Ozarks Dialysis Services - South

“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 policy review, observation, and interview, 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 and after glove removal. - Repeated the cleansing (antisepsis process - preventing the growth of infectious germs, bacteria, viruses and fungi) process of patients’ access sites before cannulation (insertion of a needle into the blood vessels to enable blood to be circulated between the patient and dialysis machine during dialysis treatment) when staff touched the area after the area was cleansed for three (#11, #12, and #13) patients out of four observations conducted of staff cannulating patients’ access sites. 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 census was 116. Findings included: 1. Review of the facility’s policy titled, “Hand Hygiene,” dated 08/16/21, in part showed staff directives: - Hand hygiene is considered the single most effective method to prevent the spread of infection. - Hand hygiene will be done routinely by dialysis staff. - Hand hygiene should be performed by staff: - After removing gloves. - Before and after any procedure. Review of the facility’s policy titled, “Initiation and Termination of Hemodialysis Treatments,” dated 03/03/21, in part showed staff directives: - Perform hand hygiene, don gloves. - Assess the access prior to needle placement: - Auscultate for bruit (an audible vascular sound associated with turbulent blood flow) - Palpate for thrill (a vibration caused by blood flowing through the fistula) - Identify anastomosis (point where a vein and artery are connected) - Remove gloves, perform hand hygiene. Observation on 02/27/24 at 10:30 AM, showed Staff C, Certified Clinical Hemodialysis Technician (CCHT), placed a glove against the dialysis machine’s screen and turned off the dialysis alarm at patient Station #5. Staff C failed to put the glove onto staff’s hand before turning off the alarm. Observation on 02/27/24 at 10:36 AM, showed Staff C, CCHT, prepared Patient #11 for cannulation. Staff C gloved, located, palpated, and assessed the patient’s access sites. After Staff C completed the assessment of the patient’s access sites, Staff C failed to remove gloves, perform hand hygiene and re-glove before Staff C cannulated the patient’s access sites. Observation on 02/27/24 at 11:19 AM, showed Staff D, CCHT, prepared Patient #12 for cannulation. Staff D gloved, located, palpated, and assessed the patient’s access sites. After Staff D completed the assessment of the patient’s access sites, Staff D failed to remove gloves, perform hand hygiene and re-glove before Staff D cannulated the patient’s access sites. Observation on 02/28/24 at 7:47 AM, showed Staff L, RN, prepared Patient #18 for a Central Venous Catheter (CVC - a line placed in a large vein used to deliver dialysis treatments) exit site dressing change. Staff L gloved and moved the patient’s shirt out of the way to cleanse the CVC exit site and lines. Staff L removed gloves and re-gloved, however, Staff L failed to perform hand hygiene after glove removal and before re-gloving. Observation on 02/28/24 at 9:33 AM, showed Staff E, Registered Nurse (RN), prepared Patient #13 for cannulation. Staff E gloved, located, palpated, and assessed the patient’s access sites. After Staff E completed the assessment of the patient’s access sites, Staff E failed to remove gloves, perform hand hygiene and re-glove before Staff E cannulated the patient’s access sites. Observation on 02/28/24 at 9:54 AM, showed Staff Q, Patient Care Technician (PCT), removed gloves, however, Staff Q failed to perform hand hygiene after glove removal. Observation on 02/28/24 at 10:10 AM and 10:25 AM, showed Staff F, CCHT, gloved without performing hand hygiene before gloving. Observation on 02/28/24 at 12:07 PM, showed Staff Q, PCT, gloved and initiated dialysis per CVC for Patient #27. Wearing the same gloves used to initiate dialysis, Staff Q opened a supply drawer, reached into the drawer, removed gloves, and retrieved needed supplies. Staff Q failed to remove gloves and perform hand hygiene before staff opened the supply drawer and reached in to retrieve needed supplies. After Staff Q retrieved supplies from the drawer, Staff Q re-gloved without performing hand hygiene. Observation on 02/28/24 at 12:13 PM, showed Staff S cleansed/disinfected patient Station #27. Staff S removed gloves and re-gloved to retrieve additional wiping clothes from the supply package and placed the wiping clothes into the bleach container. Staff S failed to perform hand hygiene after removal of gloves or before re-gloving to retrieve additional wiping clothes. Observation on 02/28/24 at 3:20 PM, showed Staff C, CCHT, cleansed/disinfected patient Station #6. Staff C wearing the same gloves to cleanse/disinfect the patient Station, retrieved additional wiping clothes from the supply package and placed the wiping clothes into the bleach container. Staff C failed to remove gloves, perform hand hygiene and re-glove before staff retrieved additional wiping clothes. Observation on 02/28/24 at 3:40 PM, showed Staff M, RN, and Staff H, CCHT, gloved without performing hand hygiene before staff gloved. Observation on 02/28/24 at 3:42 PM, showed Staff H, CCHT, removed gloves, however, Staff H failed to perform hand hygiene after glove removal. At 3:43 PM, Staff H gloved without performing hand hygiene before gloving. Staffs’ failure to: - Remove gloves, perform hand hygiene and re-glove after staffs’ assessment of patients’ access sites increased the risk of contamination and introduction of bacteria to the access sites. - Remove gloves, perform hand hygiene, and re-glove before retrieving additional wiping cloths from the supply package increased the risk of contamination of the remaining wiping cloths touched by the contaminated gloves. - Perform hand hygiene after glove removal and before retrieval of supplies from the supply drawer increased the risk of contamination of the remaining supplies. During an interview on 02/29/24 at 12:07 PM, Staff A, RN, Nurse Manager, stated staff was expected to perform hand hygiene before gloving, after removal of gloves, and before re-gloving. Staff A stated staff should perform hand hygiene when indicated and follow the facility’s “Hand Hygiene” and “Initiation and Termination of Hemodialysis Treatments” policies. 2. Review of the facility’s policy titled, “Initiation and Termination of Hemodialysis Treatments,” dated 03/03/21, in part showed staff directives: - Clean gloves must be worn and changed at any time contamination occurs. - Perform hand hygiene, don gloves. - Assess the access prior to needle placement: - Auscultate for bruit (an audible vascular sound associated with turbulent blood flow) - Palpate for thrill (a vibration caused by blood flowing through the fistula) - Identify anastomosis (point where a vein and artery are connected) - Remove gloves, perform hand hygiene. - Don PPE (Personal Protective Equipment - coat/gown, face mask, face shield/eye goggles) and gloves. Review of the facility document titled, “Skills Competency AVF (Arteriovenous Fistula - a blood vessel that is made by surgically sewing an artery and vein together, used to deliver dialysis) Cannulation/Decannulation/Catheter,” dated 11/29/23, in part showed staff directives: - Clean site with antimicrobial agent, soap/H2O (water) - Look, listen, feel the access - Perform hand hygiene - Don new gloves - Clean site with alcohol, chloraprep (sterile antiseptic solution) - Insert needles with aseptic (process that is maintained free of germs or bacteria) technique - Connect needles to blood lines use aseptic technique - Remove gloves - Perform hand hygiene Observation on 02/27/24 at 10:36 AM, showed Staff C, CCHT, cannulated Patient #11’s access sites for dialysis treatment. Staff C touched the patient’s bottom and top access sites, however, Staff C failed to repeat the skin antisepsis process before Staff C cannulated the patient’s access sites. Observation on 02/27/24 at 11:19 AM, showed Staff D, CCHT, cannulated Patient #12’s access sites for dialysis treatment. Staff D touched the patient’s top access site, however, Staff D failed to repeat the skin antisepsis process before Staff D cannulated the patient’s access site. Observation on 02/28/24 at 9:33 AM, showed Staff E, RN, cannulated Patient #13’s access sites for dialysis treatment. Staff D touched the patient’s 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 cleansing/antisepsis process of the access sites after being touched by staff, increased the risk of contamination of the site and possibly allowing for the introduction of bacteria during the cannulation process. During an interview on 02/29/24 at 12:07 PM, Staff A, RN, Nurse Manager, stated staff was expected to repeat the cleansing/antisepsis process of a patient’s access sites if staff touched the insertion sites after the initial cleansing/antisepsis process and before staff cannulated the patient’s access sites. Staff A stated neither the facility’s policy nor the skills competency “specifically” directed staff not to touch the patient’s access sites once cleansed or to repeat the cleansing/antisepsis process if staff touched the access sites, however, the expectation was for staff to repeat the cleansing/antisepsis process before cannulation.”

“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 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 made 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 In-Center Hemodialysis census was 116. Findings included: 1. Observation on 02/27/24 at 11:39 AM showed Staff F, Certified Clinical Hemodialysis Technician (CCHT), removed used bloodlines and dialyzer from the dialysis machine at patient Station #32 and carried the bio-hazardous waste items without being contained in a fluid resistant red bio-hazardous waste bag to the large red bio-hazardous cart at the end of the dirty sink located in POD #4. Staff F carried the uncontained bio-hazardous materials/items in front of Patient #28 while the patient received dialysis treatment. Staff also walked by several staff carrying the uncontained bio-hazardous materials/items. Observation on 02/28/24 at 10:05 AM, showed Staff F, CCHT, removed used bloodlines and dialyzer from the dialysis machine at patient Station #9 and carried the bio-hazardous waste items without being contained in a fluid resistant red bio-hazardous waste bag to the large red bio-hazardous cart at the end of the nurse’s station located in POD #1. Observation on 02/28/24 at 10:12 AM, showed Staff V, Registered Nurse (RN), carried used bloodlines and dialyzer without being contained in a fluid resistant red bio-hazardous waste bag to the large red bio-hazardous cart at the end of the nurse’s station located in POD #1. Observation on 02/28/24 at 10:25 AM, showed Staff C, CCHT, removed used bloodlines and dialyzer from the dialysis machine at patient Station #7 and carried the bio-hazardous waste items without being contained in a fluid resistant red bio-hazardous waste bag to the large red bio-hazardous cart at the end of the nurse’s station located in POD #1. Observation on 02/29/24 at 10:22 AM, showed Staff F, CCHT, removed used bloodlines and dialyzer from the dialysis machine at patient Station #8 and carried the bio-hazardous waste items without being contained in a fluid resistant red bio-hazardous waste bag to the large red bio-hazardous cart at the end of the nurse’s station located in POD #1 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 after a patient’s dialysis treatment increased the risk of splashing, spraying, splattering or generation of droplets and exposing both patients and staff to infections and cross-contamination when staff carried the uncontained bio-hazardous waste without being contained in a fluid resistant container. 2.During an interview on 02/29/24 at 12:07 PM, Staff A, RN, Nurse Manager, stated staff are expected to retrieve the large red bio-hazardous cart from the location stored in each POD and bring the cart to the patient Station to dispose the used bio-hazardous items from the dialysis machine at the end of a patient’s treatment. Staff A stated staff should not carry uncontained used bloodlines and dialyzer to the location of the large red bio-hazardous carts located in each POD. Staff A acknowledged the facility did not have a policy/procedure related to the expectations for staff when disposing used bloodlines and dialyzer from the dialysis machine at the end of patients’ dialysis treatments.”

“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 policy review, observation, and interview, the facility failed to ensure staff consistently, thoroughly, and properly disinfected and cleansed 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 six out of six observations made of staff performing Station disinfection. The failure to properly disinfect and clean patient Stations increased the potential for cross-contamination that could cause infection risks to all patients and staff. Staff also failed to ensure staff cleaned/disinfected the stethoscope diaphragm (medical device used to hear high-pitched sounds in a patient, for example, lungs, heart, and bruit in a dialysis patient) before and after use on patients. The In-Center Hemodialysis census was 116. Findings included: 1. Review of the facility’s policy titled, “Cleaning & Disinfection of Hemodialysis Station,” dated 08/16/21, showed in part staff directives: - Cleaning & Disinfection of procedures during patient changeover are particularly prone to error and contribute to the risk of cross-contamination if correct procedures are not observed. - A hemodialysis station is defined as the dialysis machine, a purified water connection, the dialysis concentrate container or connection, and the treatment chair. - Machine, external: Clean 1st! - Wipe down all external surfaces of machine with 1:100 bleach solution including control screen and exterior surfaces of dialysate connectors. - Chair: - Wipe down all surfaces of the chair with 1:100 bleach solution, removing any blood and contaminated dialysate. - Fold down chair trays, to visually inspect for blood when cleaning, and thoroughly clean the edges of the chair trays and arms of chair touching the trays. - Blood Pressure (B/P) Cuff: - Wipe down both sides of B/P cuff with bleach solution, ensuring that there is no blood present, and hang from pole on clean machine to dry. - TV Remote Control: - Wipe remote and attached cord with bleach solution, ensuring that there is no blood present, and hang from pole on clean machine to dry. 2. Observation on 02/27/24 at 11:39 AM, showed Staff F, Certified Clinical Hemodialysis Technician (CCHT), failed to disinfect/cleanse the following items at patient Station #32: - The sides of the dialysis machine; - The prime bucket’s interior; - The chase wall; and - Open the left side of the dialysis chair’s side arm and clean all surfaces of side arm. Observation on 02/27/24 at 3:35 PM, showed Staff R, CCHT, failed to disinfect/cleanse the following items at patient Station #8: - The dialysis machine’s supply lines and cords; - The base of the dialysis machine; - The back of the dialysis machine; - The prime bucket’s interior and exterior; - The chase wall; - The plastic sleeve with documents attached to the dialysis machine’s intravenous (IV) pole hook; - The blood pressure cuff; and - The IV pole and hooks. Observation on 02/28/24 at 10:05 AM, showed Staff F, CCHT, failed to disinfect/cleanse the following items at patient Station #9: - The prime bucket’s interior and exterior; - The plastic sleeve with documents attached to the dialysis machine’s IV pole hook; and - The IV poles and hooks. Observation on 02/28/24 at 12:13 PM, showed Staff S, Patient Care Technician (PCT) failed to disinfect/cleanse the following items at patient Station #27: - The dialysis machine supply lines and cords; - The case wall; - The plastic sleeve with documents attached to the dialysis machine’s IV pole hook. Observation on 02/28/24 at 3:20 PM, showed Staff C, CCHT, and Staff F, CCHT, failed to disinfect/cleanse the following items at patient Station #6: - The chase wall; - The plastic sleeve with documents attached to the dialysis machine’s IV pole hook; and - The IV pole and hooks. Observation on 02/28/24 at 4:00 PM, showed Staff I, CCHT, and Staff P, CCHT, failed to disinfect/cleanse the following items at patient Station #15: - The dialysis machine’s base; - The chase wall; - The plastic sleeve with documents attached to the dialysis machine’s IV pole hook; and - The IV pole and hooks. During an interview on 02/29/24 at 12:07 PM, Staff A, Registered Nurse (RN), Nurse Manager, stated staff was expected to follow the facility’s patient Station disinfection policy and procedure. 3. Observation on 02/27/24 at 10:36 AM, showed Staff C, CCHT, placed the diaphragm of staff’s stethoscope onto Patient #11’s access site to listen for a bruit (an audible vascular sound associated with turbulent blood flow), however, Staff C failed to clean/disinfect the stethoscope’s diaphragm before or after staff placed it on the patient’s access site. Observation on 02/27/24 at 11:19 AM, showed Staff D,CCHT, placed the diaphragm of staff’s stethoscope onto Patient #12’s access site to listen for a bruit, however, Staff C failed to clean/disinfect the stethoscope’s diaphragm before or after staff placed it on the patient’s access site. Observation on 02/27/24 at 11:25 AM, showed Staff E, RN, placed the diaphragm of staff’s stethoscope on Patient #12’s back to assess the patient’s lung sounds, however, Staff E failed to clean/disinfect the stethoscope’s diaphragm before or after staff placed it on the patient’s back. Observation on 02/27/24 at 11:31 AM, showed Staff E, RN, placed the diaphragm of staff’s stethoscope on Patient #29’s back to assess the patient’s lung sounds, however, Staff E failed to clean/disinfect the stethoscope’s diaphragm before or after staff placed it on the patient’s back. Observation on 02/28/24 at 9:33 AM, showed Staff E, RN, placed the diaphragm of staff’s stethoscope onto Patient #13’s access site to listen for a bruit, however, Staff E failed to clean/disinfect the stethoscope’s diaphragm before or after staff placed it on the patient’s access site. Observation on 02/28/24 at 10:49 AM, showed Staff F, CCHT, placed the diaphragm of staff’s stethoscope onto Patient #8’s access site to listen for a bruit, however, Staff F failed to clean/disinfect the stethoscope’s diaphragm before or after staff placed it on the patient’s access site. Observation on 02/28/24 at 10:52 AM, showed Staff L, RN, placed the diaphragm of staff’s stethoscope onto a patient’s back to assess the patient’s lung sounds, however, Staff L failed to clean/disinfect the stethoscope’s diaphragm before or after staff placed it on the patient’s back. Observation on 02/28/24 at 10:53 AM, showed Staff U, RN, placed the diaphragm of staff’s stethoscope onto Patient #8’s back to assess the patient’s lung sounds, however, Staff U failed to clean/disinfect the stethoscope’s diaphragm before or after staff placed it on the patient’s back. Staffs’ failure to clean the stethoscope’s diaphragm before or after use on patients increased the risk for cross-contamination to all patients staff used the unclean stethoscope diaphragm on to assess either patients’ access site or lungs. During a telephone interview on 03/04/24 at 12:31 PM, Staff A, RN, Nurse Manager, stated staff was expected to clean the stethoscope diaphragm before and after use on patients.”

“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: 18018 Based on observation and interview, the facility failed to ensure patients’ dialysis vascular (blood vessels) access sites and bloodline connections remained uncovered and in view during dialysis treatments for nine patients (#5, #16, #18, #20, #22, #23, #24, #25 and #26) observed for a non-visible access and or bloodline connection. A non-visible access and or bloodline connection could result in staffs’ failure to quickly detect needle dislodgement or bloodline disconnection, which could result in significant bleeding episodes and affect the safety of all patients that received dialysis treatment at the facility. The In-Center Hemodialysis census was 116. Findings included: 1. Observations on 02/27/24 from 9:02 AM to 9:36 AM showed Patient #16 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. Observation on 02/27/24 at 9:07 AM showed Patient #22 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. Observation on 02/27/24 at 10:20 AM showed Patient #23 received dialysis treatment, however, the patient’s bloodlines was covered by the patient’s jacket and non-visible to staff. Observation on 02/27/24 12:33 PM showed Patient #24 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. Observations on 02/27/24 from 3:22 PM to 3:49 PM showed Patient #25 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. Observations on 02/28/24 from 6:40 AM to 8:15 AM showed Patient #5 and Patient #20 received dialysis treatment. Patient #5’s access sites and bloodline connections was covered by a blanket and non-visible to staff. Patient #20’s access sites was covered by a blanket and non-visible to staff. Observations on 02/28/24 from 7:00 AM to 7:30 AM showed Patient #18 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. Observations on 02/28/24 from 7:15 AM to 9:15 AM showed Patient #26 received dialysis treatment, however, the patient’s access sites was covered by a blanket and non-visible to staff. 2. During an interview on 02/29/24 at 12:07 PM, Staff A, Registered Nurse, Nurse Manager, stated: - Staff are to ensure access sites and bloodline connections are visible to staff throughout a patient’s dialysis treatment. - When staff observe a patient’s access sites or bloodline connections covered and non-visible to staff, staff are to address the non-visible access sites/bloodline connections with the patient, uncover the non-visible access sites/bloodline connections and document in the patient’s Electronic Health Medical Record (EHMR) the patient received re-education related to risks of non-visible access sites/bloodline connections and the need to always keep the access sites/bloodline connections visible during the dialysis treatment. - The facility did not have a policy that specifically addressed visibility of patients’ access sites/bloodline connections during dialysis treatment, however, staff was expected to make sure patients’ access sites/bloodline connections are always uncovered and visible to staff throughout patients’ dialysis treatment.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 18018 Based on policy review, review of patients’ Hemodialysis Flowsheets, and interview, the Medical Director failed to ensure staff followed the facility’s policy and procedure when staff failed to administer heparin bolus (initial loading dose of heparin - medication used to thin blood and/or prevent blood clot formation) within three to five minutes before the start of the patient’s dialysis treatment for two patients (#2 and #4) out of four patients’ Hemodialysis Flowsheets reviewed for heparin bolus administration before the start of dialysis treatments. This failed practice had the potential to affect all patients receiving hemodialysis at the facility and could cause an increase in complications experienced during and after the patient’s dialysis treatment. The In-Center Hemodialysis census was 116. Findings included: 1. Review of the facility’s polity titled, “Heparin Protocol,” dated 03/07/22 in part showed staff directive: Heparin should circulate 3-5 minutes prior to initiation of treatment. 2. Review of Patient #2’s Hemodialysis Flowsheets showed: - On 02/24/24 staff documented the heparin bolus was administer at 6:18 AM and the dialysis treatment was started at 6:17 AM and not within 3-5 minutes before the start of the patient’s dialysis treatment. - On 02/27/24 staff documented the heparin bolus was administered at 6:16 AM and the dialysis treatment was started at 6:15 AM and not within 3-5 minutes before the start of the patient’s dialysis treatment. - On 02/24/24 and 02/27/24 the heparin bolus was administered after the dialysis treatment was started and not within 3-5 minutes before the start of the patient’s dialysis treatment. Review of Patient #4’s Hemodialysis Flowsheet dated 02/26/24 showed staff documented the heparin bolus was administered at 6:53 AM and the dialysis treatment was started at 6:51 AM and not within 3-5 minutes before the start of the patient’s dialysis treatment. Staff administered the heparin bolus after the dialysis treatment was started and not within 3-5 minutes before the start of the patient’s dialysis treatment. Staffs’ failure to administer the heparin bolus within 3-5 minutes before the start of the dialysis treatment increased the risk for the blood to clot during dialysis treatment because the heparin bolus did not have time to circulate to assist in keeping the dialysis circuit open and free of blockage to assist in the prevention of clot formation in the blood circuit. 3. During an interview on 02/28/24 at 4:38 AM, Staff A, Registered Nurse, Nurse Manager, stated staff was expected to administer the heparin bolus within 3-5 minutes before the start of the dialysis treatment and not after the dialysis treatment was started. Staff A stated staff are expected to follow the facility’s Heparin Protocol policy.”