Fmc - Greenville Dialysis Center

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 38766 Based on facility policy review, medical record reviews, and staff interview, the facility staff failed to monitor a patient at a minimum of every 30-45 minutes during hemodialysis treatments for 13 of 16 sampled in-center hemodialysis records reviewed (Pt. #8, #16, #9, #7, #10, #5, #11, #15, #13, #12, #6, #3 and #1). Findings included: A review on 12/17/2024 of the policy and procedure “Patient Monitoring and Safety Checks During Hemodialysis Treatment” revised 09/05/2023 revealed, “...Policy Patient monitoring and safety check guidelines: ...Patient Monitoring Monitor and document every 30 minutes or more frequently as needed but not to exceed 45 minutes or per state regulations in the FKC Treatment Record. Patient Monitoring includes: ...Blood pressure, pulse...” 1. Review of the medical record for Patient #8 revealed a 40-year-old male admitted for In-Center Hemodialysis treatments on 10/21/2022. A review of the Treatment Flowsheet for 12/02/2024 revealed the staff documented monitoring at 1232, and the next monitoring documentation was at 1332 (60 minutes later). A review of the Treatment Flowsheet for 12/06/2024 revealed the staff documented monitoring at 1139, and the next monitoring documentation was at 1233 (54 minutes later). A review revealed the staff documented monitoring at 0800, and the next monitoring documentation was at 0852 (52 minutes later). A review of the Treatment Flowsheet for 12/09/2024 revealed the staff documented monitoring at 1004, and the next monitoring documentation was at 1101 (57 minutes later). The review revealed the staff documented monitoring at 1235, and the next monitoring documentation was at 1334 (59 minutes later). A review of the Treatment Flowsheet for 12/11/2024 revealed the staff documented monitoring at 1336, and the next monitoring documentation was at 1523 (107 minutes later). An interview with the Director of Operations on 12/18/2024 at 1125 revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed the staff should have documented the monitoring in the patient’s treatment record. The interview revealed the staff failed to document the patient monitoring per policy. 2. Review of the medical record for Patient #16 revealed a 83-year-old female admitted for In-Center Hemodialysis treatments on 02/02/2022. A review of the Treatment Flowsheet for 12/05/2024 revealed the staff documented monitoring at 1000, and the next monitoring documentation was at 1108 (68 minutes later). A review of the Treatment Flowsheet for 12/13/2024 revealed the staff documented monitoring at 1305, and the next monitoring documentation was at 1412 (67 minutes later). A review of the Treatment Flowsheet for 12/14/2024 revealed the staff documented monitoring at 1204, and the next monitoring documentation was at 1302 (58 minutes later). An interview with the Director of Operations on 12/18/2024 at 1125 revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed the staff should have documented the monitoring in the patient’s treatment record. The interview revealed the staff failed to document the patient monitoring per policy. 3. Review of the medical record for Patient #9 revealed a 34-year-old female admitted for In-Center Hemodialysis treatments on 10/28/2019. A review of the Treatment Flowsheet for 12/04/2024 revealed the staff documented monitoring at 1233, and the next monitoring documentation was at 1340 (67 minutes later). The review revealed the staff documented monitoring at 1411, and the next monitoring documentation was at 1537 (87 minutes later). A review of the Treatment Flowsheet for 12/06/2024 revealed the staff documented monitoring at 1233, and the next monitoring documentation was at 1330 (57 minutes later). An interview with the Director of Operations on 12/18/2024 at 1125 revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed the staff should have documented the monitoring in the patient’s treatment record. The interview revealed the staff failed to document the patient monitoring per policy. 4. Review of the medical record for Patient #7 revealed a 55-year-old female admitted for In-Center Hemodialysis treatments on 08/09/2023. A review of the Treatment Flowsheet for 12/04/2024 revealed the staff documented monitoring at 1028, and the next monitoring documentation was at 1201 (93 minutes later). An interview with the Director of Operations on 12/18/2024 at 1125 revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed the staff should have documented the monitoring in the patient’s treatment record. The interview revealed the staff failed to document the patient monitoring per policy. 5. Review of the medical record for Patient #10 revealed a 45-year-old male admitted for In-Center Hemodialysis treatments on 09/22/2022. A review of the Treatment Flowsheet for 12/02/2024 revealed the staff documented monitoring at 0936, and the next monitoring documentation was at 1039 (63 minutes later). A review of the Treatment Flowsheet for 12/11/2024 revealed the staff documented monitoring at 0930, and the next monitoring documentation was at 1030 (60 minutes later). An interview with the Director of Operations on 12/18/2024 at 1125 revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed the staff should have documented the monitoring in the patient’s treatment record. The interview revealed the staff failed to document the patient monitoring per policy. 6. Review of the medical record for Patient #5 revealed a 52-year-old female admitted for In-Center Hemodialysis treatments on 06/10/2024. A review of the Treatment Flowsheet for 12/11/2024 revealed the staff documented monitoring at 1330, and the next monitoring documentation was at 1438 (68 minutes later). An interview with the Director of Operations on 12/18/2024 at 1125 revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed the staff should have documented the monitoring in the patient’s treatment record. The interview revealed the staff failed to document the patient monitoring per policy. 7. Review of the medical record for Patient #11 revealed a 71-year-old female admitted for In-Center Hemodialysis treatments on 07/14/2023. A review of the Treatment Flowsheet for 12/06/2024 revealed the staff documented monitoring at 1200, and the next monitoring documentation was at 1300 (60 minutes later). An interview with the Director of Operations on 12/18/2024 at 1125 revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed the staff should have documented the monitoring in the patient’s treatment record. The interview revealed the staff failed to document the patient monitoring per policy. 26622 8. Open medical record review on 12/18/2024 for Patient #15 revealed a 39-year-old male admitted to the facility for ICHD treatments on 04/01/2022. Review of the treatment sheet dated 03/19/2024 revealed the treatment started at 0644 and ended at 1113 for a duration of 269 minutes. Review of the monitoring documentation dated 03/19/2024 revealed Patient #15’s machine parameters were monitored by staff at 0930 and monitored next by staff at 1030 (60 minutes later). Review of the treatment sheet dated 03/16/2024 revealed the treatment started at 0639 and ended at 0935 for a duration of 176 minutes. Review of the monitoring documentation dated 03/16/2024 revealed Patient #15’s machine parameters were monitored by staff at 0640 and monitored next by staff at 0734 (56 minutes later). Review revealed the facility staff failed to monitor the patient’s machine parameters at least every 30-45 minutes during the hemodialysis treatment on 03/19/2024 and 03/16/2024. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy. 9. Open medical record review on 12/18/2024 for Patient #13 revealed a 32-year-old male admitted to the facility for ICHD treatments on 07/24/2018. Review of the treatment sheet dated 03/14/2024 revealed the treatment started at 0722 and ended at 1009 for a duration of 167 minutes. Review of the monitoring documentation dated 03/14/2024 revealed Patient #13’s blood pressure, pulse and machine parameters were monitored by staff at 0728 and monitored next by staff at 0838 (70 minutes later). Further review of the monitoring documentation for 03/14/2024 revealed the vital signs and machine parameters were monitored by staff at 0909 and monitored next by staff at 1008 (59 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatment on 03/14/2024. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy. 10. Open medical record review on 12/18/2024 for Patient #12 revealed a 63-year-old male admitted to the facility for ICHD treatments on 10/30/2018. Review of the treatment sheet dated 03/14/2024 revealed the treatment started at 0457 and ended at 0845 for a duration of 228 minutes. Review of the monitoring documentation dated 03/14/2024 revealed Patient #12’s machine parameters were monitored by staff at 0501 and monitored next by staff at 0551 (50 minutes later). Further review of the monitoring documentation for 03/14/2024 revealed the machine parameters were monitored by staff at 0551 and monitored next by staff at 0656 (65 minutes later). Review of the monitoring documentation dated 03/14/2024 revealed Patient #12’s blood pressure and pulse were monitored by staff at 0530 and monitored next by staff at 0630 (60 minutes later). Further review of the monitoring documentation for 03/14/2024 revealed the blood pressure and pulse were monitored by staff at 0630 and monitored next by staff at 0730 (60 minutes later). Review revealed the facility staff failed to monitor the patient’s blood pressure, pulse and machine parameters at least every 30-45 minutes during the hemodialysis treatment on 03/14/2024. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy. 11. Open medical record review on 12/18/2024 for Patient #6 revealed a 46-year-old female admitted to the facility for ICHD treatments on 02/27/2020. Review of the treatment sheet dated 03/21/2024 revealed the treatment started at 0448 and ended at 0820 for a duration of 212 minutes. Review of the monitoring documentation dated 03/21/2024 revealed Patient #6’s machine parameters were monitored by staff at 0505 and monitored next by staff at 0552 (47 minutes later). Review revealed the facility staff failed to monitor the patient’s machine parameters at least every 30-45 minutes during the hemodialysis treatment on 03/21/2024. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy. 12. Open medical record review on 12/18/2024 for Patient #3 revealed a 64-year-old female admitted to the facility for ICHD treatments on 04/21/2016. Review of the treatment sheet dated 03/21/2024 revealed the treatment started at 0706 and ended at 1113 for a duration of 247 minutes. Review of the monitoring documentation dated 03/21/2024 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 0837 and monitored next by staff at 0933 (56 minutes later). Further review of the monitoring documentation dated 03/21/2024 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 0933 and monitored next by staff at 1113 (100 minutes later). Review revealed the facility staff failed to monitor the patient’s machine parameters at least every 30-45 minutes during the hemodialysis treatment on 03/21/2024. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy. 13. Open medical record review on 12/18/2024 for Patient #1 revealed a 60-year-old male admitted to the facility for ICHD treatments on 01/18/2018. Review of the treatment sheet dated 03/14/2024 revealed the treatment started at 1048 and ended at 1238 for a duration of 110 minutes. Review of the monitoring documentation dated 03/21/2024 revealed Patient #1’s blood pressure, pulse and machine parameters were monitored by staff at 1049 and monitored next by staff at 1136 (47 minutes later). Review revealed the facility staff failed to monitor the patient’s machine parameters at least every 30-45 minutes during the hemodialysis treatment on 03/14/2024. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. Interview revealed the staff monitored vital signs, visualized the access sites, checked for wet transducers and machine parameters. Interview revealed the staff should have documented the monitoring in the patient’s treatment record. Interview revealed the staff failed to follow the facility policy.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 38766 Based on policy review, medical records review, and staff interview the facility staff failed to follow the adequacy plan of care by failing to dialyze patients at the prescribed treatment duration time, prescribed blood flow rate/dialysate flow rate and/or obtain a signed against medical advice (AMA) form for 10 of 16 (Patient #16, #9, #11, #8, #14, #15, #13, #12, #6 and #1) sampled in-center hemodialysis patient records. Findings include: Review on 12/17/2024 of the facility policy “Patient Assessment and Monitoring,” Published 05/01/2023 revealed “...During Treatment...Step 3... *Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered. ...” A review on 12/17/2024 of the policy and procedure “Early Termination or Arriving Late for Treatment” revised 11/07/2022 revealed, “...Early termination ...The RN who evaluates the patient must document the rationale for early termination and reinforce the consequences of not receiving the entire prescribed treatment. The RN is responsible to... document on the ‘AMA’, or Against Medical Advice form...” 1. Medical record review on 12/18/2024 of Patient #16, a 83-year-old male was admitted to the facility for ICHD treatments on 02/02/2022. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for four (4) hours (240 minutes). The review of the treatment sheet dated 12/12/2024 revealed that the patient received dialysis for 185 minutes (55 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 12/13/2024 revealed that the patient received dialysis for 170 minutes (70 minutes less than the prescribed 240 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 12/12/2024 and 12/13/2024. The review revealed no completed AMA form for early termination of the treatment on 12/12/2024 and 12/13/2024. An interview with the Director of Operations on 12/18/2024 at 1125 revealed that no AMA forms could be located for the patient. The interview revealed that once a patient requested to terminate their treatment, the patient should be presented with the AMA form for the patient’s signature. “We must continue to educate the staff on obtaining the AMA form for early termination of treatment. The interview confirmed that the policy was not followed. 2. Medical record review on 12/18/2024 of Patient #9, a 34-year-old female was admitted to the facility for ICHD treatments on 10/28/2019. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for four (4) hours (240 minutes). The review of the treatment sheet dated 12/06/2024 revealed that the patient received dialysis for 188 minutes (52 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 12/09/2024 revealed that the patient received dialysis for 171 minutes (69 minutes less than the prescribed 240 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 12/06/2024 and 12/09/2024. The review revealed no completed AMA form for early termination of the treatment on 12/06/2024 and 12/09/2024. An interview with the Director of Operations on 12/18/2024 at 1125 revealed that no AMA forms could be located for the patient. The interview revealed that once a patient requested to terminate their treatment, the patient should be presented with the AMA form for the patient’s signature. “We must continue to educate the staff on obtaining the AMA form for early termination of treatment. The interview confirmed that the policy was not followed. 3. Medical record review on 12/18/2024 of Patient #11, a 71-year-old male was admitted to the facility for ICHD treatments on 07/14/2023. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for four (4) hours (240 minutes). The review of the treatment sheet dated 12/06/2024 revealed that the patient received dialysis for 205 minutes (35 minutes less than the prescribed 240 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 12/06/2024. The review revealed no completed AMA form for early termination of the treatment on 12/06/2024. An interview with the Director of Operations on 12/18/2024 at 1125 revealed that no AMA forms could be located for the patient. The interview revealed that once a patient requested to terminate their treatment, the patient should be presented with the AMA form for the patient’s signature. “We must continue to educate the staff on obtaining the AMA form for early termination of treatment. The interview confirmed that the policy was not followed. 4. Medical record review on 12/18/2024 of Patient #8, a 40-year-old male was admitted to the facility for ICHD treatments on 10/21/2022. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for three (3) hours and 45 minutes (225 minutes). The review of the treatment sheet dated 12/04/2024 revealed that the patient received dialysis for 184 minutes (41 minutes less than the prescribed 225 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 12/04/2024. The review revealed no completed AMA form for early termination of the treatment on 12/04/2024. An interview with the Director of Operations on 12/18/2024 at 1125 revealed that no AMA forms could be located for the patient. The interview revealed that once a patient requested to terminate their treatment, the patient should be presented with the AMA form for the patient’s signature. “We must continue to educate the staff on obtaining the AMA form for early termination of treatment. The interview confirmed that the policy was not followed. 26622 5. Open medical record review on 12/18/2024 for Patient #14 revealed a 62-year-old female admitted to the facility for ICHD treatments on 04/20/2024. Review of the patient’s dialysis prescription orders revealed the patient’s prescribed BFR was 450 mL/min. Review of the patient’s Post Treatment Dialysis flowsheets from 12/03/2024 through 12/14/2024 revealed the facility staff failed to dialyze the patient at her ordered BFR for implementation of the patient’s adequacy plan as follows: ~Treatment on 12/03/2024 from 1144 to 1516 for 212 minutes had “330” average BFR. The review of the patient treatment sheets revealed the facility staff failed to dialyze the patient at her ordered BFR of “450” in 1 of 3 treatments with no documentation for the decreased BFR and nurse notification. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the facility’s patient care technicians should notify the nursing staff anytime they increased/decreased the patient’s BFR and/or DFR. The interview revealed the nursing staff should have assessed and documented the reason for the decreased/increased BFR/DFR during the patient’s treatment. 6. Open medical record review on 12/18/2024 for Patient #15 revealed a 39-year-old male admitted to the facility for ICHD treatments on 04/01/2022. Review of the patient’s dialysis prescription orders revealed the patient’s prescribed BFR was 400 mL/min. Review of the patient’s Post Treatment Dialysis flowsheets from 03/12/2024 through 03/23/2024 revealed the facility staff failed to dialyze the patient at his ordered BFR for implementation of the patient’s adequacy plan as follows: ~Treatment on 03/16/2024 from 0639 to 0935 for 176 minutes had “300” average BFR, and ~Treatment on 03/19/2024 from 0644 to 1113 for 269 minutes had “330” average BFR. The review of the patient treatment sheets revealed the facility staff failed to dialyze the patient at his ordered BFR of “400” in 2 of 5 treatments with no documentation for the decreased BFR and nurse notification. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the facility’s patient care technicians should notify the nursing staff anytime they increased/decreased the patient’s BFR and/or DFR. The interview revealed the nursing staff should have assessed and documented the reason for the decreased/increased BFR/DFR during the patient’s treatment. 7. Open medical record review on 12/18/2024 for Patient #13 revealed a 32-year-old male admitted to the facility for ICHD treatments on 07/24/2018. Review of the patient’s dialysis prescription orders revealed the patient’s prescribed BFR was 450 mL/min. Review of the patient’s Post Treatment Dialysis flowsheets from 03/12/2024 through 03/23/2024 revealed the facility staff failed to dialyze the patient at his ordered BFR for implementation of the patient’s adequacy plan as follows: ~Treatment on 03/12/2024 from 0752 to 1007 for 135 minutes had “400” average BFR, ~Treatment on 03/14/2024 from 0722 to 1009 for 167 minutes had “340” average BFR, ~Treatment on 03/16/2024 from 0639 to 0936 for 177 minutes had “400” average BFR, ~Treatment on 03/19/2024 from 0558 to 0823 for 145 minutes had “400” average BFR., and ~Treatment on 03/23/2024 from 0653 to 0952 for 179 minutes had “300” average BFR. The review of the patient treatment sheets revealed the facility staff failed to dialyze the patient at his ordered BFR of “450” in 5 of 6 treatments with no documentation for the decreased BFR and nurse notification. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the facility’s patient care technicians should notify the nursing staff anytime they increased/decreased the patient’s BFR and/or DFR. The interview revealed the nursing staff should have assessed and documented the reason for the decreased/increased BFR/DFR during the patient’s treatment. 8. Open medical record review on 12/18/2024 for Patient #12 revealed a 63-year-old male admitted to the facility for ICHD treatments on 10/30/2018. Review of the patient’s dialysis prescription orders revealed the patient’s prescribed BFR was 450 mL/min. Review of the patient’s Post Treatment Dialysis flowsheets from 03/12/2024 through 03/23/2024 revealed the facility staff failed to dialyze the patient at his ordered BFR for implementation of the patient’s adequacy plan as follows: ~Treatment on 03/12/2024 from 0456 to 0846 for 230 minutes had “400” average BFR, and ~Treatment on 03/14/2024 from 0457 to 0845 for 228 minutes had “430” average BFR. The review of the patient treatment sheets revealed the facility staff failed to dialyze the patient at his ordered BFR of “450” in 2 of 6 treatments with no documentation for the decreased BFR and nurse notification. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the facility’s patient care technicians should notify the nursing staff anytime they increased/decreased the patient’s BFR and/or DFR. The interview revealed the nursing staff should have assessed and documented the reason for the decreased/increased BFR/DFR during the patient’s treatment. 9. Open medical record review on 12/18/2024 for Patient #6 revealed a 46-year-old female admitted to the facility for ICHD treatments on 02/27/2020. Review of the patient’s dialysis prescription orders revealed the patient’s prescribed BFR was 450 mL/min and DFR was 800. Review of the patient’s Post Treatment Dialysis flowsheets from 03/12/2024 through 03/23/2024 revealed the facility staff failed to dialyze the patient at her ordered BFR and/or DFR for implementation of the patient’s adequacy plan as follows: ~Treatment on 03/12/2024 from 0433 to 0816 for 223 minutes had “400” average BFR, ~Treatment on 03/14/2024 from 0440 to 0811 for 211 minutes had “430” average BFR and DFR 500, ~Treatment on 03/19/2024 from 0509 to 0840 for 211 minutes had “420” average BFR., and ~Treatment on 03/21/2024 from 0448 to 0820 for 212 minutes had “500” average DFR. The review of the patient treatment sheets revealed the facility staff failed to dialyze the patient at her ordered BFR of “450” in 3 of 6 treatments and DFR of “800” in 2 of 6 treatments, with no documentation for the decreased BFR/DFR and nurse notification. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the facility’s patient care technicians should notify the nursing staff anytime they increased/decreased the patient’s BFR and/or DFR. The interview revealed the nursing staff should have assessed and documented the reason for the decreased/increased BFR/DFR during the patient’s treatment. 10. Open medical record review on 12/18/2024 for Patient #1 revealed a 60-year-old male admitted to the facility for ICHD treatments on 01/18/2018. Review of the patient’s dialysis prescription orders revealed the patient’s prescribed BFR was 450 mL/min. Review of the patient’s Post Treatment Dialysis flowsheets from 03/12/2024 through 03/23/2024 revealed the facility staff failed to dialyze the patient at his ordered BFR for implementation of the patient’s adequacy plan as follows: ~Treatment on 03/12/2024 from 1122 to 1452 for 210 minutes had “400” average BFR, and ~Treatment on 03/14/2024 from 1048 to 1238 for 110 minutes had “320” average BFR. The review of the patient treatment sheets revealed the facility staff failed to dialyze the patient at his ordered BFR of “450” in 2 of 2 treatments with no documentation for the decreased BFR and nurse notification. Interview on 12/18/2024 at 1715 with the Director of Operations revealed the facility’s patient care technicians should notify the nursing staff anytime they increased/decreased the patient’s BFR and/or DFR. The interview revealed the nursing staff should have assessed and documented the reason for the decreased/increased BFR/DFR during the patient’s 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: 26622 Based on facility policy review and manufacturer’s guidelines, observations, CWP (The CWP unit works by the purification principle reverse osmosis which is the preferred dialysis method for water purification.) disinfection logs and staff interview, the facility staff failed to document the CWP system disinfection and residual check weekly; and failed to ensure expired medication vials were not available for patient use in one (1) of two (2) treatment areas (Bedside - Pod B). Findings include: A. Review on 12/16/2024 of the facility policy “Reverse Osmosis Water Purification Operation and Maintenance” published 08/11/2021, revealed “RO (Reverse Osmosis) machine’s membranes will be cleaned and/or disinfected in accordance with manufacturer’s instruction for use ...” Review on 12/16/2024 of the “Manufacturer’s Instructions for Use for the CWP Chemical Disinfection” (Revision C) revealed “ ... Verify with a separate test that no residual disinfectant can be detected in the water. ... Disinfection once a week is a minimum. ...” Observations on 12/16/2024 at 1545, during tour of the water room with the Area Technical Operations Manager (ATOM) revealed there were no dates or markings on the minncare plastic jugs located in the CWP RO A or the CWP RO B. Review of the weekly CWP disinfect log from October 1, 2024 through December 16, 2024 revealed no available documentation of the CWP Test for Residual Chemical after Disinfect completed for RO (reverse osmosis) A CWP and RO B CWP on 11/27/2024 and 12/04/2024. Review of the CWP disinfect log revealed the CWP Initiation of Chemical Disinfection of RO A and B was performed on 11/26/2024 and on 12/03/2024. Further review of the log revealed no documentation on 11/27/2024 and 12/03/2024 of the CWP Test for Residual Chemical after Disinfect. Interview on 12/17/2024 at 1545 with the Area Technical Operations Manager (ATOM) revealed the clinical staff were expected to complete a weekly CWP disinfect and residual check. Interview revealed the staff were expected to place the disinfectant in the RO on Tuesday at the end of the day and on Wednesday morning the staff were expected to check for consumption of the disinfectant by placing a date and marking the Omnicare plastic jug located in the CWP unit and then check for residual. Interview revealed the staff completed the first step of the disinfect process but failed to document the consumption and residual the following morning prior to restarting the RO (Reverse Osmosis) CWP. 38766 B. A review on 12/16/2024 of the facility’s policy “Medication Preparation and Administration” effective 02/06/2023 revealed, “... Monitoring Expired Medication: Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded via (Named Company) off-site return program or in accordance with local and/or state law...” Observation of the Bedside area on 12/16/2024 between 1345 and 1505 revealed a medication refrigerator beside the nursing station. The observation revealed seven (7) boxes of Prevnar 13 (a vaccine that protects against pneumonia) 0.5 ml (milliliter) with an expiration date of 09/2024 (greater than 60 days after the expiration date), one (1) box of Aranesp (medication used to treat anemia) 60 mcg (microgram) with an expiration date of 09/2024 (greater than 60 days after the expiration date), five (5) boxes of parsabiv (medication used to treat hyperparathyroidism) 5 mg (milligram) with an expiration date of 07/2024 (greater than 120 days after the expiration date), and one (1) box of parsabiv 2.5mg with an expiration date of 8/2024 (greater than 90 days after the expiration date). An interview with the charge nurse on 12/16/2024 at 1440 during the observation revealed that the nursing staff was to check medications every month. However, the charge nurse was unable to locate the medication checklist log for September, October, and November of 2024. The Charge Nurse confirmed that the above medications were expired and needed to be removed from the patient care area. NC 00214908”