Fresenius Medical Care of Spring Hope

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 38766 Based on a review of facility policy, observations, and staff interviews, the facility staff failed to remove PPE (gown and face shield) before leaving the in-center treatment area for 2 of 2 observed staff members leaving the treatment area (PCT #1 and PCT #2). Findings included: A review on 11/18/2025 of the facility policy titled, “Personal Protective Equipment,” revised 11/06/2023, revealed “... Policy... Personal protective equipment, including a full-face shield or mask and protective eyewear with a full side shield, fluid-resistant gowns and gloves ...All personal protective equipment shall be removed prior to leaving the treatment area...” 1. Observation on 11/18/2025 from 1050 through 1120 in the patient treatment area revealed PCT #1 left the treatment area on multiple occasions and entered the supply room while wearing the gown and face shield used during patient care. The observation revealed that the PCT resumed patient care using the same gown and face shield. The observation indicated a sign posted on the exit door from the treatment area to the supply area, “Please remove all PPE. No PPE beyond this point.” The observation indicated that PCT #1 failed to remove PPE (gown and face shield) before leaving the treatment area, as per facility policy. An interview on 11/18/2025 at 1125 with PCT #1 revealed that the PCT did not pay attention to the signs on the door. The PCT stated that she was sorry for not remembering to remove the gown and face shield before leaving the treatment area. 2. Observation on 11/18/2025 from 1050 through 1122 in the patient treatment area revealed PCT #2 left the treatment area on multiple occasions and entered the supply room while wearing the gown and face shield used during patient care. The observation revealed that the PCT resumed patient care using the same gown and face shield. The observation indicated a sign posted on the exit door from the treatment area to the supply area, “Please remove all PPE. No PPE beyond this point.” The observation indicated that PCT #2 failed to remove PPE (gown and face shield) before leaving the treatment area, as per facility policy. An interview on 11/18/2025 at 1135 with PCT #2 revealed that the PCT did not know that she had to remove all PPE (gown and face shield) before leaving the treatment area. The PCT added that she will remove her PPE before leaving the treatment area.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 38766 Based on a review of policy and procedures, medical records review, and staff interviews, the facility staff failed to perform and/or document patient monitoring every 30-45 minutes during dialysis treatments for two of eight in-center patient records reviewed (Patients #1 and #6). Findings included: A review on 07/22/2025 of the facility’s policy and procedure, “Patient Assessment and Monitoring,” published 05/01/2023, revealed “...During Treatment: Obtaining 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 check every 30 minutes or more often as needed, but not to exceed 45 minutes per state regulations...” 1. An open medical record review on 11/18/2025 for Patient #1 revealed that a 69-year-old male had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 09/03/2025. A review of the treatment flowsheet dated 11/03/2025 revealed the treatment started at 1145 and concluded at 1452 (lasting a total of 187 minutes). The treatment flowsheet revealed no documented vital signs from 1332 through 1449 (77 minutes). A review of the treatment flowsheet on 11/07/2025 revealed the treatment started at 1130 and ended at 1457 (lasting a total of 207 minutes). The treatment flowsheet revealed no documented vital signs from 1306 through 1414 (68 minutes). A review of the treatment flowsheet on 11/12/2025 revealed the treatment started at 1130 and ended at 1531 (lasting a total of 241 minutes). The treatment flowsheet revealed no documented vital signs from 1132 through 1232 (60 minutes) and from 1232 through 1325 (54 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment, as required by policy. An interview on 11/20/2025 at 1150 with PCT/CCHT #1 revealed that the patient care technicians were responsible for monitoring patients, which included checking vital signs and conducting safety checks. The interview confirmed that these tasks should be performed and documented every 30 minutes, or more frequently if needed. 2. An open medical record review on 11/19/2025 for Patient #6 revealed that a 77-year-old female had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 11/26/2024. A review of the treatment flowsheet dated 11/06/2025 revealed the treatment started at 0713 and concluded at 1125 (lasting a total of 252 minutes). The treatment flowsheet revealed no documented vital signs from 1000 through 1056 (56 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment, as required by policy. An interview on 11/20/2025 at 1150 with PCT/CCHT #1 revealed that the patient care technicians were responsible for monitoring patients, which included checking vital signs and conducting safety checks. The interview confirmed that these tasks should be performed and documented every 30 minutes, or more frequently if needed.”

“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 and/or obtain a signed against medical advice (AMA) form for four of eight sampled in-center hemodialysis records (Patients #2, #5, #1, and #7). Findings included: A review on 11/18/2025 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 prescribed treatment. The RN was responsible for... document on the ‘AMA’ or Against Medical Advice form...” 1. Medical record review on 11/18/2025 for Patient #2 revealed a 74-year-old female admitted to the facility for ICHD treatments on 05/23/2024. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week, lasting 180 minutes. The review of the treatment sheet dated 11/07/2025 revealed that the patient received dialysis for 154 minutes (26 minutes less than the prescribed 180 minutes). The review of the treatment sheet dated 11/12/2025 revealed that the patient received dialysis for 147 minutes (33 minutes less than the prescribed 180 minutes). The review of the treatment sheet dated 11/14/2025 revealed that the patient received dialysis for 123 minutes (57 minutes less than the prescribed 180 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 11/07/2025, 11/12/2025, and 11/14/2025. The review revealed no completed AMA form for early termination of treatment on 11/07/2025, 11/12/25, and 11/14/2025. An interview on 11/20/2025 at 1150 with PCT/CCHT #1 revealed that the staff should stick to the patient’s prescribed treatment duration. If patients chose to terminate their treatment early, the staff was responsible for completing the Early Termination of Treatment Against Medical Advice form and obtaining the patient’s signature. The interview indicated that the form should be signed by the RN and the patient and should be kept in the patient’s record. 2. Medical record review on 11/19/2025 for Patient #5 revealed a 47-year-old male admitted to the facility for ICHD treatments on 01/10/2025. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week, lasting 240 minutes. The review of the treatment sheet dated 11/10/2025 revealed that the patient received dialysis for 203 minutes (37 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/15/2025 revealed that the patient received dialysis for 190 minutes (50 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 11/10/2025 and 11/15/2025. The review revealed no completed AMA form for early termination of treatment on 11/10/2025 and 11/15/2025. An interview on 11/20/2025 at 1150 with PCT/CCHT #1 revealed that the staff should stick to the patient’s prescribed treatment duration. If patients chose to terminate their treatment early, the staff was responsible for completing the Early Termination of Treatment Against Medical Advice form and obtaining the patient’s signature. The interview indicated that the form should be signed by the RN and the patient and should be kept in the patient’s record. 3. Medical record review on 11/18/2025 for Patient #1 revealed a 69-year-old male admitted to the facility for ICHD treatments on 09/03/2025. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week, lasting 240 minutes. The review of the treatment sheet dated 11/14/2025 revealed that the patient received dialysis for 201 minutes (39 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 11/14/2025. The review revealed no completed AMA form for early termination of treatment on 11/14/2025. An interview on 11/20/2025 at 1150 with PCT/CCHT #1 revealed that the staff should stick to the patient’s prescribed treatment duration. If patients chose to terminate their treatment early, the staff was responsible for completing the Early Termination of Treatment Against Medical Advice form and obtaining the patient’s signature. The interview indicated that the form should be signed by the RN and the patient and should be kept in the patient’s record. 4. Medical record review on 11/20/2025 for Patient #7 revealed a 65-year-old male admitted to the facility for ICHD treatments on 04/04/2025. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week, lasting 240 minutes. The review of the treatment sheet dated 11/10/2025 revealed that the patient received dialysis for 207 minutes (33 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 11/10/2025. The review revealed no completed AMA form for early termination of treatment on 11/10/2025. An interview on 11/20/2025 at 1150 with PCT/CCHT #1 revealed that the staff should stick to the patient’s prescribed treatment duration. If patients chose to terminate their treatment early, the staff was responsible for completing the Early Termination of Treatment Against Medical Advice form and obtaining the patient’s signature. The interview indicated that the form should be signed by the RN and the patient and should be kept in the patient’s record.”