Fmc Vernon Dialysis Unit

“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 6 of 8 sampled in-center hemodialysis records reviewed (Patient #1, #2, #3, #4, #5, and #7). Findings included: Review on 08/19/2025 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 08/20/2025 for Patient #1 revealed a 65-year-old male admitted to the facility for ICHD (In Center Hemodialysis) treatments on 12/11/2018. Review of the treatment sheet dated 08/06/2025 revealed the treatment started at 1030 and ended at 1429 for a duration of 239 minutes. Review of the monitoring documentation dated 08/06/2025 revealed Patient #1’s blood pressure, pulse and machine parameters were monitored by staff at 1256 and monitored next by staff at 1342 (46 minutes later). Review of the treatment sheet dated 08/12/2025 revealed the treatment started at 0848 and ended at 1300 for a duration of 252 minutes. Review of the monitoring documentation dated 08/12/2025 revealed Patient #1’s blood pressure, pulse and machine parameters were monitored by staff at 0905 and monitored next by staff at 1034 (89 minutes later). Review of the treatment sheet dated 08/15/2025 revealed the treatment started at 0940 and ended at 1357 for a duration of 257 minutes. Review of the monitoring documentation dated 08/15/2025 revealed Patient #1’s blood pressure, pulse and machine parameters were monitored by staff at 0940 and monitored next by staff at 1037 (57 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 08/06/2025, 08/12/2025 and 08/15/2025. Interview on 08/21/2025 at 1141 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 08/06/2025, 08/12/2025 and 08/15/2025 for Patient #1. 2. Open medical record review on 08/20/2025 for Patient #2 revealed a 34-year-old female admitted to the facility for ICHD treatments on 07/03/2025. Review of the treatment sheet dated 08/09/2025 revealed the treatment started at 1106 and ended at 1506 for a duration of 240 minutes. Review of the monitoring documentation dated 08/09/2025 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1106 and monitored next by staff at 1200 (54 minutes later). Review of the treatment sheet dated 08/14/2025 revealed the treatment started at 1145 and ended at 1550 for a duration of 245 minutes. Review of the monitoring documentation dated 08/14/2025 revealed Patient #2’s blood pressure, pulse and machine parameters were monitored by staff at 1145 and monitored next by staff at 1234 (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 treatment on 08/09/2025 and 08/14/2025. Interview on 08/21/2025 at 1141 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 08/09/2025, and 08/14/2025 for Patient #2. 3. Open medical record review on 08/20/2025 for Patient #3 revealed a 62-year-old female admitted to the facility for ICHD treatments on 07/02/2024. Review of the treatment sheet dated 08/05/2025 revealed the treatment started at 1119 and ended at 1523 for a duration of 244 minutes. Review of the monitoring documentation dated 08/05/2025 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 1302 and monitored next by staff at 1400 (58 minutes later). Review of the treatment sheet dated 08/12/2025 revealed the treatment started at 1118 and ended at 1518 for a duration of 240 minutes. Review of the monitoring documentation dated 08/12/2025 revealed Patient #3’s blood pressure, pulse and machine parameters were monitored by staff at 1138 and monitored next by staff at 1236 (58 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 08/05/2025 and 08/12/2025. Interview on 08/21/2025 at 1141 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 08/05/2025, and 08/12/2025 for Patient #3. 4. Open medical record review on 08/21/2025 for Patient #4 revealed a 72-year-old female admitted to the facility for ICHD treatments on 06/08/2023. Review of the treatment sheet dated 08/09/2025 revealed the treatment started at 0748 and ended at 1126 for a duration of 218 minutes. Review of the monitoring documentation dated 08/09/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 0858 and monitored next by staff at 0949 (51 minutes later). Review of the monitoring documentation dated 08/09/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 1029 and monitored next by staff at 1126 (57 minutes later). Review of the treatment sheet dated 08/12/2025 revealed the treatment started at 0749 and ended at 1210 for a duration of 261 minutes. Review of the monitoring documentation dated 08/12/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 0749 and monitored next by staff at 0839 (50 minutes later). Review of the treatment sheet dated 08/14/2025 revealed the treatment started at 0735 and ended at 1111 for a duration of 216 minutes. Review of the monitoring documentation dated 08/14/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 0910 and monitored next by staff at 1005 (55 minutes later). Review of the monitoring documentation dated 08/14/2025 revealed Patient #4’s blood pressure, pulse and machine parameters were monitored by staff at 1005 and monitored next by staff at 1110 (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 treatment on 08/09/2025, 08/12/2025 and 08/14/2025. Interview on 08/21/2025 at 1141 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 08/09/2025, 08/12/2025 and 08/14/2025 for Patient #4. 5. Open medical record review on 08/21/2025 for Patient #5 revealed a 75-year-old male admitted to the facility for ICHD treatments on 10/24/2019. Review of the treatment sheet dated 08/14/2025 revealed the treatment started at 0953 and ended at 1347 for a duration of 234 minutes. Review of the monitoring documentation dated 08/14/2025 revealed Patient #5’s blood pressure, pulse and machine parameters were monitored by staff at 1100 and monitored next by staff at 1212 (72 minutes later). Review of the treatment sheet dated 08/16/2025 revealed the treatment started at 0954 and ended at 1345 for a duration of 231 minutes. Review of the monitoring documentation dated 08/16/2025 revealed Patient #5’s blood pressure, pulse and machine parameters were monitored by staff at 1032 and monitored next by staff at 1134 (62 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 08/14/2025 and 08/16/2025. Interview on 08/21/2025 at 1141 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 08/14/2025, and 08/16/2025 for Patient #5. 6. Open medical record review on 08/21/2025 for Patient #7 revealed a 51-year-old female admitted to the facility for ICHD treatments on 01/12/2018. Review of the treatment sheet dated 08/04/2025 revealed the treatment started at 0925 and ended at 1205 for a duration of 160 minutes. Review of the monitoring documentation dated 08/04/2025 revealed Patient #7’s blood pressure, pulse and machine parameters were monitored by staff at 1030 and monitored next by staff at 1141 (71 minutes later). Review of the treatment sheet dated 08/11/2025 revealed the treatment started at 0720 and ended at 1121 for a duration of 241 minutes. Review of the monitoring documentation dated 08/11/2025 revealed Patient #7’s blood pressure, pulse and machine parameters were monitored by staff at 1033 and monitored next by staff at 1119 (46 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 08/04/2025 and 08/11/2025. Interview on 08/21/2025 at 1141 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 08/04/2025, and 08/11/2025 for Patient #7.”

“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: 51294 Based on policy review, medical records review, and staff interviews, the facility staff failed to follow the adequacy plan of care by not dialyzing 2 of 8 (Patients #2 and #8) in-center hemodialysis patients at the prescribed treatment duration. Findings include: A review on 08/21/2025 of the policy and procedure “Early Termination or Arriving Late for Treatment” revised 06/18/2025 revealed, “...The purpose of this policy is to provide guidelines for staff when patients arrive late for their scheduled treatment time, request early termination of treatment or when unforeseen circumstances at the facility lead to a delay in treatment...Background: Treatment duration and frequency is prescribed by a patient’s provider and the facility expects that all patients will adhere to their prescribed treatment time and schedule. Serious health related consequences may result from missed treatments or terminating treatments earlier than prescribed. Early termination: If a patient insists on terminating treatment early and this has not been previously approved by the patient’s provider, the patient must take full responsibility for consequences of the missed or shortened treatment. If a patient request to leave treatment early: ...The RN (Registered Nurse) is responsible to notify the provider, and document the “AMA”, or Against Medical Advice form...Against medical advice forms are...Signed with each early termination event and filed in the patient’s medical record...Arriving late...Staff should do their best to accomodate the patient’s prescribed treatment time. If it is not possible due to facility hours of operation, the provider must be notified to review the time delay and determine the appropraite intervention...Documentation: Document in the medical record the specific unexpected reason why the treatment was shortened. All discussions with the patient, including information, interventions, or instructions given, and any notification or discussion with the provider, must be documented in the patient’s medical record. Complete documentation of early termination of treatment against medical advice form.” 1. Open medical record review on 08/20/2025 for Patient #2 revealed a 34-year-old female admitted to the facility for ICHD treatments on 07/03/2025. A review of the Physician orders revealed Patient #2 was ordered a dialysis treatment duration for 4 hours (hrs). Review of the treatment sheet dated 08/12/2025 revealed the treatment started at 1209 and ended at 1520 for a duration of 3 hrs and 10 min (shortened by 50 minutes) with no evidence of an AMA (Against Medical Advice) form completed. Interview on 08/21/2025 at 1141 with the Clinical Manager revealed that the facility nursing staff were expected to obtain a signed AMA (Against Medical Advice) form for every patient that received a shortened treatment duration or document the patient’s refusal to sign on the AMA form. Upon review, the Clinical Manager stated that Patient #2 was an hour late for her appointment and an AMA form for Patient #2 was not found for 08/12/2025. 2. Open medical record review on 08/21/2025 for Patient #8 revealed a 40-year-old female admitted to the facility for ICHD treatments on 04/15/2020. A review of the Physician orders revealed Patient #8 was ordered a dialysis treatment duration for 4 hours (hrs) and 0 minutes (min). Review of the treatment sheet dated 08/08/2025 revealed the treatment started at 1331 and ended at 1527 for a duration of 1 hrs and 56 min (shortened by 124 minutes) with no evidence of an AMA (Against Medical Advice) form completed. Interview on 08/21/2025 at 1141 with the Clinical Manager revealed that the facility nursing staff were expected to obtain a signed AMA (Against Medical Advice) form for every patient that received a shortened treatment duration or document the patient’s refusal to sign on the AMA form. Upon review, the Clinical Manager stated that Patient #8 was late for her appointment and an AMA form for Patient #8 was not found for 08/08/2025.”