Lansing Dialysis of Fmc

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 47976 Based on record review and interview the facility failed to monitor patient vital signs per policy, failed to ensure patient treatments were delivered as prescribed, and failed to ensure social work provided necessary monitoring and intervientions, resulting in the potential for unmet needs and less than optimal patient outcomes for all 122 patients served by the facility. See specific tags: V-543 - Failure to monitor patients vital signs per policy V-544 - Failure to ensure patient treatments were delivered as prescribed V-552 - Failed to ensure social work provided necessary monitoring and interventions”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 47976 Based on observation, record review, and interview, the facility failed to ensure emergency supplies on the emergency cart were not expired per facility policy, resulting in the potential to affect the health and safety of all 122 patients receiving dialysis from this facility in the event of an actual emergency. Findings include: **Policy titled “Emergency Medications, Equipment and Supplies” (dated 5/1/23) stated under the “Emergency Cart” section on page 2, “An emergency evacuation box must: .....Be checked monthly or after use for contents, expiration dates and cleanliness.” During a tour of the dialysis floor on 12/2/24 at 0955, it was determined the following items located in the emergency cart across from station #3 were expired: 2 - Yankauer tubing (expired 11/22/23) 2 - 250 milliliter (mL) bags of 0.9% Sodium Chloride (expired 7/2023) 4 - Volumet lines (expired 8/25/24) 5 - ChloraPrep Swabsticks (1 expired 1/2022, 4 expired 1/2022) 3 - Suture Removal Trays (expired 9/30/23) 2 - Disposable AV Fistula Needles (expired 3/24/24) 11 - 0.9% Sodium Chloride Injectable Syringes (6 expired 4/1/24, 5 expired 10/31/23) 1 - Flared Tip Nasal Oxygen Cannula Tip (expired 3/15/24) Findings were reviewed with and acknowledged by the Director of Operations (Staff B) and the Clinical Manager (Staff C) during an interview on 12/4/24 at 0900.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 38304 Based on record review and interview, the facility failed to ensure their method of sharing patient information in the event of an actual emergency was accurate and updated, resulting in the potential for unaccounted patient(s) and an impaired emergency response for all 122 patients currently serviced by the facility. Findings include: On 12/2/24 at 0933, an inspection of the facility’s emergency evacuation “To Go” box was performed. The patient list located in the “To Go” box was reviewed and revealed it was last updated on 11/6/24. When this list was compared to the current patient roster, 5 patient names who were admitted after 11/6/24 were not included on the emergency patient list. At time of discovery, an interview was conducted with clinic manager (Staff D) regarding the process to incorporate newly admitted patients to ensure they would be accounted in the event of an emergency. Staff D stated, “We don’t have one currently.” This finding was reviewed and acknowledged by the Director of Operations (Staff B) during an interview on 12/2/24 at 1120. The dialysis facility failed to adhere to its policy referenced below. Facility Policy: “Guidelines for Emergency Preparedness” Version 11 (Pub. 7/3/2023) stated “The facility must develop a communication plan for all patients (in-center and home). This plan includes the following: Create and maintain staff, patient and facility emergency information contact list...””

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 46476 Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene between each glove change in accordance with facility policy resulting in the potential for spread of infectious agents to all 37 incenter patients being served by the facility at the time of observation. Findings include: Facility policy titled “Hand Hygiene” (dated 11/6/23), was reviewed on 12/4/24. On page 1., it stated “Hands will be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water ...Immediately after removing gloves ...” On 12/2/24 at 1230, Staff E, a patient care technician, was observed while connecting blood lines for the patient at station #20 in preparation for dialysis treatment. During the multi-step procedure, Staff E was observed removing used gloves between tasks and putting a new pair on two times without first performing hand hygiene. Staff E was also observed once during the procedure removing used gloves, leaving the treatment area and touching a clipboard at the nurses station before performing hand hygiene. Immediately following the observation, Staff E was queried to whether hand hygiene should be performed after each time gloves are removed. Staff E stated “yes”. This finding was reviewed and acknowledged by the Director of Operations (Staff B), and the Clinical Manager (Staff C) during interview on 12/4/24 at 1500. 47976 During dialysis floor observation on 12/2/24, the following was observed: At 0940, a Patient Care Technician (PCT, Staff K) was observed leaving station #15 wearing gloves, going to the counter to get new supplies, opening a drawer at the nurse’s station, then returning to station #15 to continue setting up the machine. After Staff K removed her gloves, she was observed throwing them away, then putting on new gloves before moving to station #16 without performing hand hygiene. Staff K then left station #16 to test the water at the “dirty” sink while wearing her gloves, removed her gloves, and again put on new gloves without performing hand hygiene. After Staff K left station #16, she removed her gloves again and failed to perform hand hygiene before putting on new gloves and returning to station #15 to assist a patient. At 1010, a PCT (Staff L) was observed disconnecting a patient from dialysis at station #22. Staff L was observed touching the patient and computer with her gloved hands, leaving the station to get the thermometer on the counter across the room, then returning to the station without removing her gloves as she continued to work with the patient. After Staff L removed her gloves, she was observed putting on new gloves without performing hand hygiene first. At 1015, a PCT (Staff J) was observed wearing gloves to carry used blood lines from a machine she just disconnected. After Staff J put the blood lines into the biohazard waste bin, she was observed removing her gloves, putting them in the waste basket, and putting on new gloves without performing hand hygiene. At 1038, a staff member (unidentified) was observed removing her gloves near station #15, standing talking to another staff member for several minutes, walking across the clinic to talk to another staff member in an office, then putting on new gloves near the patient entrance door without performing hand hygiene. Findings were reviewed with and acknowledged by the Director of Operations (Staff B) and the Clinical Manager (Staff C) during an interview on 12/4/24 at 0900.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 47976 Based on observation and interview, the facility failed to ensure supplies were not kept in staff pockets, resulting in the potential for the spread of infectious diseases to all 37 patients served by this facility at the time of observation. Findings include: During dialysis floor observation on 12/2/24 at 1105, a Certified Clinical Hemodialysis Tech (CCHT, Staff G) was observed working with the patient at station #7. Staff G was observed getting the thermometer out of the back pocket of her scrubs, taking the patient’s temperature, and returning the thermometer to her back pocket. Findings were reviewed with and acknowledged by the Clinical Manager (Staff C) during an interview on 12/4/24 at 1030.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 22050 Based on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant effecting the 37 patients receiving treatment at the time of observations, resulting in the increased likelihood for cross-contamination, bacterial harborage, and patient hazards. Findings include: On 12/02/24 at 11:40 A.M., An environmental flash tour of the facility treatment room was conducted with BioMed “H”. The following items were noted during the tour: Patient Restroom: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. BioMed “H” indicated he would have housekeeping services thoroughly clean the soiled ventilation grill as soon as possible. Soiled Utility Room: The wastewater hopper basin was observed soiled with accumulated and encrusted rust and grime deposits. Laboratory Two: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. Isolation Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. BioMed “H” indicated he would have housekeeping services thoroughly clean the soiled ventilation grill as soon as possible. Six “Germstar Instant Hand Sanitizer” base trays were observed soiled with accumulated and encrusted dust/dirt deposits, throughout the facility treatment room. On 12/02/24 at 12:35 P.M., Nine full portable oxygen cylinders were observed completely unsecured resting upright against the facility treatment room perimeter wall surface. Twelve additional portable oxygen cylinders were also observed resting upright within a secured storage rack, adjacent to the Soiled Utility Room. Six single oxygen cylinder transport carts (full) were additionally observed stored, adjacent to the nine full unsecured oxygen cylinders. One single oxygen cylinder transport cart (empty) was further observed stored, adjacent to the nine full unsecured oxygen cylinders. BioMed “H” stated: “The tanks should be in a rack.” On 12/02/24 at 01:40 P.M., Area Technical Operations Manager (ATOM) “I” entered the facility conference room and stated “The oxygen policy indicates the cylinders must be secured.” On 12/02/24 at 01:45 P.M., Record review of the Policy/Procedure entitled: “Emergency Administration of Oxygen” dated 11/01/2021 revealed under Purpose: “The purpose of this policy is to provide guidance for safe use and handling of oxygen cylinders when used in emergency situations in the dialysis facility.” Record review of the Policy/Procedure entitled: “Emergency Administration of Oxygen” dated 11/01/2021 further revealed under Oxygen Cylinders: “Oxygen cylinders must be secured in an area where they will not fall.” and “Unless in use, secondary (reserve) cylinders/tanks must be: (1) Secured to racks of rolling stands in a storage area or dedicated area for oxygen. (2) Do not store oxygen cylinders near water heaters, furnaces, sources of heat, flame, combustible material or in small or unventilated storage areas.” On 12/02/24 at 02:15 P.M., Record review of the Policy/Procedure entitled: “General Cleanliness and Infection Control Guidelines” dated 11/04/2024 revealed under Purpose: “The purpose of this policy is to provide guidance for FKC (Fresenius Kidney Care) staff on preventing the spread of infectious disease and maintaining a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors.” Record review of the Policy/Procedure entitled: “General Cleanliness and Infection Control Guidelines” dated 11/04/2024 further revealed under Policy: “(1) All areas must be kept clean and organized, including but not limited to treatment areas, water/supply rooms and offices. Walkways must be kept clear of debris and free of clutter.” 38304 On 12/2/2024 at 0950, observation of the dialysis treatment floor noted excessive insect debris in the overhead lighting near stations #36 and #37. At 1045, the Director of Operations (Staff B) and Clinic Manager (Staff C) went on the treatment floor with the surveyor and verified the finding. During subsequent interview at 1115, Staff B noted that housekeeping had no specific assignment to clean the overhead lighting on the treatment floor. Facility Policy: “General Cleanliness and Infection Control Guidelines” Version 7 (Pub. 11/4/2024) stated “The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintaining a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. All areas must be kept clean and organized, including but not limited to treatment areas...””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 47976 Based on observation, record review, and interview, the facility failed to ensure patient access sites were in view of staff during dialysis treatment at all times at 2 (#3, 28) of 37 stations, resulting in the potential for needle dislodgement or line disconnection to go undetected and for significant bleeding to occur for the 2 patients observed. Findings include: **Policy titled “Patient Assessment and Monitoring” (dated 5/1/23) stated during treatment, staff should “Observe connections are secure and visible ....Ensure access remains uncovered throughout the treatment.” During dialysis floor observation on 12/2/24, the following observations were made: At 0934, it was observed the access site for the patient at station #3 was completely covered. At 0945, Registered Nurse (RN, Staff N) was observed assisting a patient at station #4 and Patient Care Technician (PCT, Staff M) was observed disinfecting station #2 (on either side of the patient). At 0950 after both staff members left the area without uncovering the patient, Staff N was asked if she was able to see the access site at station #3. Staff N reported she was unable to see the access site and returned to station #3 to ensure it was fully visible. The patient at station #3 stated, “I’m cold.” At 0936, it was observed the access site for patient at station #28 was completely covered. At 0950, it was noted that no staff member had been in that section since the initial observation. At 0954, the PCT (Staff F) assigned to that section was observed telling another staff member she was going to leave the floor to dispose of a box. Before Staff F left the floor, she was asked if she was able to see the access site for the patient at station #28. Staff F reported she could not see it and went to station #28 to ask the patient to uncover her site. Findings were reviewed with and acknowledged by the Director of Operations (Staff B) and the Clinical Manager (Staff C) during an interview on 12/4/24 at 0900.”

“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 2 (P-1, 5) of 10 sample 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 “Early Termination or Arriving Late for Treatment” (dated 11/7/22) was reviewed on 12/4/24. On page 1., it stated “Early Termination ... If a patient insists on terminating treatment early ... The RN ... must document the rationale for early termination and reinforce the consequences of not receiving the entire prescribed treatment ... The RN is responsible to notify the physician, and document on the “AMA”, or Against Medical Advice form.” P-1: This 60-year-old began hemodialysis at the facility on 9/26/24 with diagnoses including end stage kidney disease and high blood pressure. The medical record was reviewed on 12/3/24 and included 6 in-center hemodialysis treatment sheets between the dates of 9/30/24 and 12/2/24. The active physician orders (dated 10/23/24) for dialysis included a treatment duration of 3 hours and 30 minutes each treatment. During review, the following shortened treatments were noted: On the treatment sheet dated 11/20/24, the treatment began at 1245 and ended at 1545 (3 hours out of the prescribed 3.5 hours). A note entered in the “Treatment Status:” section stated “Completed, Unexpected, Patient Request”. There was no documentation that the RN discussed the consequences of early termination of the dialysis treatment or had the patient sign the AMA form. On the treatment sheet dated 12/2/24, the treatment began at 1256 and ended at 1554 (2 hours 57 minutes). A note entered in the “Treatment Status:” section stated “Completed, Unexpected, Patient Request”. There was no documentation that the RN discussed the consequences of early termination of the dialysis treatment or had the patient sign the AMA form. This finding was reviewed and acknowledged by the Director of Operations (Staff B), and the Clinical Manager (Staff C) during interview on 12/4/24 at 1500. Staff C stated that patients should be educated on consequences and should sign the AMA form if terminating treatments early. 47976 P-5: This 32-year-old patient was admitted to this facility on 3/25/23 with the diagnosis of and acute kidney injury (AKI) with resultant diagnosis of end stage renal disease. During record review on 12/3/24, it was determined the physician orders for that day indicated a run time of 4 hours and 15 minutes. After further review of the record, it was determined the patient’s treatment on 11/7/24 was discontinued at 3 hours a 54 minutes - 21 minutes early. It was noted “Pt shorten treatment time request to be off treatment at 1530.” [sic] During an interview with the Clinical Manager (Staff C) on 11/4/24 at 0900, Staff C was asked to provide the AMA (Against Medical Advice) document the patient should have signed for that day per facility policy. Staff C was unable to locate an AMA form dated 11/7/24 and 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 address the fluid management needs in 1 patients (P-7) out of a total sample of 10 patients reviewed, resulting in the potential for less-than-optimal outcomes for all 122 patients currently receiving services at this facility. Findings include: P-7: This 47-year-old patient was admitted to the dialysis in-center unit on 8/21/2013, with a past medical history which included end-stage renal disease, acute respiratory failure with hypoxia (low oxygen), diabetes, and cerebellar (brain) stroke syndrome. P-7’s dialysis schedule is every Tuesday, Thursday, and Saturday. Review of P-7’s active treatment orders noted the prescribed target weight (TW) was 84.5 Kg., which applied to 10/12/24 through 11/16/24. P-7’s TW was increased to 91.0 Kg on the 6th or most recent treatment date of 11/21/24. P-7 has been hospitalized since 11/23/24 relating to pre-existing comorbidities. Further review of P-7’s six most recent treatment sheets (10/12/24 through 11/21/24) noted the following: On 10/12/24; post-treatment weight of 89.3 Kg. (4.8 Kg. over TW) with RN (Staff U) documenting +3 bilateral lower leg and ankle swelling. On 10/16/24; post-treatment weight of 91.9 Kg. (7.4 Kg. over TW) with RN (Staff V) documenting +3 bilateral lower leg and ankle swelling. On 10/26/24; post-treatment weight of 94.1 Kg. (9.6 Kg. over TW) with RN (Staff U) documenting +4 bilateral lower leg and ankle swelling. On 10/29/24; post-treatment weight of 96.4 Kg. (11.9 Kg. over TW) with RN (Staff N) documenting +2 bilateral lower leg and ankle swelling. On 11/16/24; post-treatment weight of 100.7 Kg. (16.2 Kg. over TW) with RN (Staff V) documenting +2 bilateral lower leg and ankle swelling. On 11/21/24; post-treatment weight of 93.7 Kg. (2.7 Kg. over TW) with RN (Staff V) documenting +2 bilateral lower leg and ankle swelling. The above findings were reviewed and acknowledged by the Director of Operations (Staff B), and the Clinical Manager (Staff C) during interview on 12/4/24 at 1320. In addition, no evidence was found in the medical record which indicated staff had reached out to the physician for guidance/orders on taking measures to adjust P-7’s TW and manage fluid overload. The facility failed to ensure staff adhered to its policy referenced below in which all 6 treatments or 100%, were greater than 1 kg. from their EDW. Facility Policy: “Quick Reference Guide: Volume Management Algorithm 2.0” pg. 2 under “6. Estimated Dry Weight Assessment” stated, “Post treatment weight variance is > (greater) 1 kg for EDW more than 30% of treatments... Consult Physician for new EDW.””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 47976 Based on record review and interview, the facility failed to ensure the interdisciplinary team (IDT) identified an unstable patient in 2 (P-4, 5) of 10 records reviewed, resulting in the potential for unmet care needs and less than optimal patient outcomes. Findings include: P-4: This 32-year-old patient was admitted to this facility on 10/30/23 with the diagnosis of end stage renal disease. During record review on 12/3/24, it was noted on the 30-day plan of care dated 12/20/23 that the patient did not attend the plan of care. It also stated the patient’s last status was “stable” and indicated the next plan of care meeting would be in 90 days. Upon further review of the details in the plan of care, the following was noted: -2 hospitalizations in November -low hemoglobin = 9.1 grams/deciliter (goal = 10-11 grams/deciliter) -poor treatment adherence (including “more than 10 missed treatments since admission to the clinic”) -poorly controlled diabetes with other medical comorbidities for “IDT to monitor” -anxiety and depression -new to dialysis and having a hard time adjusting -high phosphorus = 6.8 milligram/deciliter (normal = 3.0 - 5.5 milligrams/deciliter) During an interview with the Clinical Manager (Staff C) on 12/4/24 at 0900, Staff C was asked what classified a patient as unstable. Staff C stated it can be due to a number of reasons including, but not limited to: poor treatment adherence, low adequacy, lab values consistently outside of accepted ranges, hospitalizations, or significant life changes. Staff C was also asked how the facility addressed patients with significant non-compliance. Staff C stated the patient is typically identified as unstable for 3 months and then behavior management is considered. Staff C acknowledged the information in the plan of care, including his non-compliance, should have been enough to identify him as unstable to ensure a monthly follow-up. Staff C acknowledged the findings. P-5: This 32-year-old patient was admitted to this facility on 3/25/23 with the diagnosis of an acute kidney injury (AKI). During record review on 12/3/24, it was noted the plan of care dated 10/30/23 indicated the patient was “stable” after review. However, upon further review of the plan of care, the following was noted: -poor treatment adherence (including 8 missed visits in October) -low kt/v (measures adequacy/effectiveness of dialysis) = 0.82 (accepted value is >1.2) -high phosphorus level = 8.4 milligram/deciliter (normal = 3.0 - 5.5 milligrams/deciliter) -low albumin level = 3.2 grams/deciliter (normal = 4.0 grams/deciliter) -phone disconnection/no known address for the patient -multiple hospitalizations Upon review of the next plan of care dated 3/6/24 after the patient’s return to the clinic, it was noted the patient was still identified as “stable”. However, upon further review of this plan of care, the following was noted: -the patient only attended 2 visits since the previous plan of care -kt/v = 1.16 (still below accepted level) - low hemoglobin = 7.3 grams/deciliter (goal = 10 - 11 grams/deciliter) -other lab values were unavailable due to no recent blood work -5 hospitalizations since the last plan of care (several for fluid overload, which is often a result of ineffective dialysis treatment) - an open case with Adult Protective Services - was residing in sub-acute rehabilitation due to other complications During an interview with the Clinical Manager (Staff C) on 12/4/24 at 0900, Staff C was asked what classified a patient as unstable. Staff C stated it can be due to a number of reasons including, but not limited to: poor treatment adherence, low adequacy, lab values consistently outside of accepted ranges, hospitalizations, or significant life changes. Staff C was asked why P-5 was not identified as unstable based on the information noted in the plans of care above (dated 10/30/23 and 3/6/23). Staff C stated she was unsure why the electronic medical record system did not “flag” it as unstable due to the number of issues identified. She agreed P-5 should have been identified as unstable for both plans of care. Staff C acknowledged the findings at the time of interview.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 46476 Based on record review and interview, the facility failed to ensure patient blood pressure (BP) monitoring and assessment was performed in accordance with facility policy in 2 (P-1, P-8) of 10 sample records reviewed resulting in unmanaged fluid volume status and the potential for poor patient outcomes. Findings include: Facility policy titled “Patient Assessment and Monitoring”; Published: 05/01/2023, was reviewed on 12/3/24. On page 1., under “Data Collection”, it stated “ ... If the PCT/LPN note any changes or abnormal findings ... the registered nurse must assess the patient ... The Registered Nurse will assess/re-assess any findings pre or during treatment as needed.” On page 5., under “During Treatment”, it stated: “Follow the steps below for monitoring patient ... Blood Pressure ... Report to nurse: Systolic blood pressures greater than 180 mm/Hg ... Diastolic blood pressure greater than 100 mm/Hg ...” P-1: This 60-year-old began hemodialysis at the facility on 9/26/24 with diagnoses including end stage kidney disease and high blood pressure. The medical record was reviewed on 12/3/24 and included 6 in-center hemodialysis treatment sheets between the dates of 9/30/24 and 12/2/24. During review of the record, it was noted that there was an active physician order (start date 9/30/24) for the medication Clonidine HCl, 0.1 milligram (mg) for treating high BP which could be given during dialysis treatment as needed for systolic BP (first number in a BP reading) greater than 180 millimeters of mercury (mm/Hg). During review of the hemodialysis treatment sheets, the following were noted: On the treatment sheet dated 11/24/24, the following BP measurements were documented by 2 different staff members: At 1215, BP was 187/102 mm/Hg entered by patient care technician, Staff F At 1332, BP was 189/105 mm/Hg entered by Staff F At 1401, BP was 171/106 mm/Hg entered by Staff F At 1432, BP was 177/117 mm/Hg entered by Staff F At 1531, BP was 187/109 mm/Hg entered by a Certified Clinical Hemodialysis Technician, Staff G At 1547, BP was 162/111 mm/Hg entered by Staff G The dialysis treatment ended at 1547. There were no notes entered at any time by Staff F or Staff G indicating nurse notification of the BP’s which were outside reportable parameters according to facility policy. The registered nurse documented giving Clonidine HCl 0.1 mg for high BP at 1559 (3 hours and 44 minutes after the first high BP reading was recorded and 12 minutes after dialysis ended). This finding was reviewed and acknowledged by the Director of Operations (Staff B), and the Clinical Manager (Staff C) during interview on 12/4/24 at 1500. 38304 P-8: This 56-year-old began hemodialysis at the facility on 1/14/21 with diagnoses including end stage kidney disease, hypertension, and anemia. On 12/3/24, record review of the 6 most recent in-center hemodialysis treatment sheets (10/10/24 through 11/28/24) revealed the following significant hypertension concerns: On 11/14/24, the following documentation by patient care technician (PCT/Staff J) noted P-8 had a pre-dialysis blood pressure (BP) of 223/113 (systolic/diastolic) mm/Hg. at 1138. Staff J further documented under “Pre-Treatment Evaluation” that P-8 had “No Unusual Findings” at 1140. At 1151, BP was 233/103 mm/Hg entered by Staff J with RN notification noted. At 1234, BP was 218/96 mm/Hg entered by PCT/Staff F with no RN notification. At 1303, BP was 217/94 mm/Hg entered by Staff J with no RN notification. At 1333, BP was 210/95 mm/Hg entered by Staff J with no RN notification. At 1411, BP was 200/110 mm/Hg entered by Staff J with no RN notification. At 1350, Register Nurse (RN/Staff O) administered 0.1 mg. Clonidine (medication to lower BP) with improved results (BP 161/82 mm/Hg. at 1416). The treatment sheet documented under “Special Attentions” the following: “Per Dr. (physician/Staff O) standing order given to administer Clonidine if SBP > (greater) 200, repeat dose x1 every 15 minutes up to 0.3 mg. (3 doses in total). Initiate HD (hemodialysis) treatment if SBP < (less) than 220 mm/Hg. and if patient asymptomatic.” Per standing order above, the dialysis treatment for P-8 should not have been initiated. In addition, the Clonidine was administered over 2 hours after P-8’s first significantly high BP of 223/113 at 1138, with at least 3 additionally high BP readings which warranted Clonidine administration. Review of the treatment sheet dated 11/12/24, noted the following documentation by patient care technician (PCT/Staff K) noted P-8 had a pre-dialysis BP of 261/121 (systolic/diastolic) mm/Hg. at 1101. Staff K further documented under “Pre-Treatment Evaluation” that P-8 had “No Unusual Findings” at 1118. At 1123, BP was 252/106 mm/Hg entered by Staff K with no RN notification noted. At 1132, BP was 264/121 mm/Hg entered by PCT/Staff E with no RN notification. At 1237, BP was 242/93 mm/Hg entered by Staff E with no RN notification. At 1123 and 1142, RN/Staff Q administered 2 doses of 0.1 mg. Clonidine with improved results (BP 194/132 mm/Hg. at 1305). However, the facility failed to ensure staff adhered to the following standing order documented on the 11/12/24 treatment sheet under “Special Attentions” the following: “... Initiate HD (hemodialysis) treatment if SBP < (less) than 220 mm/Hg. and if patient asymptomatic.” On 10/10/24, the following documentation by certified clinical hemodialysis technician (CCHT/Staff S) noted P-8 had a pre-dialysis blood pressure (BP) of 235/95 (systolic/diastolic) mm/Hg. at 1059. PCT/Staff R further documented under “Pre-Treatment Evaluation” that P-8 had “No Unusual Findings” at 1117. At 1124, BP was 250/102 mm/Hg entered by Staff R with no RN notification. At 1133, BP was 241/109 mm/Hg entered by Staff R with no RN notification. At 1202, BP was 222/148 mm/Hg entered by Staff R with no RN notification. At 1235, BP was 229/88 mm/Hg entered by Staff J with no RN notification. At 1303, BP was 225/91 mm/Hg entered by Staff R with no RN notification. At 1239, 1433 and 1510, Register Nurse (RN/Staff O) administered 0.1 mg. Clonidine with improved results (BP 199/83 mm/Hg. at 1330). The treatment sheet documented under “Special Attentions” the following: “Per Dr. (physician/Staff O) standing order given to administer Clonidine if SBP > (greater) 200, repeat dose x1 every 15 minutes up to 0.3 mg. (3 doses in total). Initiate HD (hemodialysis) treatment if SBP < (less) than 220 mm/Hg. and if patient asymptomatic.” Per standing order above, the dialysis treatment for P-8 should not have been initiated. In addition, the Clonidine was administered 100 minutes after P-8’s first significantly high BP of 235/95 at 1059, with at least 6 additionally high BP readings which warranted Clonidine administration. The above findings were reviewed and acknowledged by the Director of Operations (Staff B), and the Clinical Manager (Staff C) during interview on 12/4/24 at 1347. Further, no evidence was found in the medical record which indicated staff had reached out to the physician for guidance/direction for initiating dialysis treatment(s) given the high BP readings which were significantly above the standing order threshold (220 mm/Hg.) for all the above treatment dates. The facility failed to ensure staff adhered to physician standing order(s) concerning BP management which were in place to help optimize patient safety.”

“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 record review and interview, the facility failed to ensure patient treatments were delivered as prescribed in 3 (P-1, 2, 5) of 10 sample records reviewed potentially resulting in difficulty achieving or sustaining the prescribed dose of dialysis to meet the hemodialysis needs of these patients. Findings include: P-1: This 60-year-old began hemodialysis at the facility on 9/26/24 with diagnoses including end stage kidney disease and high blood pressure. The medical record was reviewed on 12/3/24 and included 6 in-center hemodialysis treatment sheets between the dates of 9/30/24 and 12/2/24. During review of the record, it was noted that the active physician order (dated 10/11/24) for hemodialysis included that the Dialysate Flow Rate (DFR) be ran at the rate of 800 milliliters/minute (mL/min) for the duration of each treatment. During review of the treatment sheet dated 10/11/24, it was noted that the dialysis treatment began at 1239 and ended at 1604 (3 hours and 25 minutes), and the DFR was ran at 500 mL/min for the entire duration of the treatment. There was no documentation indicating a reason for the DFR being ran at 300 mL/min less than prescribed. This finding was reviewed and acknowledged by the Director of Operations (Staff B), and the Clinical Manager (Staff C) during interview on 12/4/24 at 1500. Staff C stated that the decrease in DFR must have been an oversight during machine set up. P-2: This 80-year-old was admitted to facility on 7/8/23 with diagnoses including end stage kidney disease and type 2 Diabetes. The medical record was reviewed on 12/4/24 and included 6 in-center hemodialysis treatment sheets between the dates of 11/19/24 and 11/30/24. During review of the record, it was noted that the active physician order (dated 11/9/24) for hemodialysis included the Blood Flow Rate (BFR) be ran at the rate of 400 mL/min, and the DFR to be ran at the rate of 800 mL/min for the duration of each treatment. During review of the treatment sheet dated 11/21/24, it was noted that the dialysis treatment began at 1047 and ended at 1432 (3 hours and 47 minutes), and the DFR was ran at 500 mL/min for the duration of the treatment. There was no documentation indicating a reason for the DFR being ran at 300 mL/min less than prescribed. During review of the treatment sheet dated 11/25/24, it was noted that the dialysis treatment began at 1115 and the BFR was ran at 350 mL/min until 1202. At 1202 the BFR rate was changed to 300 mL/min and stayed at that rate until treatment ended at 1445 (2 hours 43 minutes). There was no documentation indicating a reason for the BFR being changed to 100 mL/min less than prescribed. These findings were reviewed with Staff B and Staff C during interview on 12/4/24 at 1500. Staff C stated that the decreased DFR on 11/21/24 was most likely an oversight during machine set up. Staff C was not able to determine why the BFR was decreased on 11/25/24 and acknowledged both findings. 47976 P-5: This 32-year-old patient was admitted to this facility on 3/25/23 with the diagnosis of and acute kidney injury (AKI) with resultant diagnosis of end stage renal disease. During record review on 12/3/24, it was noted the blood flow rate (BFR) was ordered at 400 milliliters per minute (mL/min) and the dialysate flow rate (DFR) was ordered at 800 mL/min. During review of the last 6 treatment sheets, it was determined the BFR and DFR was run incorrectly as follows: On 10/19/24, the DFR was run at 600 mL/min for the duration of the treatment (4 hours and 7 minutes). There was no documentation indicating a reason the DFR was run at 200 mL/min below the prescribed rate. On 11/7/24, the BFR was run at 300 mL/min for the duration of the treatment (3 hours and 54 minutes). There was no documentation indicating a reason the BFR was run at 100 mL/min below the prescribed rate. On 11/16/24, the DFR was run at 500 mL/min for the duration of the treatment (3 hours and 45 minutes). There was no documentation indicating a reason the BFR was run at 300 mL/min below the prescribed rate. The findings were reviewed with and acknowledged by the Director of Operations (Staff B) and the Clinical Manager (Staff C) during an interview on 12/4/24 at 0900.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 47976 Based on record review and interview, the facility failed to ensure social work provided the necessary monitoring and interventions for 2 (P-4, 5) of 10 records reviewed, resulting in the potential for unidentified and unmet care needs. Findings include: P-4: This 32-year-old patient was admitted to this facility on 10/30/23 with the diagnosis of end stage renal disease. During record review on 12/3/24, it was noted this patient was severely non-compliant with attending treatments. Upon further review of the record, it was noted a “Root cause analysis” was done by the social worker in mid-February (not dated) to help determine the cause of the patient’s non-compliance. Upon review of the root cause analysis form, it was noted “Social workers are to utilize this document with patients who have missed 3 or more treatments within 6 weeks to identify root causes and reasons for the non-adherence.” After reviewing the patient’s missed treatment report, it was noted the patient had missed 8 visits within the first month of treatment. According to the “Letter of Concern” sent to the patient on 2/16/24, the patient had missed 29 appointments in 90 days. During an interview with the social worker (Staff O) on 12/3/24 at 1550, Staff O was asked for documentation of a root cause analysis (or similar intervention) done prior to the one done in February. Staff O was unable to provide evidence of an earlier root cause analysis or any other intervention done to address the patient’s non-compliance. Staff O was able to provide conversations with the patient and his wife. However, she was also unable to provide a reason nothing was done earlier to help determine the reason for missed visits and to assist in improving treatment adherence. P-5: This 32-year-old patient was admitted to this facility on 3/25/23 with the diagnosis of and acute kidney injury (AKI). During record review on 12/3/24, it was noted the social work documentation on the plan of care dated 10/30/23 stated under “Treatment Adherence”: “SW (social worker) unable to provide 90-day education regarding navigating dialysis and thrive. SW to assess pt at a later time and educate pt. Other reasons for missed treatment, illness/pain, doctors appointments, ‘refusal to come to dialysis’ per absence assessment. Pt with 8 missed treatment’s month of October, SW just learned on 10/28/23 that two barriers to dialysis were transportation however, SW skimmed pt chart review and notes entered, pt reason for not attending dialysis, “NCNS” (no call no show) reschedule reason transportation. SW contacted pt, listed emergency contact, local hospitals. SW/dialysis staff unable to complete standard order form for transportation due to pt’s phone being disconnected and no current address. SW to monitor due to not having a listed address to sent [sic] letter of concern.” Upon further review of the plan of care dated 10/30/23, Staff O identified the police department did a wellness check on the patient and indicated the patient was in the process of moving to East Lansing and would be transferring clinics. Continued notes of “SW to reassess” were noted throughout the plan of care. The next plan of care was dated 3/6/24, indicating the patient did not transfer clinics. During an interview on 12/3/24, Staff O was asked if a letter of concern or root cause analysis was done once the patient was located and returned to the clinic on 12/8/23 for treatment. Staff O was unable to provide documentation of social work follow-up and stated the patient’s non-compliance was the reason. During an interview on 12/4/24 at 0900, the Clinical Manager (Staff C) was asked to provide updated plan of care assessments after it was determined the patient would be returning to the clinic and her address was obtained. Staff C stated the patient had only come to dialysis twice between October 2023 and the most recent plan of care dated 3/6/24. The last visit was dated 12/8/23, however, there were no plan of care updates or documented attempts to follow-up by social work until the next plan of care dated 3/6/24. This assessment included continued documentation by Staff O of the patient’s missed treatments as well as reports of depression, anxiety, and an open Adult Protective Services case. There was no documentation of a root cause analysis done to help determine the cause of the non-compliance. There was also no documentation of a letter of concern being sent to the patient as mentioned above. The findings were reviewed with and acknowledged by the Director of Operations (Staff B) and the Clinical Manager (Staff C) during an interview on 12/4/24 at 0900.”

“GOV-INVOL DISCHARGE PROCESS REQUIREMENTS CFR(s): 494.180(f)(4) The medical director ensures that no patient is discharged or transferred from the facility unless - (4) The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team- (i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record; (ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge; (iii) Obtains a written physician’s order that must be signed by both the medical director and the patient’s attending physician concurring with the patient’s discharge or transfer from the facility; (iv) Contacts another facility, attempts to place the patient there, and documents that effort; and (v) Notifies the State survey agency of the involuntary transfer or discharge. (5) In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure. This Standard is not met as evidenced by: 47976 Based on record review and interview, the governing body failed to ensure staff follow facility policy for involuntary discharge for 1 (P-4) of 1 patient, resulting in the potential for poor patient outcomes. Findings include: **Policy titled, “Managing Treatment Adherence or Prolonged Hospitalization or Vacation” (dated 11/4/24) stated under “Managing Treatment Adherence” that, “Patients that are non-adherent to their treatment schedule: May not be involuntarily discharged or removed from the regular schedule because of their non-compliance.” **Policy titled, “Immediate and Non-Immediate Involuntary Patient Discharge” (dated 11/4/24) stated the following: -“Required Documentation” on page 3 stated, “The IDT (interdisciplinary team) must document in the patient’s medical record the reassessments, ongoing problem(s), and effort(s) made to resolve the problem(s).....The facility must contact another dialysis facility to help facilitate placement.” - “Review Process for Non-Immediate Involuntary Discharge” on page 5 that, “....notice of discharge (Patient Discharge Letter) to provide the patient outlining the reasons and attempts to resolve them.” -“Facility Unable to Meet Documented Medical Needs” stated on page 6 that, “All reasonable alternatives for continuing to provide care to the patient in the facility must be considered before discharge occurs. A meeting between the IDT and the patient and/or the patient’s representative or family should take place to discuss the patient’s current status and barriers to providing a safe treatment environment for the patient.” P-4: This 32-year-old patient was admitted to this facility on 10/30/23 with the diagnosis of end stage renal disease. During record review on 12/3/24, it was noted the patient was involuntarily discharged (IVD) from the facility on 4/10/24. According to the IVD paperwork submitted to the State Agency on 3/18/24, the patient was going to be involuntarily discharged because the “Facility can no longer meet the patient’s documented and medical needs” as the patient’s physician would no longer write orders for the patient due to his poor treatment adherence. Upon further review of the record, the following was noted: -The initial comprehensive assessment that is due within the latter of 30 days of the first dialysis treatment was not completed until 12/20/23 - 21 days late. There was no documentation at 30 days to acknowledge and identify issues early-on with treatment adherence. -Upon review of the initial comprehensive assessment dated 12/20/23, it was noted the patient did not attend the meeting and the information in the report was limited due to the patient’s poor treatment adherence. The social worker (Staff O) documented the patient had poor treatment compliance after missing more than 10 visits since starting dialysis. Staff O also identified the patient was new to dialysis and was having a hard time adjusting to treatment. He was also struggling with anxiety and depression. It was noted the social worker would educate the patient and his wife, continue to support them as needed, and would identify barriers to improve treatment adherence. There was no evidence in the record of the interventions above being completed. The patient was identified as “stable” for this plan of care and the next comprehensive assessment was planned for 90 days. -The second plan of care was dated 2/14/24. This plan of care documented continued non-compliance. The medical record noted the patient had attended 1 out of 14 scheduled treatments in January 2024 and had attended 1 out of 5 scheduled treatments in February 2024 (as of 2/14/14). The plan of care stated the physician was aware and the plan was to continue to provide resources and education. There was no documentation the interdisciplinary team (IDT) evaluated the effectiveness of the interventions implemented in the patient’s initial plan of care despite the lack of improvement in attendance. A root cause analysis was done at this time, however, there were no specific interventions documented to address the barriers identified. The root cause analysis also noted the patient was aware he may be assigned a new physician due to his non-compliance, but there was no mention of the risk for an IVD. The patient was identified as “unstable” at that time so his case would be reviewed the following month. -A “letter of concern” was sent to the patient on 2/16/24 by the Medical Director (Staff A), the Clinical Manager (Staff C), and the social worker (Staff O). This letter indicated concern for the patient’s health after missing 29 visits in 90 days. The letter included education on the health risks of missing treatment, however, there was no mention or education regarding the risk for an involuntary discharge. -On 3/7/24, a letter informing the patient he would be involuntarily discharged on 4/10/24 was sent to the patient by Staff A. The letter stated the decision was based on the patient’s nephrologist (also Staff A) terminating his care. The letter provided resources for other nephrologists and stated the facility would be “happy to continue to provide” him with dialysis treatment if he could find a nephrologist with privileges at the facility who was willing to see him. The letter failed to document the attempts to resolve the concerns per the policy mentioned above. It was also documented that the Renal Network was made aware of the 30-day notice letter at that time. -A follow-up to the unstable care plan from 2/14/24 was performed on 3/13/24 - after the decision was made to involuntarily discharge the patient. Staff C documented the patient had not been to treatment for 7 weeks, however, noted the clinic had been in contact with the patient. Documentation from Staff O stated the patient was very overwhelmed with his situation but was still interested in attending dialysis. The patient’s interest to continue dialysis was expressed several times throughout the note. Staff O also documented non-compliance as the reason for the plan to IVD. There was no documentation of a plan set with the patient to help improve his treatment adherence. Additionally, the note reported “no accepting provider at the clinic”, however, there was no documentation of communication with the other physicians in the clinic. -E-mail communication dated 4/12/24 documented communication with the Renal Network that indicated Staff O had “actively tried” to assist the patient in getting a new placement. There was no documentation of active efforts to contact other clinics for the patient per the policy above. It was noted the patient was sent a list of providers in the area. -The patient was involuntarily discharged from the facility on 4/10/24. During an interview with Staff A on 12/3/24 at 1430, Staff A was asked about the decision to involuntarily discharge this patient. Staff A stated that he was also the patient’s nephrologist, and he terminated his care at his office due to non-compliance. As a result, the patient did not have orders to continue at this facility. Staff A stated no other physician at the clinic wanted to take the patient, however, he was unable to provide documentation of communication with the other physicians in the clinic. There was also no documentation by Staff A which stated the patient was aware of his risk for an IVD or active interventions to improve treatment adherence. When asked about the agency policy which stated a patient cannot be involuntarily discharged due to non-compliance, Staff A stated the patient was discharged from his clinic due to non-compliance but was involuntarily discharged from the facility due to no physician orders. During an interview with Staff O on 12/3/24 at 1550, Staff O was asked for further documentation of efforts to change the patient’s behavior to improve his compliance. Staff O provided the root cause analysis again and stated she continued to support and educate the patient; however, she was unable to provide evidence of specific interventions based off the information collected in the root cause analysis. Staff O was also asked if the patient had been made aware of the potential risk of being involuntarily discharged from the facility prior to the 30-day notice letter. Staff O did not know if the patient had been made aware of the risk. During an interview with Staff C on 12/4/24 at 0900, Staff C was asked about efforts prior to February 2024 to address the patient’s non-compliance. Staff C stated resources and education were provided to the patient, however, no other specific or alternate interventions were identified besides the root cause analysis in February 2024 (less than 1 month prior to the involuntary discharge decision). Staff C was also asked what the facility procedure is for poor compliance. Staff C stated the patient is made unstable for 3 months and then behavior management is considered. Staff C was asked for evidence this occurred with P-4. Staff C stated no behavior contract was made with the patient due to Staff O stating she doesn’t do behavior contracts with individuals with mental health issues. Staff C stated this is not a facility policy and that there has been some discussion on whether that should be the procedure. Staff C also acknowledged P-4 had not been made unstable for 3 months prior to the involuntary discharge. The findings were also reviewed with the Director of Operations (Staff B) during the interview with Staff C on 12/4/24 at 0900. Staff C and Staff B stated they felt their hands were tied with the physician’s decision; however, they acknowledged the interventions lacked specificity to demonstrate a robust effort to actively assist the patient prior to the IVD.”