Fmc Dialysis Services South Ramsey

“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: 51294 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 5 of 6 sampled in-center hemodialysis records reviewed (Patients #2, #3, #4, #5 and #6). Findings included: Review on 12/04/2025 of the facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, revealed, “...During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes per state regulations. Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes or per state regulations.” 1. Open medical record review on 12/04/2025 for Patient #2 revealed a 75-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 01/16/2024. Review of the treatment sheet dated 11/15/2025 revealed the treatment started at 0839 and ended at 1203 for a duration of 202 minutes. Review of the monitoring documentation dated 11/15/2025 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 0839 and monitored next by staff at 0932 (53 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 treatments on 11/15/2025. Interview on 12/04/2025 at 1650 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. 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 on 11/15/2025 for Patient #2. 2. Open medical record review on 12/04/2025 for Patient #3 revealed a 93-year-old female admitted to the facility for ICHD (In Center Hemodialysis) treatments on 07/29/2025. Review of the treatment sheet dated 10/21/2025 revealed the treatment started at 1336 and ended at 1656 for a duration of 221 minutes. Review of the monitoring documentation dated 10/21/2025 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 1438 and monitored next by staff at 1526 (48 minutes later) and monitored again at 1603 and 1655 (52 minutes between readings). 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 treatments on 10/21/2025. Interview on 12/04/2025 at 1650 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. 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 on 10/21/2025 for Patient #3. 3. Open medical record review on 12/04/2025 for Patient #4 revealed a 39-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 08/09/2023. Review of the treatment sheet dated 11/12/2025 revealed the treatment started at 0855 and ended at 1021 for a duration of 86 minutes. Review of the monitoring documentation dated 11/12/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 0856 and monitored next by staff at 0948 (52 minutes later). Review of the treatment sheet dated 11/19/2025 revealed the treatment started at 0823 and ended at 1216 for a duration of 233 minutes. Review of the monitoring documentation dated 11/19/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 1003 and monitored next by staff at 1108 (65 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 treatments on 11/12/2025 and 11/19/2025. Interview on 12/04/2025 at 1650 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. 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 on 11/12/2025 and 11/19/2025 for Patient #4. 4. Open medical record review on 12/04/2025 for Patient #5 revealed an 88-year-old female admitted to the facility for ICHD (In Center Hemodialysis) treatments on 05/18/2017. Review of the treatment sheet dated 11/18/2025 revealed the treatment started at 1045 and ended at 1415 for a duration of 210 minutes. Review of the monitoring documentation dated 11/18/2025 revealed Patient #5’s blood pressure, pulse and machine parameters were monitored by staff at 1141 and monitored next by staff at 1230 (49 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 treatments on 11/18/2025. Interview on 12/04/2025 at 1650 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. 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 on 11/18/2025 for Patient #5. 5. Open medical record review on 12/04/2025 for Patient #6 revealed a 58-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 05/09/2025. Review of the treatment sheet dated 11/17/2025 revealed the treatment started at 1255 and ended at 1706 for a duration of 251 minutes. Review of the monitoring documentation dated 11/17/2025 revealed Patient #6’s blood pressure, pulse and machine parameters were monitored by staff at 1431 and monitored next by staff at 1530 (59 minutes later). Review of the treatment sheet dated 11/19/2025 revealed the treatment started at 1326 and ended at 1650 for a duration of 204 minutes. Review of the monitoring documentation dated 11/19/2025 revealed Patient #6’s blood pressure, pulse and machine parameters were monitored by staff at 1356 and monitored next by staff at 1443 (47 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 treatments on 11/17/2025 and 11/19/2025. Interview on 12/04/2025 at 1650 with the Clinical Manager revealed the staff were expected to monitor the patients every 30-45 minutes during treatments. 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 on 11/17/2025 and 11/19/2025 for Patient #6.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 38766 Based on policy review, observation, and staff interviews, the facility staff failed to prevent cross-contamination by not ensuring sinks were identified as clean or dirty for 9 of 13 sinks observed in the patient treatment area. The findings included: A review 04/15/2024 of the facility policy “Hand Hygiene” published 11/06/2023 revealed, “... Sink Policy... Hand washing sinks should be dedicated for hand washing only and should remain clean...” Observations on 04/15/2024 from 1220 and 1335 and on 04/16/2024 from 0945 and 1230 on the treatment area revealed, 9 of 13 sinks (one sink between Bay A and C, two sinks in Bay D across from the back nursing station, one sink towards the back window, two sinks in Bay A on the left side of the front nursing station, two sinks in Bay B on the right side of the front nursing station, and one sink in the isolation room) were not designated as clean or dirty. An interview on 04/18/2024 at 1105 with PCT #1 revealed that the sink should be labeled clean or dirty so the staff would know which sinks were dedicated to hand washing or not. The interview revealed that the signs may have been removed when they (the clinic) changed the cabinets and the sinks recently in the treatment area. In an interview on 04/18/2024 at 1330 with the Clinical Manager (CM) revealed that the facility had new cabinets installed and the signs for the sinks were taken down during the remodeling (date unspecified). The CM stated that she was unable to find the signs after the replacement of the sinks and the cabinets. The interview confirmed that the sinks should have been labeled. .”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 38766 Based on policy review, chlorine log review, and staff interview, the facility failed to ensure chlorine tests were performed, documented, resulted, and or verified every four hours per policy. The findings included: A review on 04/15/2024 of the facility’s policy titled “Carbon Filtration Monitoring for Incenter Central Water Systems Policy” revised 11/07/2022 revealed “...What to Test: Worker Carbon Filter. When to Test: Prior to the initiation of the first patient treatment of the day and at a minimum of every four hours... Routine Chlorine Testing: Routine Total Chlorine Testing will be documented in the approved electronic documentation system or paper TCL-1 Log... Clinical Oversight: The Clinical Manager (CM) or the nurse in charge is responsible for the oversight of the daily testing and documentation of the total chlorine testing...” A review on 04/16/2024 of the facility’s Water System Log for System 1 (54640) with Serial Number 9BPS2261 from 02/01/2024 through 03/31/2024 revealed the facility staff failed to perform Total Chlorine Testing every four hours on the following dates: 1. 02/06/2024: Time Reading: 0330, and the following Time Reading: 0750 (20 minutes late), 2. 02/15/2024: Time Reading: 0830, and the following Time Reading: 1510 (160 minutes late), and 3. 02/21/2024: Time Reading: 1115, and the following Time Reading: 1645 (90 minutes late). A review on 04/16/2024 of the facility’s Water System Log for System 2 (54640) with Serial Number 9BPS2197 from 02/01/2024 through 03/31/2024 revealed the facility staff failed to perform Total Chlorine Testing every four hours on the following dates: 1. 02/06/2024: Time Reading: 0330, and the following Time Reading: 0750 (20 minutes late), 2. 02/15/2024: Time Reading: 0830, and the following Time Reading: 1510 (160 minutes late), and 3. 02/21/2024: Time Reading: 1115, and the following Time Reading: 1645 (90 minutes late). An interview on 04/16/2024 at 1440 with the Biomedical Technician during Total Chlorine Log reviews revealed that Total Chlorine Testing should be done at a minimum of every four (4) hours. The logs were audited and documented monthly by the Biomedical Technician, and the data was reported to the Clinical Manager during quality meetings. The Clinical Manager was responsible for developing any action plans for the clinical staff regarding late or missing Total Chlorine Testing and requested the Biomedical Technician to provide reeducation to the staff when needed. The Biomedical Technician added that there were audible alarms at the nursing stations to remind the staff of the timing of the water tests. An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that Total Chlorine Testing should be done within four hours per policy. The review revealed that late tests were reported during quality meetings, and the Clinical Manager followed up with the staff during huddles. The interview revealed that the clinic had four audible alarms, two in the front nursing station and two in the back nursing station, but the two in the back nursing station were inoperable. The interview revealed that the plan was to obtain two alarms for the back nursing station, and that they (the new alarms) will need to be manually reset. A request was made to the Clinical Manager for documentation of staff reeducation on the late Total Chlorine Testing in February 2024. No documentation was provided.”

“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: 38766 Based on observation, medical record review, and staff interview, the facility staff failed to promote patient safety by failing to ensure a patient’s access site was visible during treatment for 1 of 23 in-center patients observed (Patient #13). Findings included: A review on 04/16/2024 of the facility’s policy titled “Patient Assessment and Monitoring, “ published on 05/01/2023, revealed “...During Treatment ...Follow the steps for monitoring patient and machine parameters during treatment: ...Access: Observe connections are secure and visible... Ensure access remains uncovered throughout the treatment...” Observation on 04/16/2024 at 1115 revealed the patient located in Station #A4 HDM #50 had the access site covered with a blanket. Observation revealed that at 1150 (35 minutes later), the access site remained covered and was not visible for direct observation. At 1200, observation revealed that PCT #2 entered the station for safety checks and documentation and left the station without visualizing the access site and the connections. The observation revealed the access site was uncovered at 1215 by PCT #2 after being prompted by the surveyor. The observation revealed the access site remained covered for 60 minutes. An interview on 04/16/2024 at 1215 with PCT #2 during the observation revealed that access sites were to always remain uncovered during treatment. PCT #2 revealed that she did not check the access site during the vital signs and safety check because there was so much going on, and she did not remember to check on the access site. The interview confirmed that the policy was not followed. An interview on 04/18/2024 at 1330 with the Clinical Manager revealed access sites should remain visible to prevent or minimize the risk of bleeding complications. The interview revealed that “if a patient persisted in covering the access during treatment, the patient should be reeducated, and uncover the site for visualization.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 38766 Based on policies and procedures review, medical records review, and staff interviews, the facility’s IDT members failed to identify a patient as unstable and perform a monthly reassessment or revision of the plan of care for 1 of 1 sampled patient after an extended hospitalization (Patient #9). Findings included: A review on 04/17/2024 of the facility’s policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care” revised 07/03/2023 revealed “...CIA/POC for Unstable Patients Unstable patients must be reassessed by the IDT monthly. Monthly reassessment and any POC updates related to the reason the patient is considered ‘unstable’ must be documented until the issues have been resolved or the IDT (including the patient if possible) determines that the condition is chronic. The following are unstable criteria: a. Hospitalization of more than 15 days with discharge occurring within the last 30 days. ...” Medical record review on 04/17/2024 of Patient #9 revealed the patient was admitted to the facility on 09/01/2020 for in-center hemodialysis treatment. A review of the record revealed the patient was admitted to the hospital from 02/25/2024 through 03/14/2024 (18 days) with an admitting diagnosis of “hyperkalemia (elevated potassium)” and a discharge diagnosis of “1. volume overload due to missed hemodialysis 2. Acute on chronic hypoxemic respiratory failure secondary to viral infection/flu on admission 3. Sepsis was secondary to hemodialysis catheter present on admission ...” The review revealed the patient’s previous plan of care was an annual plan of care on 07/26/2023 with documentation that the patient was “stable.” The review revealed no documentation that a monthly reassessment or revisions of the plan of care was done considering the patient as unstable by the IDT after the hospitalization. An interview on 04/17/2024 at 1230 with the Social Worker revealed that the clinic had a computer system to determine unstable patients based on length of hospitalization stay or out-of-range lab results. The interview revealed the Social worker did not know why patient #9 was not flagged by the computer system. An interview on 04/18/2024 at 1300 with the Medical Director revealed that Patient #9 was non-compliant and had multiple hospitalizations with fluid overload and hypertension. The interview revealed the patient had housing issues and transportation concerns in the past year. The Medical Director added that “we (IDT) discussed the patient during rounds but did not recall him being made unstable.” An interview on 04/18/2024 at 1330 with the Clinical Manager revealed we (the clinic) had a computer system that identified unstable patients based on the number of hospitalizations in one month and length of stay of 15 days or greater. The interviewer revealed, “I guess we missed this one.””

“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 interviews, the facility staff failed to monitor a patient at a minimum of every 30 minutes during hemodialysis treatments for 8 of 14 sampled in-center hemodialysis records reviewed (Pt. #14, #12, #2, #5, #9, #15, #1, and #7). Findings included: A review on 04/15/2024 of the facility policy titled “Patient Assessment and Monitoring” revised 05/01/2023 revealed, “...During Treatment Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes per state regulations. 1. Review of the medical record for Patient #14 revealed a 76-year-old female admitted for In-Center Hemodialysis treatments on 12/02/2021. A review of the Treatment Flowsheet for 10/17/2023 revealed the staff documented monitoring at 0843, and the next monitoring documentation was at 1004 (81 minutes later). A review of the Treatment Flowsheet for 03/02/2024 revealed the staff documented monitoring at 0601, and the next monitoring documentation was at 0705 (64 minutes later). A review revealed the staff documented monitoring at 0800, and the next monitoring documentation was at 0852 (52 minutes later). An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed that documentation of vital signs and safety checks had been an issue. 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 #12 revealed a 90-year-old male admitted for In-Center Hemodialysis treatments on 03/30/2023. A review of the Treatment Flowsheet for 03/05/2024 revealed the staff documented monitoring at 1235, and the next monitoring documentation was at 1335 (60 minutes later). A review of the Treatment Flowsheet for 04/02/2024 revealed the staff documented monitoring at 1111, and the next monitoring documentation was at 2131 (80 minutes later). The review revealed the staff documented monitoring at 1307, and the next monitoring documentation was at 1403 (56 minutes later). A review of the Treatment Flowsheet for 04/04/2024 revealed the staff documented monitoring at 1237, and the next monitoring documentation was at 1332 (55 minutes later). A review of the Treatment Flowsheet for 04/09/2024 revealed the staff documented monitoring at 1200, and the next monitoring documentation was at 1301 (61 minutes later). An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed that documentation of vital signs and safety checks had been an issue. 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 #2 revealed a 73-year-old male admitted for In-Center Hemodialysis treatments on 01/16/2024. A review of the Treatment Flowsheet for 04/09/2024 revealed the staff documented monitoring at 1231, the next monitoring documentation was at 1346 (75 minutes later), and the following monitoring documentation was at 1439 (53 minutes later). A review of the Treatment Flowsheet for 04/11/2024 revealed the staff documented monitoring at 1335, and the next monitoring documentation was at 1430 (55 minutes later). An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed that documentation of vital signs and safety checks had been an issue. 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 #5 revealed a 45-year-old male admitted for In-Center Hemodialysis treatments on 11/07/2013. A review of the Treatment Flowsheet for 03/02/2024 revealed the staff documented monitoring at 0900, and the next monitoring documentation was at 1000 (60 minutes later). The review revealed the staff documented monitoring at 1133, and the next monitoring documentation was at 1254 (81 minutes later). An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed that documentation of vital signs and safety checks had been an issue. 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 #9 revealed a 38-year-old male admitted for In-Center Hemodialysis treatments on 09/01/2020. A review of the Treatment Flowsheet for 04/05/2024 revealed the staff documented monitoring at 1132, and the next monitoring documentation was at 1232 (60 minutes later). A review of the Treatment Flowsheet for 04/08/2024 revealed the staff documented monitoring at 1208, and the next monitoring documentation was at 1306 (558 minutes later). A review of the Treatment Flowsheet for 04/12/2024 revealed the staff documented monitoring at 1234, and the next monitoring documentation was at 1336 (62 minutes later). An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed that documentation of vital signs and safety checks had been an issue. 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 #15 revealed a 66-year-old female admitted for In-Center Hemodialysis treatments on 06/30/2015. A review of the Treatment Flowsheet for 04/09/2024 revealed the staff documented monitoring at 1206, and the next monitoring documentation was at 1301 (55 minutes later). A review of the Treatment Flowsheet for 04/11/2024 revealed the staff documented monitoring at 0938, and the next monitoring documentation was at 1030 (52 minutes later). An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed that documentation of vital signs and safety checks had been an issue. 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 #1 revealed a 55-year-old male admitted for In-Center Hemodialysis treatments on 12/08/2018. A review of the Treatment Flowsheet for 03/22/2024 revealed the staff documented monitoring at 0636, and the next monitoring documentation was at 0728 (52 minutes later). A review of the Treatment Flowsheet for 04/01/2024 revealed the staff documented monitoring at 0635, and the next monitoring documentation was at 0730 (55 minutes later). An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed that documentation of vital signs and safety checks had been an issue. 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. 8. A review of the medical record for Patient 7 revealed a 68-year-old male admitted for In-Center Hemodialysis treatments on 02/01/2024. A review of the Treatment Flowsheet for 04/11/2024 revealed the staff documented monitoring at 0830, and the next monitoring documentation was at 0939 (69 minutes later). An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that the staff were expected to monitor the patients every 30 minutes or more frequently if needed during treatments. The interview revealed that documentation of vital signs and safety checks had been an issue. 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.”

“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 record 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 and/or obtain a signed against medical advice (AMA) form for 5 of 15 (Patient #5, #11, #10, #3, and #2) sampled in-center hemodialysis records. Findings included: A review on 04/15/2024 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 04/17/2024 for Patient #5 revealed a 45-year-old male admitted to the facility for ICHD treatments on 11/07/2013. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for a duration of 270 minutes. The review of the treatment sheet dated 10/05/2023 revealed that the patient received dialysis for 196 minutes (74 minutes less than the prescribed 270 minutes). The review of the treatment sheet dated 10/17/2023 revealed that the patient received dialysis for 259 minutes (11 minutes less than the prescribed 270 minutes). The review of the treatment sheet dated 03/02/2024 revealed that the patient received dialysis for 195 minutes (75 minutes less than the prescribed 270 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 10/05/2023, 10/17/2023, and 03/02/2024. The review revealed no completed AMA form for early termination of the treatment on 10/05/2023, 10/17/2023, and 03/02/2024. Interview on 04/18/2024 at 1330 with the Clinical Manager revealed early termination was considered any treatment less than the prescribed duration time. The interview revealed the expectation was that the staff educated the patient on the risk of early termination of treatments and documented the education in the patient’s medical record. The staff were expected to obtain a signed AMA form from the patients when treatments were terminated early. The interview added that the patients refused to sign the AMA form claiming that if their treatments started on time, they would not have to terminate their treatments early. The Clinical Manager added that in these circumstances, two staff were expected to sign the form. 2. Medical record review on 04/16/2024 for Patient #11 revealed a 65-year-old male admitted to the facility for ICHD treatments on 05/08/2023. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for a duration of 240 minutes. The review of the treatment sheet dated 04/03/2024 revealed that the patient received dialysis for 183 minutes (57 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 04/08/2024 revealed that the patient received dialysis for 211 minutes (29 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 04/10/2024 revealed that the patient received dialysis for 230 minutes (10 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 04/12/2024 revealed that the patient received dialysis for 183 minutes (57 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 04/03/2024, 04/08/2024, 04/10/2024, and 04/12/2024. The review revealed no completed AMA form for early termination of the treatment on . Interview on 04/18/2024 at 1330 with the Clinical Manager revealed early termination was considered any treatment less than the prescribed duration time. The interview revealed the expectation was that the staff educated the patient on the risk of early termination of treatments and documented the education in the patient’s medical record. The staff were expected to obtain a signed AMA form from the patients when treatments were terminated early. The interview added that the patients refused to sign the AMA form claiming that if their treatments started on time, they would not have to terminate their treatments early. The Clinical Manager added that in these circumstances, two staff were expected to sign the form. 3. Medical record review on 04/17/2024 for Patient #10 revealed a 59-year-old male admitted to the facility for ICHD treatments on 12/17/2019. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for a duration of 240 minutes. The review of the treatment sheet dated 03/22/2024 revealed that the patient received dialysis for 205 minutes (35 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 04/08/2024 revealed that the patient received dialysis for 220 minutes (20 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 04/12/2024 revealed that the patient received dialysis for 209 minutes (31 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 03/22/2024, 04/08/2024, and 04/12/2024. The review revealed no completed AMA form for early termination of the treatment on 03/22/2024, 04/08/2024, and 04/12/2024. Interview on 04/18/2024 at 1330 with the Clinical Manager revealed early termination was considered any treatment less than the prescribed duration time. The interview revealed the expectation was that the staff educated the patient on the risk of early termination of treatments and documented the education in the patient’s medical record. The staff were expected to obtain a signed AMA form from the patients when treatments were terminated early. The interview added that the patients refused to sign the AMA form claiming that if their treatments started on time, they would not have to terminate their treatments early. The Clinical Manager added that in these circumstances, two staff were expected to sign the form. 4. Medical record review on 04/17/2024 for Patient #3 revealed a 73-year-old male admitted to the facility for ICHD treatments on 03/10/2023. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for a duration of 240 minutes. The review of the treatment sheet dated 04/08/2024 revealed that the patient received dialysis for 225 minutes (15 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 04/08/2024. The review revealed no completed AMA form for early termination of the treatment on 04/08/2024. Interview on 04/18/2024 at 1330 with the Clinical Manager revealed early termination was considered any treatment less than the prescribed duration time. The interview revealed the expectation was that the staff educated the patient on the risk of early termination of treatments and documented the education in the patient’s medical record. The staff were expected to obtain a signed AMA form from the patients when treatments were terminated early. The interview added that the patients refused to sign the AMA form claiming that if their treatments started on time, they would not have to terminate their treatments early. The Clinical Manager added that in these circumstances, two staff were expected to sign the form. 5. Medical record review on 04/17/2024 for Patient #2 revealed a 73-year-old male admitted to the facility for ICHD treatments on 01/16/2024. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week for a duration of 240 minutes. The review of the treatment sheet dated 03/05/2024 revealed that the patient received dialysis for 225 minutes (15 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 04/02/2024 revealed that the patient received dialysis for 195 minutes (45 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 04/11/2024 revealed that the patient received dialysis for 221 minutes (19 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 03/05/2024, 04/02/2024, and 04/11/2024. The review revealed no completed AMA form for early termination of the treatment on 03/05/2024, 04/02/2024, and 04/11/2024. Interview on 04/18/2024 at 1330 with the Clinical Manager revealed early termination was considered any treatment less than the prescribed duration time. The interview revealed the expectation was that the staff educated the patient on the risk of early termination of treatments and documented the education in the patient’s medical record. The staff were expected to obtain a signed AMA form from the patients when treatments were terminated early. The interview added that the patients refused to sign the AMA form claiming that if their treatments started on time, they would not have to terminate their treatments early. The Clinical Manager added that in these circumstances, two staff were expected to sign the form.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 38766 Based on policies and procedures review, observations, and staff interviews, the facility staff failed to follow the facility policy in cannulating an AVF/G (Arterial Venous Fistula/Graft) in 1 of 4 observations (PCT #3). Findings included: A review of the facility’s current policy “Access assessment and Cannulation” revised 07/05/2022 revealed, “... Policy Evaluation and preparation of the access will be performed routinely prior to cannulation at each dialysis session. A tourniquet must be used with an AV Fistula... Assessment of Vascular access ...6. Listen ...Note: Staff /patients/care partners who have trained to auscultate vascular accesses should listen to the entire length of the access for changes in the sound of the bruit - a normal low-pitched bruit should be present...” Observation on 04/16/2024 at 1005 revealed PCT #3 entered station #A7 to initiate dialysis with an AVF/G for Patient #16. The observation revealed PCT #3 cleaned the access site with alcohol, palpated the access to evaluate the access, performed hand hygiene, changed gloves, and proceeded directly to cannulation. The observation revealed PCT #3 failed to listen to the access with a stethoscope and apply a tourniquet above the access site before cannulation. The observation of Patient #16’s treatment orders at chairside with PCT #3 revealed that Patient #16 had an AFV. An interview on 04/16/2024 at 1015 with PCT #3 revealed that he was new to the clinic and the patient’s access “looked like a graft.” The interview revealed that PCT #3 did not look at the order to confirm the patient’s access type. The interview revealed that listening to the access with a stethoscope and applying a tourniquet were required steps in accessing an AVF. PCT #3 stated, “I did not follow the policy. “ An interview on 04/18/2024 at 1330 with the Clinical Manager revealed that the expectation was for the staff to check the treatment order before cannulating a patient, listen to all accesses, and use a tourniquet for all cannulation of a fistula. The interview revealed all staff had been educated on the policy. NC00209208 NC00210895”