Fms Six Forks Dialysis Clinic

“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 policy and procedure review, observation, and interviews, the facility staff failed to ensure a visitor wore a gown while in the treatment area during patient care for 1 of 1 observation. Findings included: A review on 04/23/2025 of the facility’s policy, “Visitor Policy,” published 02/06/2023, revealed that “... Visitors in the Patient Care Area... Visitors Assisting with Care... PPE will be provided along with instructions for proper use if there is a likelihood that the visitor may be exposed to bloodborne pathogens during the time that he/she is in the treatment area...” Observation on 04/23/2025 at 1150 revealed a patient entered the treatment area accompanied by a visitor/family member. The observation showed that the visitor assisted in holding the patient’s arm during the cannulation procedure. The observation revealed that the visitor did not have a gown or a face shield on during the patient’s cannulation process. The observation revealed the visitor was at increased risk of exposure to bloodborne pathogens during patient cannulation. An interview conducted on 04/23/2025 at 1200 with RN #1 revealed that the visitor should have been given a gown and a face shield upon entering the treatment area. The RN added that there was no reason for the visitor not wearing PPE while in the station during the patient’s cannulation. An interview on 04/23/2025 at 1215 with the CN revealed that the visitors were required to wear gowns while in the treatment area and a face shield during cannulation if they were closed to the patient. The CN added that he did not realize the visitor was not wearing PPE until after he cannulated the patient. The interview confirmed the findings.”

“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-minute during dialysis treatments for six (6) of eight (8) in-patient records reviewed (Patient #7, #6, #1, #2, #3, and #5). Findings included: A review on 04/16/2025 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 checks every 30 minutes or more often as needed, but not to exceed 45 minutes per state regulations...” 1. An open medical record review on 04/24/2025 for Patient #7 revealed that a 60-year-old male was admitted to the facility for ICHD treatment on 04/19/2022. A review of the treatment sheet dated 04/09/2025 revealed the treatment started at 1124 and concluded at 1507 (223 minutes). The treatment flowsheet revealed no documented vital signs from 1239 through 1334 (55 minutes). A review of the treatment flowsheet on 04/14/2025 revealed the treatment started at 1100 and ended at 1505 (245 minutes). The treatment flow sheet revealed no documented vital signs from 1130 through 1237 (67 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment per the facility policy. An interview on 04/24/2025 at 1330 with PCT #2 revealed that the patient’s vitals and safety checks should be performed and documented every 30 to 45 minutes. The interview confirmed the findings. 2. An open medical record review on 04/24/2025 for Patient #6 revealed that a 60-year-old male was admitted to the facility for ICHD treatment on 01/03/2025. A review of the treatment sheet dated 04/09/2025 revealed the treatment started at 0613 and concluded at 1017 (244 minutes). The treatment flowsheet revealed no documented vital signs from 0801 through 0904 (63 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment per the facility policy. An interview on 04/24/2025 at 1330 with PCT #2 revealed that the patient’s vitals and safety checks should be performed and documented every 30 to 45 minutes. The interview confirmed the findings. 3. An open medical record review on 04/23/2025 for Patient #1 revealed that a 63-year-old female was admitted to the facility for ICHD treatment on 02/26/2025. A review of the treatment sheet dated 04/18/2025 revealed the treatment started at 0650 and concluded at 1006 (196 minutes). The treatment flowsheet revealed no documented vital signs from 0905 through 1007 (62 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment per the facility policy. An interview on 04/24/2025 at 1330 with PCT #2 revealed that the patient’s vitals and safety checks should be performed and documented every 30 to 45 minutes. The interview confirmed the findings. 4. An open medical record review on 04/22/2025 for Patient #2 revealed that a 61-year-old female was admitted to the facility for ICHD treatment on 06/25/2024. A review of the treatment sheet dated 04/14/2025 revealed the treatment started at 1139 and concluded at 1514 (215 minutes). The treatment flowsheet revealed no documented vital signs from 1336 through 1436 (60 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment per the facility policy. An interview on 04/24/2025 at 1330 with PCT #2 revealed that the patient’s vitals and safety checks should be performed and documented every 30 to 45 minutes. The interview confirmed the findings. 5. An open medical record review on 04/23/2025 for Patient #3 revealed that a 79-year-old female was admitted to the facility for ICHD treatment on 06/25/2024. A review of the treatment sheet dated 04/09/2025 revealed the treatment started at 0752 and concluded at 1110 (198 minutes). The treatment flowsheet revealed no documented vital signs from 1041 through 1133 (52 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment per the facility policy. An interview on 04/24/2025 at 1330 with PCT #2 revealed that the patient’s vitals and safety checks should be performed and documented every 30 to 45 minutes. The interview confirmed the findings. 6. An open medical record review on 04/24/2025 for Patient #5 revealed that a 67-year-old male was admitted to the facility for ICHD treatment on 08/29/2015. A review of the treatment sheet dated 04/09/2025 revealed the treatment started at 1218 and concluded at 1550 (212 minutes). The treatment flowsheet revealed no documented vital signs from 1507 through 1558 (51 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment per the facility policy. An interview on 04/24/2025 at 1330 with PCT #2 revealed that the patient’s vitals and safety checks should be performed and documented every 30 to 45 minutes. The interview confirmed the findings.”

“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 interviews, the facility staff failed to follow the adequacy plan of care by not dialyzing 4 of 8 (Patients #1, #2, #7, and #5) in-center hemodialysis patients at the prescribed BFR/DFR. Findings included: A review on 04/22/2025 of the facility’s policy, “Patient Assessment and Monitoring,” published 05/012023 revealed, “...During Treatment ...3. Machine Parameters and Extracorporeal Circuit Check prescribed blood flow is being achieved, or reason is documented in the medical record if unable to meet prescribed blood flow rate. Check that the dialysate flow rate setting is correct, and the prescribed flow is being delivered...” 1. An open medical record review on 04/23/2025 for Patient #1 revealed a 63-year-old female admitted to the facility for ICHD treatments on 02/26/2025. A review of the physician orders revealed Patient #1’s Blood Flow Rate (BFR) was ordered at 450 and Dialysate Flow Rate (DFR) at autoflow of 1.5 times the BFR. A review of the treatment flowsheet on 04/07/2025 revealed the treatment started at 0655 and ended at 1053 (238 minutes). A review of the Flowsheet revealed Patient #1’s BFR/DFR averages were 400/600, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 04/11/2025 revealed the treatment started at 0702 and ended at 1047 (225 minutes). A review of the Flowsheet revealed Patient #1’s BFR/DFR averages were 350/560, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 04/14/2025 revealed the treatment started at 0647 and ended at 1052 (245 minutes). A review of the Flowsheet revealed Patient #1’s BFR/DFR averages were 390/640, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 04/18/2025 revealed the treatment started at 0650 and ended at 1006 (196 minutes). A review of the Flowsheet revealed Patient #1’s BFR/DFR averages were 390/620, with no documentation for the decrease in the BFR/DFR. An interview on 04/24/2025 with PCT #2 revealed that the patient’s BFR/DFR was part of the treatment order, and the staff was responsible for ensuring they were set correctly. The PCT added that if the patient was unable to run at the ordered BFR/DFR, the staff should notify the RN, follow the RN’s instructions, and document the intervention in the treatment record. 2. An open medical record review on 04/22/2025 for Patient #2 revealed a 61-year-old female admitted to the facility for ICHD treatments on 06/25/2024. A review of the physician orders revealed Patient #2’s Blood Flow Rate (BFR) was ordered at 450 and Dialysate Flow Rate (DFR) at 800. A review of the treatment flowsheet on 04/04/2025 revealed the treatment started at 1204 and ended at 1512 (188 minutes). A review of the Flowsheet revealed Patient #2’s BFR/DFR averages were 400/800, with no documentation for the decrease in the BFR. A review of the treatment flowsheet on 04/14/2025 revealed the treatment started at 1139 and ended at 1514 (215 minutes). A review of the Flowsheet revealed Patient #2’s BFR/DFR averages were 340/740, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 04/04/2025 revealed the treatment started at 1154 and ended at 1523 (209 minutes). A review of the Flowsheet revealed Patient #2’s BFR/DFR averages were 350/590, with no documentation for the decrease in the BFR/DFR. An interview on 04/24/2025 with PCT #2 revealed that the patient’s BFR/DFR was part of the treatment order, and the staff was responsible for ensuring they were set correctly. The PCT added that if the patient was unable to run at the ordered BFR/DFR, the staff should notify the RN, follow the RN’s instructions, and document the intervention in the treatment record. 3. An open medical record review on 04/24/2025 for Patient #7 revealed a 60-year-old male was admitted to the facility for ICHD treatments on 04/19/2022. A review of the physician’s orders indicated that Patient #7 had a Blood Flow Rate (BFR) set at 450 and a Dialysate Flow Rate (DFR) set to autoflow at twice the BFR. A review of the treatment flowsheet on 04/11/2025 revealed the treatment started at 1053 and ended at 1457 (244 minutes). A review of the Flowsheet revealed Patient #7’s BFR/DFR averages were 410/740, with no documentation for the decrease in the BFR/DFR. A review of the treatment flowsheet on 04/18/2025 revealed the treatment started at 1105 and ended at 1506 (241 minutes). A review of the Flowsheet revealed Patient #7’s BFR/DFR averages were 400/590, with no documentation for the decrease in the BFR/DFR. An interview on 04/24/2025 with PCT #2 revealed that the patient’s BFR/DFR was part of the treatment order, and the staff was responsible for ensuring they were set correctly. The PCT added that if the patient was unable to run at the ordered BFR/DFR, the staff should notify the RN, follow the RN’s instructions, and document the intervention in the treatment record. 4. An open medical record review on 04/24/2025 for Patient #5 revealed a 67-year-old male was admitted to the facility for ICHD treatments on 08/29/2015. A review of the physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 350 and Dialysate Flow Rate (DFR) at 500. A review of the treatment flowsheet on 04/16/2025 revealed the treatment started at 1218 and ended at 1550 (202 minutes). A review of the Flowsheet revealed Patient #5’s BFR/DFR averages were 310/500, with no documentation for the decrease in the BFR. An interview on 04/24/2025 with PCT #2 revealed that the patient’s BFR/DFR was part of the treatment order, and the staff was responsible for ensuring they were set correctly. The PCT added that if the patient was unable to run at the ordered BFR/DFR, the staff should notify the RN, follow the RN’s instructions, and document the intervention in the treatment record.”