Fmc - Lansing

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 38905 Based on interview and record review, the facility did not ensure communication and coordination with the local or regional Emergency Operations Center (EOC) . This has the potential to decrease the effectiveness of the facility’s emergency preparedness which could affect all patients and staff in the event of an emergency. Findings Include: During an interview with Clinical Manager (CM) “B” and Charge Nurse “E”, on 1/23/25 at 1311, it was found that they were unaware of ongoing communication with the local or regional EOC. When asked if they had any staff that attended their region’s EOC trainings or updates, CM “B” stated “No”. During a review of the facility’s Emergency Preparedness binder, no documentation was found for how the facility collaborates with local, regional, or statewide emergency preparedness officials. A review of the facility provided document entitled “Guidelines for Emergency Preparedness”, published 04/05/2021, found that: “Per procedure, annually, the facility will contact their local disaster management agency to ensure that the agency is aware of the dialysis facility’s presence in the community in the event of an emergency.””

“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: 38304 Based on observation, interview, and record review, the Facility failed to ensure staff took measures to reduce the risk for central venous catheter (CVC) bloodstream infections for 1 (P-11) of 2 patients observed for CVC exit site care prior to the initiation of dialysis treatment, resulting in the potential for bloodstream infections and less than optimal outcomes. Findings include: On 1/21/25 at 1157, Staff F was observed at Station #12 performing exit site care and initiation of treatment for P-11. Staff F removed the dressing, opened an anti-septic swab and cleansed around the CVC site in a back-and-forth motion, moving outward and back again contacting the CVC insertion site multiple times. Staff F proceeded in this fashion all the way around (360 degrees) the CVC site which subsequently increases the risk of bringing potential pathogens into contact with the CVC. Staff F was queried afterwards at 1218 on what the correct procedure for appropriately cleaning a CVC site/area would be. Staff F stated cleansing should be done from the inside near the catheter outward and not return to the catheter area with the same swab. Staff F then acknowledged this was not done during the observation of CVC exit site care at 1157. This finding was reviewed and acknowledged by the Facility Administrator (Staff A) and Clinic Manager (Staff B) during an interview on 1/24/25 at 1150. Both noted this did not meet Facility expectations or its policy referenced below. Facility Policy: “Changing the Catheter Dressing Procedure” (revised 2/5/2024) Version * stated, “Using gentle back and forth friction, clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied (2 inches) in a concentric circle for 30 seconds and allow to dry for a minimum of 30 seconds.””

“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: 38905 Based on observation and interview, the facility failed to maintain upkeep of facility plumbing. This resulted in an increased risk of contamination of the potable water. This deficient practice has the potential to affect all patients and staff in the facility. Findings Include: During a tour of the facility, on 1/23/25 at 1000, with Bio-med “D”, it was observed that the mop sink was left on and connected to a pre-dispense chemical unit. A sign hung up on the mop sink faucet reads “Please Keep Eyes Open ...Turn Water Off Daily”. A review of the mop sink found it had an internal atmospheric vacuum breaker (AVB) as well as a hose bib AVB installed on the faucet. These devices are not approved for constant back pressure, and over time, the buildup of calcium, lime, and rust will erode the integrity of the devices. During a tour of the Bio-hazard room, on 1/23/25 at 1012, with Bio-med “D”, the surveyor noticed a strong sewer gas smell emanating from the room. Bio-med “D” stated that he must make sure the trap in the hopper doesn’t evaporate or else the smell gets bad. At this time, the hopper was full of water and the surveyor found that the floor drain in the room was pushing up air in the space. When asked if staff use the hopper, Bio-med “D” stated yes. Upon using the sprayer to the hopper, it was found that black and brown water came out of the sprayer momentarily when the cold water was turned on. Further review found that the AVB for the sprayer would leak when the sprayer was put into use.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 47976 Based on record review and interview, the facility failed to ensure the patient received medication as ordered in the plan of care in 1 (P-3) of 7 records reviewed, resulting in the potential for poor patient outcomes. Findings include: P-3: This 75-year-old patient was admitted to this dialysis facility on 9/27/17 with the diagnosis of end stage renal disease. During record review on 1/23/25, it was determined the order (dated 2/12/24) ordered “Heparin Sodium (Porcine) 1000 Units/milliliter” (a medication used to prevent blood clotting during treatment) to be delivered via an intravenous pump (IVP) at 500 units per hour. It also indicated the pump should be shut off 90 minutes prior to the end of each treatment. During an interview with the Clinical Manager (Staff B) on 1/24/25 at 1115, Staff B was asked how much Heparin she would expect this patient to be given based on the order above. Staff B stated the patient should be given 1.125 milliliters (mL) each treatment. Upon review of the last 6 treatment sheets, it was determined the patient was given the following doses of Heparin incorrectly (documented under the column labeled “Total Infused (ml)”): 2/12/24 = 4.000 mL (greater than 3 times the prescribed dose) 2/16/24 = 1.700 mL (0.575 mL over the prescribed dose) 2/19/24 = 3.700 mL (greater than 3 times the prescribed dose) 2/21/24 = 1.700 mL (0.575 mL over the prescribed dose) Staff B and the Charge Nurse (Staff E) were asked how the number under “Total Infused (ml)” was determined on the treatment sheet. Staff B stated the machine calculated the total amount of heparin administered during treatment and the staff manually input this information into the system. When asked if the numbers recorded above were actual totals of Heparin administered or documentation errors, Staff B and Staff E were unable to determine that based on the documentation. The facility failed to ensure the medication was delivered as ordered in the plan of care. Staff B and Staff E acknowledged the findings at the time of interview.”

“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 Registered Nurse incorporated and documented pertinent information needed to perform an Initial Nursing Assessment (INA) in 2 (P-1, P-2) of 7 total sampled records reviewed, failed to ensure the INA contained vaccination history in 4 (P-1, P-2, P-5 and P-6) of 7 total sampled records reviewed, and failed to document the assessment of an unstable to stable in 1 (P-6) of 7 total sampled records reviewed, resulting in the potential for poor patient outcomes. Findings include: P-1: This 28-year-old female patient started dialysis treatment at this Facility on 11/22/24 with the diagnosis of end-stage renal disease, Lupus (autoimmune disease attacking healthy body tissues), and hypertension. During record review on 1/23/25, it was determined that the INA was void/blank concerning the following relevant assessments: Hospitalization history, patient understanding of home dialysis options, kidney transplant options, and Hepatitis B vaccination status with subsequent immune response (this is needed to protect P-1 and other patients from potential exposure to Hepatitis B). Further, under “Neurological findings, Gastrointestinal Status, Genitourinary Status, and Skin Color/Integrity, the RN (Staff G) documented “N/A” (not applicable). Also, Staff G failed to document P-1’s dialysis catheter description along with an entry/exit site assessment. P-2: This 39-year-old male patient started dialysis treatment at this Facility on 1/19/23 with the diagnosis of end-stage renal disease, anemia, and hypertension. During record review on 1/23/25, it was determined that the INA performed by the RN (Staff H) was void/blank concerning the following assessment information: “Date and Time, Allergies, Dialysis Access, Orientation, Hearing, Speech/Communication, Skin, Circulatory/Heart, Elimination, Understanding of Renal Disease, Patient Support System, and Special Needs. In addition, no dates or status regarding Pneumonia, Flu, and Hepatitis B vaccination was evidenced in the INA. The above findings were reviewed with and acknowledged by the Facility Administrator (Staff A) and Clinic Manager (Staff B) during an interview on 1/24/25 at 1157. Both noted this did not meet Facility expectations or its policy referenced below. Facility Policy: “Comprehensive Interdisciplinary Assessment and Plan of Care” Version 6 (Revised 7/3/2023) stated, “The comprehensive interdisciplinary assessment includes the following: Current health status including co-morbid conditions... Prescribed lab testing, immunization history and medical history...” 37411 P-5: This 80-year-old female was admitted to the Facility on 4/27/22, with diagnoses of end stage renal disease and Hypertension. During record review on 1/23/25, it was determined that the Initial Nursing Assessment was blank under the Hep B vaccination history. The agency failed to verify the patient’s vaccination status. P-6: This 80-year-old male was admitted to the Facility on 3/9/22, with a diagnosis of end stage renal disease. During record review on 1/23/25, it was determined that the Initial Nursing Assessment was blank under the Hep B vaccination history. The agency failed to verify the patient’s vaccination status. Additionally, the Plan of Care (POC) dated 10/14/24 stated, “Last patient status: Unstable. Reason for meeting: Monthly CIA (Comprehensive Interdisciplinary Assessment) (Unstable). Reason(s) Unstable: Other Significant, not meeting treatment goals, FVO (Hypervolemia) ...” The following POC dated 11/11/24 stated, “Last patient status: Stable. Reason for meeting: Monthly CIA (Unstable) ...” The agency failed to document a resolution or reason to change the patient’s status from Unstable to Stable. These findings were reviewed with and acknowledged by the Clinical Manager (Staff B) during an interview on 1/24/25 at 1410 and stated, “There is no documentation of the Hep B vaccination status and there is no documentation why P-6 was changed from unstable to stable”.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 47976 Based on record review and interview, the facility failed to evaluate the appropriateness of the dialysis prescription in 1 (P-3) of 7 records reviewed, resulting in the potential for poor patient outcomes. Findings include: P-3: This 75-year-old patient was admitted to this dialysis facility on 9/27/17 with the diagnosis of end stage renal disease. During record review on 1/23/25, it was noted the order (dated 2/12/24) ordered “Heparin Sodium (Porcine) 1000 Units/milliliter” (a medication used to prevent blood clotting during treatment) to be delivered via an intravenous pump (IVP) at 500 units per hour. It also indicated the pump should be shut off 90 minutes prior to the end of each treatment. Upon review of the last 6 treatment sheets, it was determined the heparin pump was run for the entire treatment on 6 of 6 visits reviewed (dated 2/7/24, 2/12/24, 2/14/24, 2/16/24, 2/19/24, and 2/21/24). During an interview with the Charge Nurse (Staff E) on 1/24/25 at 1115, Staff E was shown the total treatment time compared to the heparin pump run time on the treatment sheets noted above. Staff E acknowledged the heparin pump was run for the entire treatment on these visits. Staff E stated this was because the patient’s central venous catheter was used for access during these treatments due to an issue with the patient’s fistula. Staff C stated the order should have been updated based on the access type used (see policy below) and acknowledged the findings. **Policy titled “Heparinization” (published 8/3/2020) stated, “It is recommended the heparin pump be stopped: 30 minutes prior to the end of treatment in accordance with a physician order on patients dialyzing through a fistula or graft; at the end of treatment in accordance with a physician order on patient’s dialyzing through a central venous catheter.” Findings were also reviewed with the Clinical Manager (Staff B) at the time of interview. Staff B and Staff E acknowledged the findings.”

“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 dose of dialysis for 5 (P-1, P-3, P-4, P-6, and P-7) of 7 in-center patient records reviewed resulting in failure to achieve optimal effectiveness of dialysis treatments provided and the potential for poor patient care outcomes for all 90 patients currently receiving services. Findings include: P-1: This 28-year-old female patient started dialysis treatment at this Facility on 11/22/24 with the diagnosis of end-stage renal disease, Lupus (autoimmune disease attacking healthy body tissues), and hypertension. During record review on 1/23/25, it was noted the physician ordered a treatment duration of 4 hours, with a BFR (blood flow rates) at 400 mL/min. and the DFR (dialysate flow rate) 2 times (800 mL/min.) the BFR. Upon review of the last 6 treatment sheets (all with the same orders above), it was determined the DFR was run incorrectly as follows: On 1/7/25, the DFR was administered at 500 mL/min. in 8 of 8 documented DFR entries (0613 through 1015). No documentation was found in the medical record why the DFR was decreased to only 63% of the prescribed rate. On 1/16/25, the DFR was administered at 500 mL/min. in 8 of 8 documented DFR entries (0628 through 1031). No documentation was found in the medical record why the DFR was again decreased to 63% of the prescribed rate. The above findings were reviewed with and acknowledged by the Facility Administrator (Staff A) and Clinic Manager (Staff B) during an interview on 1/24/25 at 1206. Both noted this did not meet Facility expectations or its policy referenced below. Facility Policy: “Patient Assessment and Monitoring” Version 4 (revised 5/1/2023) stated, “Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” 47976 P-3: This 75-year-old patient was admitted to this dialysis facility on 9/27/17 with the diagnosis of end stage renal disease. During record review on 1/23/25, it was noted the treatment order (dated 1/26/24) ordered the blood flow rate (BFR) at 400 milliliters per minute (mL/min) and the dialysate flow rate (DFR) was ordered at 500 mL/min. Upon review of the last 6 treatment sheets, it was determined the BFR and DFR were run incorrectly as follows: On 2/21/24, the BFR was started at 400 mL/min at 1114, however, it was recorded at 300 mL/min from 1205 to 1305, back up to 350 mL/min at 1332, and back down to 320 mL/min at 1405 until the treatment ended at 1445. On 2/19/24, the BFR was started at 400 mL/min at 1119, however, it was recorded at 350 mL/min at 1202, then 320 mL/min at 1301 until the treatment ended at 1502. On 2/7/24, the BFR started at 400 mL/min at 1144, however, it was recorded at 305 mL/min from 1330 until the treatment ended at 1500. There was no documentation regarding the reason the BFR was decreased during these treatments. P-4: This 68-year-old patient was admitted to this dialysis facility on 6/19/24 with the diagnosis of end stage renal disease. During record review on 1/23/25, it was noted the treatment order ordered the BFR at 425 mL/min and the DFR at 2 times the BFR. Upon review of the last 6 treatment sheets, it was determined the BFR and DFR were run incorrectly as follows: On 1/20/25, the BFR started at 425 mL/min at 1151, but was recorded at 200 mL/min at 1333, 0 mL/min at 1401, 200 mL/min at 1433 until 1539 when it was recorded at 350 mL/min. There was no documentation regarding the reason the BFR was decreased during the treatment. Findings were also reviewed with and acknowledged by the Clinical Manager (Staff B) and the Charge Nurse (Staff E) during an interview on 1/24/25 at 1115. 37411 P-6: This 80-year-old male was admitted to the Facility on 3/9/22, with a diagnosis of end stage renal disease. On 1/23/25, record review of P-6’s six most recent in-center dialysis treatments (1/8/25 through 1/20/25) noted the following concern: The treatment flow sheet dated 1/8/25 documented the physician ordered Dialysis Prescription as BFR (Blood Flow Rate) and DFR (Dialysate Flow Rate) were to be delivered at 400 milliliters/minute (mL/min) and Autoflow 2.0 mL/min respectively throughout treatment. However, the 1/8/25 treatment sheet documented that the BFR was ran at 300 with no documented reason for the lower rate. This finding was reviewed with and acknowledged by the Clinical Manager (Staff B) during an interview on 1/24/25 at 1400 and stated, “There is no documentation or order for running a lower DFR”. 46476 P-7: This 68-year-old was admitted to the facility on 12/8/22 with diagnoses of acute kidney injury and high blood pressure. The medical record was reviewed on 1/23/25 and included the last 6 hemodialysis treatment sheets dated from 1/7/25 through 1/21/25. Active physician orders for the period reviewed included a blood flow rate (BFR) of 400 milliliters per minute (mL/min), and the dialysate flow rate (DFR) was written as “Autoflow 2.0” which means the DFR would be 2 times the BFR (800 mL/min) each treatment. On the treatment sheet dated 1/7/25, the treatment started at 0546. The dialysis prescription was run at the prescribed rate (BFR: 400 mL/min, DFR: 800 mL/min) until 0734 (108 minutes). At 0734, the BFR was adjusted down to 385 mL/min (DFR was 800 mL/min) and run at that rate until 0816 (42 minutes). At 0816, the BFR was adjusted down again to 350 mL/min (50 mL/min below the prescribed rate) and the DFR automatically adjusted down to 700 mL/min (100 mL/min below prescribed rate) until the treatment ended at 0941 (85 minutes). There was no documentation indicating a reason why the BFR and DFR were decreased during the treatment. On the treatment sheet dated 1/9/25, the treatment started at 0545. The dialysis prescription was run at the prescribed rate until 0604 (19 minutes into the treatment), when the BFR was adjusted down to 350 mL/min. At 0639, the BFR was adjusted down again to 340 mL/min (60 mL/min less than prescribed) and the DFR automatically adjusted down to 700 mL/min (100 mL/min less than prescribed) until 0739 (60 minutes later) when the BFR was turned back up to 400 mL/min and DFR automatically turned up to 800 mL/min. The prescription ran at that rate until 0902 (82 minutes later) when the BFR was again adjusted down to 350 mL/min, and the DFR decreased to 700 mL/min until treatment ended at 0940. There was no documentation indicating a reason why the BFR and DFR were decreased, increased, and decreased again during the treatment. On 1/24/25 at 1000, interview was conducted with the Medical Director (Staff C). Staff C was asked when/why staff would change the hemodialysis prescription for BFR and/or DFR before or during hemodialysis treatments. Staff C stated that staff should run the dialysis as prescribed. Staff C stated that if there was an issue with the dialysis access site which caused a need for change in BFR or DFR rates, an RN would need to determine what change would be needed for the dialysis session to continue and then notify the physician for an ongoing issue. Staff C was asked if staff should be documenting the need to change the dialysis prescription. Staff C stated “yes, of course” and agreed that changes to the prescription can affect dialysis adequacy. Staff C stated that all staff should be following the policies and procedures of the facility. On 1/24/25 at 1310, these findings were also reviewed and acknowledged by the Facility Administrator (Staff A) and Clinical Manager (Staff B).”

“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: 38304 Based on record review and interview, the Facility failed to ensure the Plan of Care (POC) was reviewed and revised under the section designated for Social Work services in 1 (P-2) of 7 records, resulting in the increased potential for unrecognized needs and less than optimal outcomes. Findings include: P-2: This 39-year-old male patient started dialysis treatment at this Facility on 1/19/23 with the diagnosis of end-stage renal disease, anemia, and hypertension. During record review on 1/23/25, it was noted that a series of POCs for P-2 had the following concerns: POC date: 2/7/23 with unstable status due to AKI (acute kidney injury) and non-compliance. The LMSW (Licensed Medical Social Worker/Staff K) at the time documented under “Treatment Adherence” the following five interventions: “Identify and address barriers leading to missed/shortened tx (treatments); Identify small actions to achieve goals; Provide education; Provide short term counseling; and Refer to community resources.” POC date: 3/9/23 with unstable status due to AKI (acute kidney injury) and non-compliance. Staff K documented under “Treatment Adherence” the following five interventions: “Identify and address barriers leading to missed/shortened tx (treatments); Identify small actions to achieve goals; Provide education; Provide short term counseling; and Refer to community resources.” Staff K’s documented response to each of the five interventions above were, “In Progress” with no other information concerning how P-2 benefited (or not) from any of the listed interventions. POC date: 4/11/23 with unstable status due to AKI (acute kidney injury) and non-compliance. Staff K documented under “Treatment Adherence” the following five interventions: “Identify and address barriers leading to missed/shortened tx (treatments); Identify small actions to achieve goals; Provide education; Provide short term counseling; and Refer to community resources.” Staff K’s documented response to each of the five interventions above were again, “In Progress” with no other information concerning how P-2 benefited (or not) from any of the listed interventions. POC date: 5/13/23 with unstable status due to AKI (acute kidney injury) and continued non-compliance. Staff K documented under “Treatment Adherence” the following five interventions: “Identify and address barriers leading to missed/shortened tx (treatments); Identify small actions to achieve goals; Provide education; Provide short term counseling; and Refer to community resources.” Again, Staff K’s documented response to each of the five interventions above were “In Progress” with no other information concerning how P-2 benefited (or not) from any of the listed interventions. POC date: 5/22/23 with unstable status due to AKI (acute kidney injury) and continued non-compliance. Staff K documented under “Treatment Adherence” the following five interventions: “Identify and address barriers leading to missed/shortened tx (treatments); Identify small actions to achieve goals; Provide education; Provide short term counseling; and Refer to community resources.” Staff K’s documented response to each of the five interventions above were “In Progress” with no other information concerning how P-2 benefited (or not) from any of the listed interventions. POC date: 7/31/23 with unstable status due to AKI (acute kidney injury) and continued non-compliance. RN/Staff L documented, “Patient continues to leave AMA (against medical advice)... Patient clearing only at 0.72 (lower acceptable limit is 1.2 which represent the effectiveness of dialysis treatment) and still working with patient to run full treatment...” Staff K documented under “Treatment Adherence” the following five interventions: “Identify and address barriers leading to missed/shortened tx (treatments); Identify small actions to achieve goals; Provide education; Provide short term counseling; and Refer to community resources.” Again, Staff K’s documented response to each of the five interventions above were “In Progress” with no other information concerning how P-2 benefited (or not) from any of the listed interventions. POC date: 8/21/23 with unstable status due to AKI (acute kidney injury) and continued non-compliance. Staff K documented under “Treatment Adherence” the following five interventions: “Identify and address barriers leading to missed/shortened tx (treatments); Identify small actions to achieve goals; Provide education; Provide short term counseling; and Refer to community resources.” Staff K’s documented response for each of the five interventions were the same as the previous five unstable POC reviews which were “In Progress” with no other information concerning how P-2 benefited (or not) from any of the listed interventions. Evaluation of P-2’s six POC reviews (2/7/23 through 8/21/23) showed the Medical Social Worker and IDT (inter-disciplinary team) in general failed to document any results or findings from the noted interventions implemented under “Treatment Adherence” to help meet/optimize P-2’s dialysis treatment compliance. The above findings were reviewed with and acknowledged by the Facility Administrator (Staff A) and Clinic Manager (Staff B) during an interview on 1/24/25 at 1208. Both noted this did not meet Facility expectations or its policy referenced below. Facility Policy: “Comprehensive Interdisciplinary Assessment and Plan of Care” Version 6 (Revised 7/3/2023) stated, “The patient plan of care will be developed from the findings gathered in the CIA. The IDT members are expected to interact and share information from the comprehensive assessment to facilitate the development of the plan of care. If the patient specific expected outcome as determined by the attending physician, IDT and patient for the Plan of care is not achieved within the identified timeframe: The IDT must adjust the patient’s Plan of Care and document changes made to the POC.””

“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: 47976 Based on record review and interview, the facility failed to ensure the patient care technician notified the nurse of heart rates outside of reportable parameters per facility policy in 1 (P-3) of 7 records reviewed; and failed to ensure high arterial pressures were investigated and documented per facility policy in 1 (P-4) of 7 records reviewed, resulting in the potential for poor patient outcomes. Findings include: **Policy titled “Patient Monitoring” (published 5/1/2023) stated under “During Treatment” on page 4 to, “ ....Report to the nurse patients whose heart rates have dropped below 60, risen above 100 or become irregular.” P-3: This 75-year-old patient was admitted to this dialysis facility on 9/27/17 with the diagnosis of end stage renal disease. During record review of the last 6 treatment sheets on 1/23/25, the following heart rates were noted and recorded by the patient care technician (PCT) during treatment: On 2/7/24: 50 at 1144; 40 at 1200; 53 at 1400 There was no documentation the nurse had been notified of the heart rates recorded outside the reportable parameters per facility policy. On 2/12/24: 52 at 1115; 48 at 1131; 54 and 39 at 1205; 44 and 37 at 1331 There was no documentation the nurse had been notified of the heart rates recorded outside the reportable parameters per facility policy. On 2/14/24: 44 at 1316; 52 at 1331; 47 and 52 at 1403; 54 at 1448 At 1331 and 1403, comments documented by the PCT indicated “RN notified”, however, it was unclear what the nurse was notified of. On 2/16/24: 46 at 1332; 56 at 1402; 58 at 1402; 51 at 1505; 53 at 1521 There was no documentation the nurse had been notified of the heart rates recorded outside the reportable parameters per facility policy. On 2/21/24: 59 at 1234; 55 and 49 at 1305; 54 at 1432 At 1305 and 1432, comments documented by the PCT indicated “RN notified”, however, it was unclear what the nurse was notified of. “RN notified” was also documented after recordings that were not outside of reportable parameters. Findings were reviewed with and acknowledged by the Clinical Manager (Staff B) and Charge Nurse (Staff E) during an interview on 1/24/25 at 1115. P-4: This 68-year-old patient was admitted to this dialysis facility on 6/19/24 with the diagnosis of end stage renal disease. During record review on 1/23/25, it was noted the treatment order ordered the blood flow rate (BFR) at 425 milliliters per minute (mL/min) and the dialysate flow rate (DFR) at 2 times the BFR. Upon review of the treatment sheet dated 1/17/25, it was noted in the first comment section when dialysis was started that the BFR was run at 250 mL/min for the entire treatment (3 hours and 56 minutes) due to high arterial pressure. Upon review of the arterial pressure recorded during this treatment, it was noted the arterial pressure was recorded from -128 millimeters of mercury (mmHg) to -232 mmHg. **Policy titled “Pre-Pump Arterial Pressure Monitoring Guidelines” (published 5/2.2022) stated, “If the PPAP (Pre-pump arterial pressure) is more negative than -250 mmHg, the blood pump speed should be reduced until the PPAP becomes less negative than -250 mmHg and then potential etiologies should be explored to correct.” The policy also included a list of potential interventions for high PPAP. Lastly, the policy stated to, “Document all findings in the patient’s FKC medical record.” During an interview with the Charge Nurse (Staff E) on 1/24/25 at 1130, Staff E was asked what the expectation was for lowering the BFR with high arterial pressures during treatment. Staff E stated the machine will alarm when the pressure reaches -250 mmHg (millimeters of mercury). When the alarm sounds, staff should first try to adjust the patient or needle to see if the pressure can be corrected without having to lower the BFR. If the pressure cannot be corrected, the BFR should be turned down until the pressure lowers and then reassessed per policy (see below). Staff E stated attempts to adjust the needle position should be documented in the record. Staff E was also asked if staff should attempt to increase the BFR again during treatment to achieve the prescribed rate. Staff E stated yes, an attempt to return the BFR to the prescribed rate should be attempted if pressures have lowered to a safer level. Staff E stated this should be documented as well. There was no documented evidence of attempts to investigate the reason for the high arterial pressure. There was also no documented attempts to return the BFR to the prescribed rate. Findings were also reviewed with and acknowledged by the Clinical Manager (Staff B) during the interview.”