Fmc - Springfield Midwest

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 17026 Based on observation and staff interview, the facility staff failed to maintain three out of three hot water heaters and one floor drain in the water room. This had the potential to effect all patients on dialysis and cause an increase in water contamination and complications. The facility census was 106 In-Center Hemodialysis (Hemodialysis, a machine used to filter wastes, fluids, and salts from blood when the kidneys are no longer able to perform the filtering process) patients; four In-Center Transitional Care Unit (TCU, an outpatient dialysis unit for patients initiating dialysis with little or no pre-dialysis care and provides education to facilitate a smooth transition to either home or in-center dialysis services, and expedites referrals to transplant clinics) patients; 17 Home Hemodialysis (HHD, hemodialysis received in a patient’s home) patients; 62 Home Peritoneal Dialysis (HPD, a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body that the patient receives in their home) patients; and one Long-Term Care HPD (LTC-HPD, peritoneal dialysis received by the patient in a Long-Term Care facility) patient for a total facility census of 190. Findings included: 1. Observation on 12/8/25 at 2:33 PM, of the facility’s water room showed three hot water heaters approximately two feet in diameter that had rust areas around the edges and under the bottom of the hot water heaters. 2. During an interview on 12/9/25 at 9:44 AM, Staff A, Area Technical Operations Manager (ATOM), stated staff need to repair or replace all three of the facility’s hot water heaters. 3. Observation on 12/8/25 at 2:35 PM, of the water room showed an approximately one foot by one foot floor drain behind the central water plant that had yellow and brown areas around and inside of the floor drain. 4. During an interview on 12/9/25 at 9:45 AM, Staff A, ATOM, stated staff need to ensure the floor drains remain clean to help prevent contamination of the water system.”

“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: 18018 Based on observation, interview and policy review, the facility failed to ensure staff: - Performed hand hygiene (washing hands with soap and water or use of appropriate hand sanitizer) when indicated when staff provided care and treatments to patients. - Wore gloves when indicated and performed hand hygiene before gloving, after glove removal, and before re-gloving. - Removed gloves after staff assessed/palpated patients’ access sites, performed hand hygiene, and re-gloved before staff cleaned patients’ access sites to prepare for cannulation (insertion of a needle into the blood vessels to enable blood to be circulated between the patient and dialysis machine during dialysis treatment) for dialysis treatment for two (#29 and #30) patients out of two observations conducted of staff assessing patients’ access sites. - Repeated the cleansing process of patients’ access sites before cannulation when staff touched the area after the area was cleansed for one (#29) patient out of two observations conducted of staff cannulating patients’ access sites. - Removed gloves, performed hand hygiene and re-gloved after staff removed and discarded the old dressing on patients’ Central Venous Catheter (CVC, a line placed in a large vein used to deliver dialysis treatments) exit site prior to cleansing the CVC exit site and applying a sterile dressing for two (#25 and #26) patients out of six observations made of staff providing CVC exit site care. These failures to ensure staff practiced appropriate infection control prevention had the potential for cross-contamination and the spread of infections to both patients and staff. The facility’s In-Center Hemodialysis census was 106; the In-Center Transitional Care Unit census was four; the Home Hemodialysis census was 17; the Home Peritoneal Dialysis census was 62; and the Long-Term Care Home Peritoneal Dialysis Census was one for a total census of 190. Findings included: Hand Hygiene - Glove Use 1. Observation on 12/08/25 at 3:11 PM, showed Staff M, Licensed Practical Nurse (LPN), removed the disposable bloodlines and dialyzer from patient Station #10, however, Staff M failed to remove gloves, perform hand hygiene and re-glove before continuing with the Station disinfection/cleansing process. At the completion of the patient Station disinfection/cleansing process, Staff M removed gloves and re-gloved but failed to perform hand hygiene after glove removal or before re-gloving to string the bloodlines into the dialysis machine. 2. Observation on 12/08/25 at 3:28 PM, showed Staff R, Certified Clinical Hemodialysis Technician (CCHT), performed CVC exit site care for Patient #6. Staff R applied gloves and moved Patient #6’s hair out of the way of the CVC exit site and wearing the same gloves, Staff R cleansed the CVC exit site and applied a sterile dressing. Staff R failed to remove gloves, perform hand hygiene, and re-glove before cleansing the CVC exit site after touching Patient #6’s hair. 3. Observation on 12/09/25 at 10:10 AM, showed Staff O, CCHT, removed gloves and re-gloved, however, Staff O failed to perform hand hygiene after glove removal or before re-gloving. 4. Observation on 12/09/25 at 10:22 AM, showed Staff Q, CCHT, failed to perform hand hygiene before gloving. 5. Observation on 12/09/25 at 11:32 AM, showed Staff P, CCHT removed the disposable bloodlines and dialyzer from patient Station #5, however, Staff P failed to remove gloves, perform hand hygiene and re-glove before continuing with the Station cleansing/disinfection process. 6. Observation on 12/09/25 at 2:25 PM, showed Staff M, Licensed Practical Nurse (LPN), removed the disposable bloodlines and dialyzer from patient Station #29, however, Staff M failed to remove gloves, perform hand hygiene and re-glove before continuing with the Station cleansing/disinfection process. During the patient Station cleansing/disinfection process, Staff M, wearing the same gloves retrieved additional wiping cloths twice from the bleach container. Staffs’ failure to: - Remove gloves, perform hand hygiene and re-glove after discarding disposable items increased the risk of the gloves becoming contaminated with body fluids and/or blood and increased the risk of cross-contamination of all surfaces touched wearing the contaminated gloves during the patient Station cleaning/disinfection process. - Remove gloves, perform hand hygiene and re-glove after touching the patient’s hair increased the risk of contamination of the CVC exit site. - Perform hand hygiene after glove removal and before re-gloving increased the risk of staff contaminating the gloves during re-gloving. - Remove gloves, perform hand hygiene, and re-glove before retrieving additional wiping cloths from the bleach container increased the risk of contamination of the remaining wiping cloths touched by the contaminated gloves. 7. Review of the facility’s policy titled, “Hand Hygiene,” dated 11/06/23, showed staff directives: - Hands will be washed with antimicrobial soap and water when hands are dirty or contaminated with proteinaceous material, blood, or other body fluids. - Hands will be decontaminated using alcohol-based hand rub or by washing hands with soap and water when: - Before and after direct contact with patients. - Entering and leaving the treatment area. - Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications. - After contact with body fluids or excretion, mucous membranes, on-intact skin, and wound dressings if hands are not visibly soiled. - After contact with inanimate objects near the patient. - When moving from a contaminated body site to a clean body site of the same patient. - After contact with the dialysis wall box, concentrate, drain, or water lines. - After contact with other objects within the patient station or treatment space. AVF - AVG Access Care and Cannulation 8. Observation on 12/12/25 at 8:05 AM, showed Staff N, CCHT, prepared Patient #30 for cannulation of the patient’s Arteriovenous Fistula (AVF - a permanent access that is surgically created by sewing an artery to a vein, usually located in the arm) access sites. After Staff N assessed and palpated the patient’s AVF access sites, Staff N failed to remove gloves, perform hand hygiene and re-glove before Staff N applied antiseptic (process that is maintained free of germs or bacteria) to the patient’s skin for cannulation. 9. Observation on 12/09/25 at 7:53 AM, showed Staff R, CCHT: -Prepared Patient #29 for cannulation of the patient’s AVF access sites. - After Staff R assessed and palpated the patient’s access sites, Staff E failed to remove gloves, perform hand hygiene, and re-glove before Staff R applied an antiseptic to the patient’s skin for cannulation. - Cannulated Patient #29’s AVF access sites for dialysis treatment. Staff R touched the top access site, however, Staff R failed to repeat the skin antisepsis process before Staff R cannulated the patient’s top access site. Staffs’ failure to: - Remove gloves, perform hand hygiene and re-glove before applying antiseptic to patients’ skin/access sties increased the risk of contamination to the skin/access sites from the gloves worn to assess/palpate the patients’ access sites. -Remove gloves, perform hand hygiene and re-glove to repeat the antiseptic cleansing of the patient’s access sites after being touched by staff increased the risk of contamination and introduction of bacteria to the access sites. 10. Review of the facility’s policy titled, “Access Assessment and Cannulation,” dated 05/05/25 showed staff directives: - Wash hands and don PPE (Personal Protective Equipment, gloves, gown/apron, safety glasses and mask, or full-face shield). - Assess the vascular access by: Look, Listen, and Feel. - Remove gloves and perform hand hygiene. Don new gloves. After assessing the access, staff must perform hand hygiene and don new gloves. With the new gloves, staff may perform the full cannulation procedure (both needles) including skin disinfection, lidocaine administration (if applicable) and cannulation. If any of the steps in the procedure are interrupted, hand hygiene must be performed, and new gloves must be donned. - Do not touch cannulation sites after skin disinfection. CVC Exit Site Care 11. Observation on 12/09/25 at 10:49 AM, showed Staff P, CCHT, prepared Patient #25 for a CVC exit site dressing change. Staff P removed and discarded the old CVC dressing, however, Staff P failed to remove gloves, perform hand hygiene and re-glove after removal and discarding the old dressing. Wearing the same gloves, Staff P cleansed the CVC exit site and applied a sterile dressing. 12. Observation on 12/09/25 at 11:55 AM, showed Staff M, LPN, prepared Patient #26 for a CVC exit site dressing change. Staff M removed and discarded the old CVC dressing, however, Staff M failed to remove gloves, perform hand hygiene and re-glove after removal and discarding the old dressing. Wearing the same gloves, Staff M cleansed the CVC exit site and applied a sterile dressing. Staffs’ failure to remove gloves, perform hand hygiene and re-glove after removal and discarding the old CVC dressing and prior to the cleansing process increased the risk of contaminating supplies, the CVC exit site, CVC hubs/ports, and bloodlines used to connect the patient to dialysis. 13. Review of the facility’s policy titled, “Central Venous Catheter (CVC) Dressing Change for Inpatient Services,” dated 05/06/24 showed staff directive: Discard dressing and remove gloves. Perform hand hygiene. 14. During an interview on 12/10/25 at 3:19 PM, Staff F, Registered Nurse, Clinical Manager, stated she conducted monthly practice audits of staff performing direct patient care and addressed any concerns with staffs’ practice in real-time. Staff F stated the expectation of staff was to follow the facility’s policy and procedures.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 18018 Based on observation, policy review, and interview, the facility failed to ensure staff appropriately disposed of bio-hazardous waste (blood and/or body fluids) for five out of five observations conducted of staff disposing bio-hazardous waste materials/items (used bloodlines and dialyzer) after patients’ dialysis treatments. This failed practice had the potential for increased exposure to blood and/or body fluids to both patients and staff. The facility’s In-Center Hemodialysis census was 106; the In-Center Transitional Care Unit census was four; the Home Hemodialysis census was 17; the Home Peritoneal Dialysis census was 62; and the Long-Term Care Home Peritoneal Dialysis Census was one for a total census of 190. Findings included: 1. Observations on 12/08/25 and 12/09/25 showed Staff M, Licensed Practical Nurse (LPN): - On 12/08/25 at 3:12 PM, removed used bloodlines/dialyzer from patient Station #10 located in POD 1 and carried the uncontained bio-hazardous items to the large red bio-hazardous cart. The large red bio-hazardous cart was located next to a supply cabinet that was under the shelf of the nurse’s station and under the shelf at the end of the nurse’s station and both the cabinet and shelf contained various dialysis supplies. Staff M carried the uncontained bio-hazardous items in front of Patient #31 while the patient sat in the dialysis chair receiving dialysis treatment. - On 12/09/24 at 10:41 AM, carried uncontained used bloodlines/dialyzer from patient Station #27 located in POD 4 to the large red bio-hazardous cart located next to the dirty sink. Staff M carried the bio-hazardous waste items in front of Patient #31 while the patient sat in the dialysis chair receiving dialysis treatment. - On 12/09/25 at 2:25 PM, removed used bloodlines/dialyzer from patient Station #29 located in POD 3 and carried the uncontained bio-hazardous items to the large red bio-hazardous cart located in front of the dirty sink. 2. Observation on 12/09/25 at 10:10 AM, showed Staff O, Certified Clinical Hemodialysis Technician (CCHT), removed used bloodlines/dialyzer from a patient Station located in POD 1 and carried the uncontained bio-hazardous items to the large red bio-hazardous cart located next to the supply cabinet and under the nurse’s station shelf that contained dialysis supplies. Staff O carried the uncontained bio-hazardous items in front of Patient #24 and Patient #33 while the patients sat in the dialysis chairs receiving dialysis treatment. 3. Observation on 12/09/25 at 11:32 AM, showed Staff P, CCHT, removed used bloodlines/dialyzer from patient Station #5 located in POD 3 and carried the uncontained bio-hazardous items to the large red bio-hazardous cart located across from patient Stations #29 and #30. Staff P carried the uncontained bio-hazardous items in front of Patient #25 and Patient #30 while the patients sat in the dialysis chairs receiving dialysis treatment. 4. Observation on 12/09/25 at 11:45 AM, showed the large red bio-hazardous cart located in POD 1 next to the supply cabinet and under the shelf at the end of the nurse’s station contained the following supplies: - On top of the supply cabinet: Six boxes of non-sterile gloves, one box of alcohol prep pads, paper tape, and one stack of blue barrier pads. - The supply cabinet did not have a splash guard between the cabinet and parked large red bio-hazardous cart to prevent contamination of the supplies on top of the cabinet. - On the shelf at the end of the nurse’s station: Three Bicarb 900 g (grams, unit of measurement) bags. - The shelf above the large red bio-hazardous cart did not have a splash guard in place to prevent contamination of the three Bicarb bags. Without a splash guard in place increased the risk of all supplies placed on top of the cabinet and shelf becoming contaminated from splashing, spraying, splattering or generation of droplets from the used bloodlines/dialyzer when staff placed the uncontained bio-hazardous items into the large red bio-hazardous cart. Staffs’ failure to bring the large red bio-hazardous cart to the patient Station to dispose of used bloodlines and dialyzer removed from the dialysis machine after a patient’s dialysis treatment increased the risk of splashing, spraying, splattering or generation of droplets and exposing patients and staff to infections and cross-contamination when staff carried the uncontained bio-hazardous waste without being contained in a fluid resistant container. 5. Review of the facility’s policy titled, “Transporting Medical Waste Containers to the Medical Waste Room,” dated 11/02/25, showed the policy did not direct staff to either bring the large red bio-hazardous cart to the patient Station to discard used bloodlines/dialyzer or to bring a red bio-hazardous waste bag to the patient Station to place the used bloodlines and dialyzer in the red bio-hazardous waste bag when staff transported the used bio-hazardous items from the patient Station to the location where the large bio-hazardous carts were located. 6. During an interview on 12/10/25 at 3:19 PM, Staff F, Registered Nurse, Clinical Manager, stated she conducted monthly practice audits of staff performing infection control prevention and addressed any concerns with staffs’ practice in real-time.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 18018 Based on observation, policy review, and interview the facility failed to ensure staff consistently, thoroughly, and properly disinfected/cleansed all external surfaces of patient Stations at the end of a patient’s dialysis treatment and prior to the initiation of the next patient’s dialysis treatment for six out of six observations made of staff performing patient Station disinfection/cleansing. Staff also failed to consistently only clean/disinfect the patient Station after the patient had vacated the patient Station at the completion of patient’s dialysis treatment for one out of six station disinfection/cleansing observations conducted. These failures to properly disinfect/clean external surfaces that are frequently touched by patients and staff and to ensure the patient vacated the patient Station prior to the disinfection/cleansing process increased the potential for cross-contamination that could cause infection risks to all patients and staff. The facility’s In-Center Hemodialysis census was 106; the In-Center Transitional Care Unit census was four; the Home Hemodialysis census was 17; the Home Peritoneal Dialysis census was 62; and the Long-Term Care Home Peritoneal Dialysis Census was one for a total census of 190. Findings included: 1. Observation on 12/08/25 at 3:11 PM, showed Staff M, Licensed Practical Nurse (LPN), failed to clean/disinfect the following items at patient Station #10: - The dialysis machine’s sides, back, and supply lines/cords; - The chase wall and supply wall/box; - The emergency kit attached to the intravenous (IV) pole hook; - The television (TV), TV remote control, and TV arm; - IV pole hooks; and - The outside surface of the red sharps container and garbage can. 2. Observation on 12/09/25 at 9:49 AM, showed Staff Q, Certified Clinical Hemodialysis Technician (CCHT), started to clean/disinfect the dialysis machine as the patient sat in the dialysis chair while Staff O, CCHT, removed the needles from the patient’s access sites. 3. Observation on 12/09/25 at 10:10 AM, showed Staff O, CCHT, failed to clean/disinfect the following items at a patient Station: - The dialysis machine’s base, back, and supply lines/cords; - The prime bucket’s interior and exterior surfaces; - The emergency kit attached to the IV pole hook; - The TV, TV remote control, and TV arm; and - The IV pole hooks. 4. Observation on 12/09/25 at 11:32 AM, showed Staff P, CCHT, failed to clean/disinfect the following items at patient Station 5: - The dialysis machine’s back and supply lines/cords; - The prime bucket’s interior and exterior surfaces; - The emergency kit attached to the IV pole hook; - The TV remote control and TV arm; - The IV pole hooks; and - The outside surface of the red sharps container. 5. Observation on 12/09/25 at 2:11 PM, showed Staff P, CCHT, failed to clean/disinfect the following items at patient Station #30: - The dialysis machine’s sides, base, back, and supply lines/cords; - The emergency kit attached to the IV pole hook; and - The TV, TV remote control, and TV arm; 6. Observation on 12/09/25 at 4:25 PM, showed Staff M, LPN, failed to clean/disinfect the following items at patient Station #29: - The dialysis machine’s top, base, and supply lines/cords; - The emergency kit attached to the IV pole hook; - The TV, TV remote control, and TV arm; and - The outside surface of the red sharps container. 7. Review of the facility’s policy titled, “Cleaning and Disinfecting the Dialysis Station,” dated 09/02/25, showed staff directives: - To prevent cross-contamination between patients, it is important that the previous patient completely vacates the station before staff begin cleansing and disinfecting the station and setting up for the next patient. - The patient must completely vacate the station before the dialysis machine can be externally disinfected, allowed to dry and set up for the next treatment. - Use a cloth wet with 1:100 bleach solution or EPA-approved disinfectant to clean and disinfect the dialysis station chair, tables, machine, television, IV pole, blood pressure cuff, sharps container, chase wall behind the chair. - Place the chair in Trendelenburg position and open side panels if chair has swing open sides so all surfaces of the chair are accessible. - Surface disinfect the dialysis wall box and the area/wall around the wall box at the end of each treatment day. 8. During an interview on 12/10/25 at 3:19 PM, Staff F, Registered Nurse, Clinical Manager, stated she conducted monthly practice audits of staff performing infection control prevention and addressed any concerns with staffs’ practice in real-time. Staff F stated the expectation of staff was to follow the facility’s policy and procedures.”

“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: 18018 Based on review of patients’ Treatment Sheets, policy review, and interview, the facility failed to ensure staff followed physician orders for: - Heparin bolus (medication used to thin blood and/or prevent blood clot formation) administration for six (#9, #14, #15, #16, #18, and #23) patients out of 15 In-Center Hemodialysis patients’ Treatment Sheets reviewed for administration of heparin bolus. - Hourly heparin infusion stop time for one (#13) patient out of one In-Center Hemodialysis patient’s Treatment Sheets reviewed for hourly heparin infusion stop time. The failure to follow the heparin order had the potential for dialysis complications including excessive bleeding or clotting for all patients that received heparin. - Blood flow rate (BFR, how fast blood is pumped through the dialyzer - artificial kidney and then pumped back into the patient during their hemodialysis treatment) for six (#4, #9, #10, #13, #14, and #23) patients out of 15 In-Center Hemodialysis patients’ Treatment Sheets reviewed for BFR. - Dialysate flow rate (DFR, how fast toxins are removed from blood into the dialysate) for two (#13 and #18) patients out of 15 In-Center Hemodialysis patients’ Treatment Sheets reviewed for DRF. The failure to follow the BFR and DFR order had the potential to affect the adequacy of patients’ dialysis treatments. These failures had the potential to affect all In-Center Hemodialysis patients that received dialysis treatments at the facility. The facility’s In-Center Hemodialysis census was 106; the In-Center Transitional Care Unit census was four; the Home Hemodialysis census was 17; the Home Peritoneal Dialysis census was 62; and the Long-Term Care Home Peritoneal Dialysis Census was one for a total census of 190. Findings included: Heparin Bolus - Hourly Heparin Infusion 1. Review of Patient #9’s Treatment Sheet dated 10/31/25, showed staff documented the heparin bolus was administered at 6:59 AM and the dialysis treatment start time was 6:52 AM. Staff failed to administer the heparin bolus within three (3) to five (5) minutes before the initiation of the patient’s dialysis treatment. 2. Review of Patient #14’s Treatment Sheet dated 12/06/25, showed staff documented the heparin bolus was administered at 7:26 AM and the dialysis treatment start time was 7:26 AM. Staff failed to administer the heparin bolus within 3 to 5 minutes before the initiation of the patient’s dialysis treatment. 3. Review of Patient #15’s Treatment Sheet dated 12/04/25, showed staff documented the heparin bolus was administered at 3:00 PM and the dialysis treatment start time was 11:40 AM. Staff failed to administer the heparin bolus within 3 to five minutes before the initiation of the patient’s dialysis treatment. 4. Review of Patient #16’s Treatment Sheet dated 12/04/25, showed staff documented the heparin bolus was administered at 8:53 AM and the dialysis treatment start time was 8:53 AM, and on 12/09/25, showed staff documented the heparin bolus was administered at 9:04 AM and the dialysis treatment start time was 9:04 AM. Staff failed to administer the heparin bolus within 3 to 5 minutes before the initiation of the patient’s dialysis treatments. 5. Review of Patient #18’s Treatment Sheet dated 11/25/25, showed staff documented the heparin bolus was administered at 3:59 PM and the dialysis start time was 3:55 PM. Staff failed to administer the heparin bolus within 3 to 5 minutes before the initiation of the patient’s dialysis treatment. 6. Review of Patient #22’s Treatment Sheet dated 11/11/25, showed staff documented the heparin bolus was administered at 1:55 PM and the dialysis treatment start time was 11:10 AM, and on 11/15/25, showed staff documented the heparin bolus was administered at 11:18 AM and the dialysis treatment start time was 11:17 AM. Staff failed to administer the heparin bolus within 3 to 5 minutes before the initiation of the patient’s dialysis treatment. 7. Review of Patient #23’s Treatment Sheet dated 09/19/25, showed staff documented the heparin bolus was administered at 10:02 AM and the dialysis treatment start time was 8:05 AM. Staff failed to administer the heparin bolus within 3 to 5 minutes before the initiation of the patient’s dialysis treatment. 8. Review of Patient #13’s Treatment Sheets showed the physician directed staff to stop the hourly heparin infusion 60 minutes before the end of the patient’s dialysis treatment. The Treatment Sheets dated 11/28/25, 12/03/25 and 12/08/25, showed staff failed to stop the hourly heparin infusion 60 minutes before the end of the patient’s dialysis treatments. Staff failed to document on the patients’ Treatment Sheets the reason the heparin bolus was not administered within 3 to 5 minutes before the start of patients’ dialysis treatments and the reason the hourly heparin infusions were not stopped 60 minutes before the end of the patient’s dialysis treatments per physician orders. BFR 9. Review of Patient #4’s Treatment Sheet showed the physician directed staff to set the BFR rate at 450 millimeters (mL, unit of measurement) per/minute (min). The Treatment Sheet dated 12/04/25, showed staff set the BFR rate to run at 400 mL/min during the patient’s dialysis treatment and not at the ordered rate of 450 mL/min. 10. Review of Patient #9’s Treatment Sheet showed the physician directed staff to set the BFR rate at 550 mL/min. The Treatment Sheet dated 11/07/25, showed staff set the BFR rate to run at 400 mL/min during the patient’s dialysis treatment and not at the ordered rate of 550 mL/min. 11. Review of Patient #10’s Treatment Sheet showed the physician directed staff to set the BFR rate at 450 mL/min. The Treatment Sheet dated 11/26/25, showed staff set the BFR rate to run at 400 mL/min during the patient’s dialysis treatment and not at the ordered rate of 450 mL/min. 12. Review of Patient #13’s Treatment Sheets showed the physician directed staff to set the BFR rate at 400 mL/min. The Treatment Sheets dated 11/28/25 and 12/03/25, showed the BFR rate was not consistently recorded/documented during the patient’s dialysis treatment and the Treatment Sheet dated 12/08/25, showed no recorded documentation for the BFR rate during the patient’s dialysis treatment. 13. Review of Patient #14’s Treatment Sheet showed the physician directed staff to set the BFR rate at 450 mL/min. The Treatment Sheet dated 12/04/25, showed staff set the BFR rate to run at 400 mL/min for approximately two out of four hours during the patient’s dialysis treatment and not at the ordered 450 mL/min. Staff failed to document the reason the BFR was not ran at the physician’s order for approximately two hours. 14. Review of Patient #18’s Treatment Sheet showed the physician directed staff to set the BFR rate at 400 mL/min. The Treatment Sheet dated 11/25/25, showed staff set the BFR to run at 300 mL/min for approximately one and a half hours out of three and a half hours without documentation as to the reason staff decreased the BFR rate. 15. Review of Patient #22’s Treatment Sheets showed the physician directed staff to set the BFR rate at 450 mL/min. The Treatment Sheets dated 11/11/25, 11/13/25, and 11/15/25, showed staff set the BFR rate to run between 350 mL/min and 400 mL/min during the patient’s dialysis treatment and not at the ordered rate of 450 mL/min. 16. Review of Patient #23’s Treatment Sheets showed the physician directed staff to set the BFR rate at 350 mL/min. The Treatment Sheets dated 09/19/25 and 09/24/25, showed staff set the BFR rate to run at 300 mL/min during the patient’s dialysis treatment and not at the ordered rate of 350 mL/min. Staff failed to document on the patients’ Treatment Sheets the reason the BFR was not set to run at the rate ordered by the physician. DFR 17. Review of Patient #13’s Treatment Sheet showed the physician directed staff to set the DFR rate at 800 mL/min. The Treatment Sheet dated 11/28/25 and 12/03/25, showed the DFR rate was not consistently recorded/documented during the patient’s dialysis treatment and the Treatment Sheet dated 12/08/25, showed no recorded documentation for the DFR rate during the patient’s dialysis treatment. 18. Review of Patient #18’s Treatment Sheet showed the physician directed staff to set the DFR rate at 800 mL/min. The Treatment Sheet dated 11/28/25, showed staff set the DFR rate to run at 700 mL/min during the patient’s treatment and not at the ordered rate of 800 mL/min. 19. Review of Patient #20’s Treatment Sheet showed the physician directed staff to set the DFR rate at 500 mL/min. The Treatment Sheet dated 12/01/25, showed staff set the DFR rate to run at 800 mL/min during the patient’s treatment and not at the ordered rate of 500 mL/min. Staff failed to document on the patients’ Treatment Sheets the reason the DFR was not set to run at the rate ordered by the physician. 20. Review of the facility’s policy titled, “Heparin Bolus Administration,” dated 05/05/25, showed the directive for staff: Allow heparin to circulate within the bloodstream for a minimum of 3-5 minutes before initiating treatment to prevent blood from clotting in the dialysis circuit. 21. During an interview on 12/10/25 at 3:19 PM, Staff F, Registered Nurse, Clinical Manager, stated for prescription errors/not following physician’s orders, Staff F will perform audits on patients’ Treatment Sheets and provide re-education for staff on following physician’s orders for dialysis prescriptions. 17026”