Bma Independence

“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, policy review, and interview the facility failed to ensure staff: - Performed hand hygiene when indicated when staff provided care and treatments to patients. - Wore gloves when indicated and performed hand hygiene after glove removal and before re-gloving after removal. - Removed gloves after staff assessed/palpated patients’ access sites, performed hand hygiene, and re-gloved before staff applied antiseptic (used to slow or stop the growth of microorganisms on the surface of the body to assist in the prevention of infection) to 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 eight (#4, #7, #11[two observations for #11], #12, #13, #14 and #15) out of eight observations conducted of staff assessing/palpating patients’ access sites. - Repeated the cleansing process of patients’ access site(s) before cannulation when staff touched the area after the area was cleansed for three (#7, #11, and the patient at patient Station #12) patients out of nine observations conducted of staff cannulating patients’ access site(s). 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 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) census was 43. Findings included: HAND HYGIENE - GLOVE USE 1. Observations on 01/28/25 showed: - At 1:18 PM, Staff C, Certified Clinical Hemodialysis Technician (CCHT), removed gloves and re-gloved without performing hand hygiene before re-gloving twice. - At 1:34 PM, Staff M, Patient Care Technician (PCT), removed gloves and re-gloved without performing hand hygiene before re-gloving twice. 2. Observations on 01/29/25 showed Staff E, PCT: - At 8:10 AM, turned off the alarm on the dialysis machine with a glove wrapped around staff’s finger. Staff E failed to place the glove on the hand before touching the dialysis machine. - From 9:02 AM to 9:14 AM, removed gloves and re-gloved without performing hand hygiene before re-gloving four times while providing care to Patient #16. - At 9:21 AM, removed gloves and re-gloved without performing hand hygiene before re-gloving. - From 9:24 AM to 9:31 AM, removed gloves four times, and re-gloved without performing hand hygiene after each glove removal and before re-gloving. - At 10:18 AM, gloved without performing hand hygiene before gloving to turn off the dialysis machine alarm located at patient Station #4. - At 10:22 AM, 11:21 AM. and at 11:30 AM removed gloves and re-gloved without performing hand hygiene before re-gloving four times. - At 10:35 AM, turned off the dialysis machine alarms located at patient Stations #11 and #10 wearing the same gloves. - At 11:26 AM, gloved without performing hand hygiene before gloving to turn off the dialysis machine alarm located at patient Station #11. - At 11:48 AM and at 11:52 AM, removed gloves and re-gloved without performing hand hygiene before re-gloving while providing care to Patient #7. 3. Observations on 01/29/25 showed Staff F, PCT: - From 9:31 AM to 9:36 AM, and at 9:45 AM, gloved without performing hand hygiene before gloving and removed gloves three times and re-gloved without performing hand hygiene before re-gloving when providing care to Patient #17. - At 9:48 AM, removed gloves and re-gloved without performing hand hygiene after glove removal to turn off the dialysis machine alarm located at patient Station #14. - At 10:49 AM, removed gloves and re-gloved without performing hand hygiene while providing care to Patient #12. - At 11:04 AM, touched the dialysis machines located at patient Stations #2 and #3 wearing the same gloves. - On 01/30/25 at 9:50 AM, removed gloves and re-gloved without performing hand hygiene after glove removal to turn off the dialysis machine alarm located at patient Station #17. 4. Observations on 01/29/25 showed Staff G, CCHT: - At 10:19 AM, removed gloves and re-gloved without performing hand hygiene before re-gloving. - At 10:57 AM, touched the dialysis machine without wearing gloves. - At 11:25 AM and at 11:54 AM, gloved without performing hand hygiene before gloving. Staffs’ failure to perform hand hygiene after glove removal and before re-gloving increased the risk of staff contaminating the gloves during re-gloving. 5. Review of the facility’s policy titled, “Hand Hygiene,” dated 1/06/23, showed staff directives: - Hands will be washed with antimicrobial soap and water when hands are visibly 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 antimicrobial soap and water immediately after removing gloves. - After contact with inanimate objects near the patient. 6. During an interview on 01/30/25 at 2:13 PM, Staff A, Registered Nurse-Clinical Manager (RN-CM), stated the expectation for staff was to: - Perform hand hygiene before gloving, after glove removal and before re-gloving. - Wear a glove on the hand when touching the dialysis machine and not just wrap the glove around staffs’ finger. - Change gloves, perform hand hygiene and re-glove when going from one patient Station to the next. AVF - AVG Access Care and Cannulation 7. Observation on 01/28/25 at 10:07 AM, showed Staff C, CCHT, prepared Patient #11 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 C assessed and palpated the patient’s access sites, Staff C failed to remove gloves, perform hand hygiene and re-glove before Staff C applied antiseptic to the patient’s skin for cannulation. 8. Observations on 01/29/25 showed: - At 8:00 AM, Staff G, CCHT, prepared Patient #4 for cannulation of the patient’s AVF access sites. After Staff C assessed and palpated the patient’s access sites, Staff G failed to remove gloves, perform hand hygiene and re-glove before Staff G applied antiseptic to the patient’s skin for cannulation. - At 10:34 AM, Staff F, PCT, prepared Patient #12 for cannulation of the patient’s AVF access sites. After Staff F assessed and palpated the patient’s access sites, Staff F failed to remove gloves, perform hand hygiene and re-glove before Staff F applied antiseptic to the patient’s skin for cannulation. - At 10:55 AM, Staff G, CCHT, prepared Patient #13 for cannulation of the patient’s AVF access sites. After Staff G assessed and palpated the patient’s access sites, Staff G failed to remove gloves, perform hand hygiene and re-glove before Staff G applied antiseptic to the patient’s skin for cannulation. - At 11:36 AM, Staff E, PCT, prepared Patient #7 for cannulation of the patient’s access sites. After Staff E assessed and palpated the patient’s access sites, Staff E removed gloves and re-gloved without performing hand hygiene before re-gloving to apply antiseptic to the patient’s skin for cannulation. 9. Observations on 01/30/25 showed: - At 9:44 AM, Staff G, CCHT, prepared Patient #11 for cannulation of the patient’s AVF access sites. After Staff G assessed and palpated the patient’s access sites, Staff G failed to remove gloves, perform hand hygiene and re-glove before Staff G applied antiseptic to the patient’s skin for cannulation. - At approximately 10:30 AM, Staff B, PCT, prepared Patient #14 for cannulation of the patient’s AVF access sites. After Staff B assessed and palpated the patient’s access sites, Staff B failed to remove gloves, perform hand hygiene and re-glove before Staff B applied antiseptic to the patient’s skin for cannulation. - At approximately 10:45 AM, Staff F, PCT, prepared Patient #15 for cannulation of the patient’s access sites. After Staff F assessed and palpated the patient’s access sites, Staff F failed to remove gloves, perform hand hygiene and re-glove before Staff F applied antiseptic to the patient’s skin for cannulation. Staffs’ failure to remove gloves, perform hand hygiene and re-glove before applying antiseptic to patients’ skin/access sites for cannulation increased the risk of contamination to the skin/access sites from the gloves worn to assess/palpate the access sites. 10. Observation on 01/28/25 at 10:07 AM, showed Staff C, CCHT, cannulated Patient #11’s AVF access sites for dialysis treatment. Staff C touched both the bottom and top access sites, however, Staff C failed to repeat the skin antisepsis process before Staff C cannulated the patient’s access sites. 11. Observations on 01/29/25 showed: - At 10:31 AM, Staff C, CCHT, was at patient Station #12 and cannulated the patient’s access sites for dialysis treatment. Staff C touched the top access site, however, staff C failed to repeat the skin antisepsis process before staff C cannulated the top access site. - At 1:36 PM, Staff E, PCT, cannulated Patient #7’s access sites for dialysis treatment. Staff E touched both the bottom and top access sites, however, Staff E failed to repeat the skin antisepsis process before Staff E cannulated the patient’s access sites. Staffs’ failure to repeat the antisepsis process before cannulation after staff touched the patient’s access site(s) increased the risk of contamination to the access site(s) and the possibility to allow for the introduction of bacteria during cannulation. 12. Review of the facility’s policy titled, “Hand Hygiene,” dated 11/06/23 showed staff directives: - Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water: - Before and after direct contact with patients. - Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications. - Immediately after removing gloves. - When moving from a contaminated body site to a clean body site of the same patient. 13. During an interview on 01/30/25 at 2:13 PM, Staff A, RN-CM, stated staff was expected to: - Perform hand hygiene after glove removal and before re-gloving. - Change gloves after staff assessed/palpated patients’ access sites, perform hand hygiene and re-glove to apply antiseptic to the patients’ access sites for cannulation. - Repeat the antiseptic process to patients’ access site(s) if staff touched the site(s) before staff cannulate the patients’ access site(s) to reduce the risk of contamination and possible entrance of bacteria when staff cannulate the access site(s). - Follow the facility’s policy and procedure related to hand hygiene.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 18018 Based on observation, policy review and interview, the facility failed to ensure staff wore Personal Protective Equipment (PPE - coat or gown, face shield or goggles, face mask and gloves) when staff either cannulated (insertion of a needle into the blood vessels to enable blood to be circulated between the patient and dialysis machine during dialysis treatment) a patient’s Arteriovenous Fistula (AVF - a permanent access that is surgically created by sewing an artery to a vein, usually in the arm) access sites or a patient’s Arteriovenous Graft (AVG - a permanent access made by connecting an artery and a vein with a synthetic material) to initiate dialysis treatment or disconnected (removed) needles from a patient’s access sites at the completion of dialysis treatment. This failure increased the potential for cross-contamination and infections to both patients and/or staff. The facility’s 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) census was 43. Findings included: Cannulation of Patients’ AVF - AVG Access Sites 1. Observations conducted of Staff G, Certified Clinical Hemodialysis Technician (CCHT) cannulating patients’ access sites showed Staff G failed to wear a face mask during the cannulation process on: - 01/28/25 at 10:07 AM, when Staff G cannulated Patient #4’s access sites; - 01/29/25 at 10:55 AM, when Staff G cannulated Patient #13’s access sites; and - 01/30/25 at 9:44 AM, when Staff G cannulated Patient #11’s access sites. Discontinuation of Patients’ AVF - AVG Access Sites 2. Observations conducted of staff showed staff failed to wear a face mask when removing needles from patients’ access sites at the completion of dialysis treatment on: - O1/28/25 at 1:18 PM, Staff C, CCHT, failed to wear a face mask when Staff C removed the needles from Patient #5’s access sites at the completion of the dialysis treatment. - On 01/29/25 at 10:25 AM, Staff G, CCHT, failed to wear a face mask when Staff G removed the needles from Patient #3’s access sites at the completion of the dialysis treatment. - 01/29/25 at 2:47 PM, Staff G, CCHT, failed to wear a face mask when Staff G removed the needles from Patient #12’s access sites at the completion of the dialysis treatment. 3. Review of the facility’s policy titled, “Personal Protective Equipment,” dated 11/06/23, showed staff directives: Personal protective equipment including a full-face shield or mask and protective eyewear with full side shield, fluid-resistant gowns, and gloves, must be worn to protect employees from blood or other potentially infectious materials (OPIM). PPE is used to protect employees who are occupationally exposed to blood or OPIM when performing procedures during which spurting or splattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). 4. During an interview on 01/30/25 at 2:13 PM, Staff A, Registered Nurse-Case Manager stated the expectation for staff was to wear either a face shield or goggles and a face mask when staff either cannulated or removed needles from a patient’s access sites. Staff A stated staff was expected to follow the facility’s policy related to PPE.”

“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 15 out of 15 observations conducted of staff disposing bio-hazardous waste 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 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) census was 43. Findings included: 1. Observations on 01/28/25, 01/29/25, and 01/30/25, showed staff removed used bloodlines/dialyzer from the dialysis machine at the end of patients’ treatment and carried the used waste items without being contained in a fluid resistant red bio-hazardous waste bag to the large red bio-hazardous carts located across from patient Station #1 and under the fire extinguisher across from patient Station #11. 2. On 01/28/25 Showed Staff: - At 1:26 PM, Staff C, Clinical Certified Hemodialysis Technician (CCHT), carried uncontained used bio-hazardous items from patient Station #1. - At 1:28 PM, Staff B, Patient Care Technician (PCT), carried uncontained used bio-hazardous items from patient Station #7. Staff C carried the uncontained bio-hazardous waste items in front of Patient #15 and Patient #20 as the patients sat in the dialysis chairs receiving dialysis treatment. - At 1:54 PM, Staff C, CCHT, carried uncontained used bio-hazardous items from patient Station #3. - At 1:57 PM, Staff D, PCT, carried uncontained used bio-hazardous waste items from patient Station #5. Staff D carried the uncontained bio-hazardous waste items in front of Patient #20 as the patient sat in the dialysis chair receiving dialysis treatment. 3. On 01/29/25 Showed Staff: - At 9:06 AM, Staff E, PCT, carried uncontained used bio-hazardous waste items from patient Station #7. Staff E carried the uncontained bio-hazardous waste items in front of Patient #18 and Patient #21 as the patients sat in the dialysis chairs receiving dialysis treatment. - At 9:28 AM, Staff E, PCT, carried uncontained used bio-hazardous waste items from patient Station #5. Staff E carried the uncontained bio-hazardous waste items in front of Patient #18 as the patient sat in the dialysis chair receiving dialysis treatment. - At 9:42 AM, Staff F, PCT, carried uncontained used bio-hazardous waste items from patient Station #1. - At 10:09 AM, Staff M, PCT, carried uncontained used bio-hazardous waste items from patient Station #14. - At 10:12 AM, Staff G, CCHT, carried uncontained used bio-hazardous waste items from patient Station #8. Staff G carried the uncontained used bio-hazardous waste items in front of Patient #3, Patient #22, and Patient #4 as the patients sat in the dialysis chairs receiving dialysis treatment. - AT 10:37 AM, Staff G, CCHT, carried uncontained used bio-hazardous waste items from patient Station #9. Staff G carried the uncontained used bio-hazardous waste items in front of Patient #22 and Patient #4 as the patients sat in the dialysis chairs receiving dialysis treatment. - At 11:19 AM, Staff E, PCT, carried uncontained used bio-hazardous waste items from patient Station #4. - At 11:33 AM, Staff F, PCT, carried uncontained used bio-hazardous waste items from patient Station #2. - At 11:58 AM, Staff G, CCHT, carried uncontained used bio-hazardous waste items from patient Station #10. Staff G carried the uncontained used bio-hazardous items in front of Patient #4 as the patient sat in the dialysis chair receiving dialysis treatment. - At 2:30 PM, Staff G, CCHT, carried uncontained used bio-hazardous waste items from patient Station #3. 4. Observation on 01/30/25 at 10:16 AM, showed Staff B, PCT, carried uncontained used bio-hazardous waste items from patient Station #8. Staff B carried the uncontained used bio-hazardous items in front of Patient #23 as the patient sat in the dialysis chair receiving dialysis treatment. Staffs’ failure to either bring a fluid resistant red bio-hazardous waste bag or move 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 both patients and staff to blood and or body fluids when staff carried the uncontained bio-hazardous waste without being contained in a fluid resistant container. 5. Review of the facility’s policy titled, “General Cleanliness and Infection Control Guidelines,” dated 11/04/24, showed staff directives: - Regulated medical waste shall be placed in a container that is in accordance with OSHA bloodborne standard 1910.1030 and is closeable, leak proof and labeled and/or color-coded. - Regulated waste shall be placed in containers which are: - Closable; - Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, or shipping; and - Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. 6. During an interview on 01/30/25 at 2:13 PM, Staff A, Registered Nurse-Clinical Manager, stated the expectation of staff was to dispose of used bloodlines and dialyzers in the large red bio-hazardous carts located throughout the treatment floor. Staff A stated going forward staff should not carry uncontained used bio-hazardous waste items from patient Stations to the location of the large red bio-hazardous carts without being placed in a fluid resistant red bio-hazardous bag.”

“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 and cleansed all external surfaces of patients’ dialysis stations at the end of a patient’s dialysis treatment and prior to the initiation of the next patient’s dialysis treatment for nine out of nine observations made of staff performing patient Station disinfection. - Consistently only cleaned/disinfected the patient Station after the patient had vacated the patient Station at the completion of patients’ dialysis treatment for two out of nine station disinfection observations conducted. - Discarded the cleansing cloth after being dropped on the floor and not used to continue to clean/disinfect the patient Station with the cleansing/disinfection cloth that had been dropped on the floor for one out of nine observations made of staff performing patient Station disinfection. These failures to properly clean external surfaces that are frequently touched by patients and staff; and to ensure the patient vacated the patient Station prior to the cleansing/disinfection process; and not using the cleansing/disinfection cloth when dropped on the floor to continue with the cleansing/disinfection process of the patient Station increased the potential for cross-contamination that could cause infection risks to all patients and staff. The 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) census was 43. Findings included: 1. Observation on 01/28/25 at 1:06 PM, showed Staff B, Patient Care Technician (PCT), failed to cleanse/disinfect the following items at patient Station #2: - The dialysis machine’s base and back; - Place the dialysis chair in the reclined position prior to the cleansing/disinfection process; - The intravenous (IV - in a vein) pole and hooks; and - The outside surface of the red sharps container and garbage can. 2. Observation on 01/28/25 at 1:34 PM, showed Staff M, PCT, failed to cleanse/disinfect the following items at patient Station #1: - Failed to wait to clean/disinfect the patient Station until Patient #5 had completely vacated the patient Station with their belongings before Staff M began the cleansing/disinfection process. Patient #5 sat in the dialysis chair holding gauze to the access sites post removal of the needles. - The dialysis machine’s base, back, supply lines and cords; - The prime bucket’s interior and exterior; - The IV pole and hooks; and - The outside surface of the garbage can. 3. Observation on 01/28/25 at 2:09 PM, showed Staff D, PCT, failed to wait to clean/disinfect patient Station #4 until Patient #20 had completely vacated the patient Station with their belongings before Staff D began the cleansing/disinfection process. While Patient #20 sat in the dialysis chair, Staff D cleansed/disinfected the dialysis machine’s front, back, sides and the supply/wall box and chase wall. 4. Observation on 01/29/25 at 9:16 AM, showed Staff E, PCT, failed to cleanse/disinfect the following items at patient Station #7: - The dialysis machine’s back, supply lines and cords; - The prime bucket’s interior and exterior; - The supply/wall box and chase wall; - The blood pressure cord; - The IV pole and hooks; and - The outside surface of the red sharps container and garbage can. 5. Observation on 01/29/25 at 9:45 AM, showed Staff E, PCT, dropped the cleansing/disinfection cloth on the floor, picked up the dropped cleansing/disinfection cloth and continued to cleanse/disinfect the dialysis chair at patient Station #13. 6. Observation on 01/29/25 at 10:20 AM, showed Staff E, PCT, failed to cleanse/disinfect the following items at patient Station #8: - The machine’s back; - The prime bucket’s interior and exterior; - The supply/wall box and chase wall; - The blood pressure cord; - The television (TV), TV remote and TV arm; - The IV pole and hooks; and - The outside surface of the red sharps container and garbage can. 7. Observation on 01/29/25 at 11:30 AM, showed Staff E, PCT, failed to cleanse/disinfect the following items at patient Station #4: - The dialysis machine’s back; - The supply/wall box and chase wall; and - The outside surface of the red sharps container and garbage can. 8. Observation on 01/29/25 at 11:56 AM, showed Staff F, PCT, failed to cleanse/disinfect the following items at patient Station #10: - The supply/wall box and chase wall; - The blood pressure cuff and cords; and - The TV, TV remote control and TV arm. 9. Observation on 01/29/25 at 11:56 AM, showed Staff M, PCT, failed to cleanse/disinfect the dialysis machine’s back, the IV pole and hooks at patient Station #10. 10. Review of the facility’s policy titled, “Cleaning and Disinfection of the Dialysis Station,” dated 09/05/23, showed: - Dialysis Station: Area including the dialysis machine, chair and other reusable equipment or supplies, utilized during dialysis treatment. - Externally disinfect the dialysis machine with 1:100 bleach solutions after each dialysis treatment. - Dialysis wall boxes and the area/wall around the wall box must be routinely cleaned at the end of each treatment day or immediately if splattered with blood. - Discard all fluid and clean and disinfect all containers associated with the prime waste (including buckets attached to the machines). - To prevent cross-contamination between patients, it is important that the previous patient completely vacate the station before staff begin cleaning and disinfection of the station and set up for the next patient. For patients dialyzing in a treatment area where multiple patients dialyze, the patient must completely vacate the dialysis station before the dialysis machine can be externally disinfected, allowed to dry and set up for the next treatment. - Use a cloth wetted with 1:100 bleach solution or EPA-approved disinfectant to clean and disinfect the dialysis station: - Chair; - Tables; - Machine; - Television; - IV pole; and - B/P cuff. - Place chair in Trendelenburg (reclined position) position and open side panels if chair has swing open sides so all surfaces of the chair are accessible. - Clean all surfaces. - Surface disinfect dialysis wall box and the area/wall around the wall box at the end of each treatment day or immediately if splattered with blood. 11. During an interview on 01/30/25 at 2:13 PM, Staff A, Registered Nurse-Clinical Manager, stated the expectation for staff was to cleanse/disinfect all surfaces of the patient Stations to include all surfaces of the dialysis chair, dialysis machine, chase wall and supply/wall box.”

“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: 18018 Based on Treatment Flowsheet review, policy review, and interview, the facility failed to ensure staff monitored and documented patients’ blood pressure every 30 minutes during the patients’ dialysis treatment for five (#1, #2, #3, #4, and #5) patients out of five patients’ Treatment Flowsheets reviewed for blood pressure monitoring during patients’ dialysis treatment. The failure to monitor patients’ blood pressure every 30 minutes during dialysis treatments increased the risk for all patients receiving dialysis to experience medical complications related to adverse effects from changes in patients’ blood pressure while dialyzing. The 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) census was 43. Findings included: Review of Patients’ Treatment Flowsheets showed the patients’ blood pressures was not monitored every 30 minutes when the patient received dialysis treatments. 1. Review of Patient #1’s Treatment Flowsheets showed: - On 01/28/25, staff failed to document the patient’s blood pressure at 1:00 PM. - On 01/23/25, staff failed to document the patient’s blood pressure at 2:30 PM. - On 01/21/25, staff failed to document the patient’s blood pressure from 1:02 PM to 3:04 PM. 2. Review of Patient #2’s Treatment Flowsheet dated 01/21/25, showed staff failed to document the patient’s blood pressure from 1:34 PM to 3:00 PM. 3. Review of Patient #3’s Treatment Flowsheet dated 01/20/25, showed staff failed to document the patient’s blood pressure from 9:01 AM to 10:02 AM. 4. Review of Patient #4’s Treatment Flowsheets showed: - On 01/22/25, staff failed to document the patient’s blood pressure at 10:30 AM. - On 01/20/25, staff failed to document the patient’s blood pressure from 10:33 AM to 11:33 AM. 5. Review of Patient #5’s Treatment Flowsheet dated 01/23/25, showed staff failed to document the patient’s blood pressure at 10:00 AM. 6. Review of the facility’s policy titled, “Patient Assessment and Monitoring,” dated 05/01/23, showed staff directive: During Treatment - Obtain blood pressure every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. 7. During an interview on 01/30/25 at 2:13 PM, Staff A, Registered Nurse-Clinical Manager, stated the expectation for staff was to document patients’ blood pressure every 30 minutes during the patients’ dialysis treatments and to follow the facility’s policy related to blood pressure monitoring during patients’ dialysis treatment.”