end stage renal disease and was receiving dialysis treatments 3 times per week. During record review on 1/9/24, the most recent comprehensive assessments were reviewed. Upon review of the annual comprehensive assessment dated 12/21/22, it was noted the entire sections for the nurse and the social worker were left completely blank. This included the sections for: current status (stable versus unstable), physical assessment and pain, cardiopulmonary health, blood pressure and fluid management, anemia, bone health, dialysis adequacy, dialysis access, infection, vaccinations, psychosocial evaluation, modality options, disaster review, dialysis experience, medication review, and falls review. The last page of the assessment included a signature by the registered nurse on 12/20/22 indicating that the assessment was complete. There was no signature recorded by the social worker. During an interview on 1/10/24 at 1100, the Facility Administrator (Staff A) was shown the blank assessments and asked if there was documentation anywhere else that completed it. Staff A was unable to provide any evidence of this comprehensive assessment being completed. She reported that this is unacceptable and acknowledged the findings.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 38304 Based on record review and interview, the facility failed to ensure MSW (Master of Social Work) services participated and developed a Plan of Care (POC) for 1 (P-8) of 8 in-center patients reviewed, out of a total sample of 8 in-center records, resulting in the potential for less-than-optimal outcomes for all 94 in center-patients receiving services at this facility. Findings include: Review of P-8’s medical record on 1/9/2024 revealed a 77-year-old male admitted to the in-center unit at this dialysis facility on 5/20/23, with a past medical history which included end-stage renal disease, bilateral below the knee amputation, anemia, and diabetes-type 2. P-8’s dialysis schedule was every Tuesday, Thursday, and Saturday. P-8’s POC was changed to “Unstable” on 5/15/23 due to hospitalizations relating to co-morbid complications. Further review of P-8’s monthly POC’s (dated 5/15/23 and 6/16/23) each revealed the entire “PSYCHOSOCIAL” was void of any documentation in 9 of 9 assessments each. The team member who is responsible for the psychosocial content is MSW (Master of Social Work) services, which had no POC signatures evidenced on 5/15/23 and 6/16/23. During an interview with the facility Administrator (Staff A) on 1/10/24 at 1230, the above findings were reviewed and acknowledged. Staff A noted two per-diem (as needed) MSW’s are filling in until a full-time MSW is hired. The facility failed to be compliant with its policy referenced below. Facility Policy: “Patient Assessment and Care Planning” No. I-4.2 (Revised 08/2020) stated, “The facility ’ s interdisciplinary team (IDT), consists of the patient or the patient ’ s designee (if the patient chooses), a registered nurse, a physician treating the patient for AKI/ESRD, a social worker (MSW), and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive IDT assessment will be used to develop the patient ’ s treatment plan and expectations for care.””

“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: 46476 Based on record review and interview, the facility failed to ensure the physician was notified of patient findings during dialysis treatments which were outside of facility policy reportable parameters in 3 (P #’s 1, 5, and 6) of 8 incenter records reviewed potentially resulting in poor patient outcomes. Finding included: Facility policy titled “Patient Monitoring Guidelines”; Revised: 05/18/2023, was reviewed on 1/10/24. On page 2., it stated: “V. Reportable Guidelines: Dialysis staff should report abnormal findings and/or vital signs that vary from the listed parameters and are not limited to the situations listed below. These must be reported to the patient’s nephrologist or advance practice provider (APP), unless otherwise directed by the supervising physician/APP ... 3. Patient Ultrafiltration rate over 13ml/kg/hour ... 6. Pulse greater than 110 bpm or less than 60 bpm ...” P-5: This 69-year-old was admitted to the facility on 6/24/19 with end stage kidney disease; high blood pressure; and type 2 Diabetes. The medical record was reviewed on 1/9/24 and included 6 hemodialysis flowsheets between the dates of 12/21/23 and 1/6/24. During review of the hemodialysis flowsheet dated 12/21/23, it was noted that the delivered Ultrafiltration Rate (UFR, rate at which fluid is removed from the patient during dialysis treatment) was 18.8 milliliters/kilogram/hour (mL/kg/hour). The UFR was delivered at 5.8 mL/kg/hour greater than the reportable parameter per policy. There was no documentation indicating why the UFR was delivered at this higher rate or that the physician was notified. P-6: This 76-year-old was admitted to the facility on 5/27/21 with end stage kidney disease and diabetes. The medical record was reviewed on 1/9/24 and included 6 hemodialysis flowsheets between the dates of 12/22/23 and 1/8/24. During review the following were noted: On the hemodialysis flowsheet dated 12/22/23, P-6’s pulse was checked a total of 7 times during treatment. The pulse was documented to be between 43-47 beats per minute (bpm) for the entire 251-minute treatment. On the hemodialysis flowsheet dated 12/27/23, P-6’s pulse was checked a total of 5 times during treatment. The pulse was documented to be between 41-47 bpm for the entire 258-minute treatment. On the hemodialysis flowsheet dated 1/5/24, P-6’s pulse was checked a total of 6 times during treatment. The pulse was documented to be between 39-50 bpm for the entire 245-minute treatment. There was no documentation on any of the hemodialysis flowsheets above indicating that the physician had been notified of the pulse rate below 60 (per facility policy). There were also no special orders indicating different pulse parameters for P-6’s pulse rate. During interview with the Covering Medical Director (Staff O) on 1/10/24 at 1030, Staff O stated that all staff are expected to follow the facility policies and procedures. These findings were reviewed and acknowledged during interview on 1/10/24 at 1400 with the Facility Administrator (Staff A). 47976 P-1: This 60-year-old patient was admitted to this dialysis facility on 12/4/23 with the diagnosis of end stage renal disease and was receiving dialysis treatments 3 times per week. During record review of the last 6 hemodialysis flowsheets on 1/9/24, it was note the patient’s pulse was persistently recorded outside reportable parameters according to the facility policy as follows: On 12/23/23, 52 at 1354, 57 at 1401, 59 at 1501, and 46 at 1552 On 12/24/23, 58 at 0730, 58 at 0733, 55 at 0803, 55 at 0903, 54 at 0955 On 12/31/23, 58 at 0531, 56 at 0556, 53 at 0601, 60 at 0614, 58 at 0625, 57 at 0627, 55 at 0627, 55 at 0701, and 53 at 0802 On 1/5/24, 55 at 1005, 59 at 1034, 59 at 1104, 58 at 1237, 58 at 1238, 59 at 1304, 57 at 1334, 57 at 1335, 57 at 1338, and 55 at 1340 There were no notes on the hemodialysis flow sheets to indicate the treating staff were aware of the pulse persistently below 60 beats per minute and there were no notes that the physician was contacted regarding theses values. During an interview on 1/10/24 at 1100, the Facility Administrator (Staff A) was queried whether it was documented anywhere else in the record that the physician was contacted per facility policy. She reported that this may be the patient’s baseline, but acknowledged there should be a special order indicating this. She confirmed there was no record of the physician being contacted either.”

“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: 46476 Based on record review and interview, the facility failed to maintain accurate records of medications given during dialysis in 4 (P #’s 1, 2, 5, 7) of 8 incenter records reviewed resulting in an unclear picture of treatment provided and potential for poor patient outcomes. Findings include: P-5: This 69-year-old was admitted to the facility on 6/24/19 with end stage kidney disease; high blood pressure; and type 2 Diabetes. The medical record was reviewed on 1/9/24 and included 6 hemodialysis flowsheets between the dates of 12/21/23 and 1/6/24. The active physician orders for the period reviewed included orders for a treatment duration 255 minutes, and orders for Heparin (a powerful blood thinner) 1000 Units/hour maintenance dose to be given until the last 60 minutes of the treatment. The total Heparin maintenance dose each treatment (if P-5 completed the full duration of the treatment) would be 3250 Units. During review, it was noted on the flowsheet dated 12/21/23, the total treatment duration was 129 minutes. In the section of the flowsheet titled Hemodialysis Service/Meds, it indicates that 1900 Units of Heparin for maintenance were given during treatment however the Heparin infusion details document that 1200 Units were given during treatment. There was no other documentation which explained this 700 Unit discrepancy in documentation. P-7: This 78-year-old was admitted to the facility on 10/15/13 with end stage kidney disease and type 2 Diabetes. The medical record was reviewed on 1/9/24 and included 6 hemodialysis flowsheets between the dates of 12/30/23 and 1/8/24. The active physician orders for the period reviewed included orders for a treatment duration 255 minutes, and orders for Heparin 1000 Units/hour maintenance dose to be given until the last 60 minutes of the treatment. The total Heparin maintenance dose each treatment (if P-7 completed the full duration of the treatment) would be 3250 Units. During review, it was noted on the flowsheet dated 1/8/24, the total treatment duration was 183 minutes. In the section of the flowsheet titled Hemodialysis Service/Meds, it indicates that 3300 Units of Heparin for maintenance were given during treatment however the Heparin infusion details document that 1900 Units were given during treatment. There was no other documentation which explained this 1400 Unit discrepancy in documentation. These findings were reviewed and acknowledged during interview on 1/10/24 at 1400 with the Facility Administrator (Staff A). Staff A stated that staff are not properly editing the Heparin dose in the section Heparin Service/Meds and agreed that this reflected an inaccuracy in the medical record and unclear picture of services provided. 47976 P-1:This 60-year-old patient was admitted to this dialysis facility on 12/4/23 with the diagnosis of end stage renal disease and was receiving dialysis treatments 3 times per week. During record review of the last 6 hemodialysis flowsheets on 1/9/24, it was noted a maintenance dose of Heparin was on the most recent active orders for 1000 units per hour for the entire duration of the treatment (3 hours and 30 minutes), for a total of 3500 units per treatment. Upon further review of the last 6 hemodialysis flowsheets, it was determined the visit on 12/23/23 was shortened by 82 minutes and the visit on 12/24/23 by 65 minutes. This means the patient would not have received the last 1000 unit dose as both treatments were cut short by more than an hour and the total should be closer to 2500 units. Although the Heparin infusion documentation showed the appropriate amount, the section under “Hemodialysis Service/Meds” recorded a total of 3500 units administered. P-2: This 75-year-old patient was admitted to this dialysis facility on 10/1/23 with the diagnosis of end stage renal disease due to diabetes and hypertension (high blood pressure). During record review of the last 6 hemodialysis flowsheets on 1/9/24, it was noted a maintenance dose of Heparin was on the most recent active orders for 2000 units per hour for the entire duration of the treatment (4 hours and 30 minutes), for a total of 9000 units per treatment Upon further review of the last 6 hemodialysis flowsheets, it was determined the visit on 12/30/23 was shortened by 74 minutes and the visit on 1/4/24 was shortened by 88 minutes. This means the patient would not have received the last 2000 unit dose as both treatments were cut short by more than an hour and the total should be closer to 7000 units. Although the Heparin infusion documentation showed the appropriate amount, the section under “Hemodialysis Service/Meds” recorded a total of 9000 units administered. During an interview on 1/10/24 at 1100, the Facility Administrator (Staff A) was queried regarding the conflicting numbers. Staff A was able to show on the computer how the total number can be edited to reflect the actual total units given. She reported staff should be doing this, but they are not. She acknowledged that this makes the medical record inaccurate.”