Davita North Charlotte Dialysis Center

“IC-HBV-ISOLATION-STAFFING CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients Staff members caring for HBsAg positive patients should not care for HBV susceptible patients at the same time, including during the period when dialysis is terminated on one patient and initiated on another. This Standard is not met as evidenced by: 35306 Based on observation, policy reviews, medical record reviews, physician and staff interviews, the facility failed to prevent staff members from providing care to HBsAg (Hepatitis B Surface Antigen) positive patients and HBV (Hepatitis B) susceptible patients concurrently during hemodialysis treatment for 3 of 3 observed HBV susceptible patients receiving care diagonally across from the facility’s dedicated isolation room (Patient #11, #12, and #17). Findings included: Review on 12/04/2024 of policy titled, “HEPATITIS B SURVEILLANCE, VACCINATION, INFECTION CONTROL MEASURES AND ISOLATION GUIDANCE”, Policy: 1-05-02, Revision Date: April 2024, revealed, “PURPOSE: To prevent the spread of hepatitis B infections in the dialysis setting. ...21. TEAMMATE ASSIGNMENT a. Teammates caring for confirmed or suspect hepatitis B surface antigen positive (HBsAg) positive patient(s) do not care for surface antibody negative (susceptible) patients simultaneously and will only be assigned to care for surface antibody positive (immune) patients. b. If the Hepatitis B surface antigen positive patient’s clinical condition requires immediate temporary assistance by another teammate who is caring for susceptible patients, the teammate must change all PPE [personal protective equipment] and perform hand hygiene both prior to entering and immediately upon leaving the isolation room/area or station. c. When possible, only HBV immune teammates should be assigned to care for the Hepatitis B antigen positive patients. d. Teammates will not change patient seating assignments unless approved by the Charge Nurse. ...” Observation on 12/04/2024 at 1045 in the facility’s patient treatment area revealed one (1) RN (RN #2) and two (2) PCTs (#1 and #2) providing care to patients in Pods E, H, and I. Observation revealed patient #11 (HBsAg negative patient) was receiving HD treatment in patient station #20, and patient #12 (HBsAg negative patient) was receiving HD treatment in patient station #18, both located diagonally across from the dedicated isolation treatment room (Pod I, stations #30, #31, #32, and #33). The observation revealed the isolation room had patients #15 and #16 (BOTH HBsAg positive patients) receiving HD treatment concurrently with the observation of patients #11 and #12’s hemodialysis treatment. Observation revealed RN #1 inside of the isolation room wearing PPE and providing care to patients #15 and #16. Observation on 12/04/2024 at 1130 in the facility’s patient treatment area revealed patients #13, and #14 (BOTH HBsAG positive patients) were receiving HD treatment in the facility’s dedicated isolation room. Observation revealed RN #2 inside of the isolation room wearing PPE and providing care to patient #13. Further observation revealed RN #2 came out of the isolation room, went to station #20, and assessed patient #12 (HBsAg negative patient) prior to initiation of HD treatment. Further observation revealed the facility had one (1) RN (#2) providing nursing care to both patients at station #20 (BOTH HBsAG negative). Observation revealed the facility failed to ensure teammates caring for confirmed HBsAg positive patients were not assigned to care for HBsAg negative patients simultaneously. Review of the patient assignment sheet on 12/04/2024 revealed RN #2 was assigned to Pods E, F, H, and I. Review of the seating schedule for Pod E revealed patient #12, assigned to station #18 for HD treatments from 1045-1445; patient #11, assigned to station #20 for HD treatments from 0615-1015; and patient #17, assigned to station #20 for HD treatments from 1115-1515 were all HBsAg negative patients. Review of the seating schedule for Pod I revealed patient #18, assigned to station #30 in the isolation room for HD treatments from 0545-0915; patient #13, assigned to station #30 in the isolation room for HD treatments from 1030-1430; patient #16, assigned to station #31 in the isolation room for HD treatment from 0600-1000; and patient #14, assigned to station #31 in the isolation room for HD treatments from 1045-1445 were all HBsAg positive. Review of the staffing assignments revealed, RN #2 was the nurse assigned for providing care to HBsAg (Hepatitis B Surface Antigen) positive patients and HBV (Hepatitis B) susceptible patients concurrently during hemodialysis treatment. 1. Medical record review on 12/04/2024 for Patient #11 revealed the patient was admitted to the facility on 07/10/2024 for ICHD treatment. Review of the patient’s “IMMUNOLOGY TEST” results revealed the patient was documented as Hepatitis B “Negative”. 2. Medical record review on 12/04/2024 for Patient #12 revealed the patient was admitted to the facility on 08/05/2024 for ICHD treatment. Review of the patient’s “IMMUNOLOGY TEST” results revealed the patient was documented as Hepatitis B “Negative”. 3. Medical record review on 12/04/2024 for Patient #13 revealed the patient was admitted to the facility on 11/25/2020 for ICHD treatment. Review of the patient’s “IMMUNOLOGY TEST” results revealed the patient was documented as Hepatitis B “Positive”. 4. Medical record review on 12/04/2024 for Patient #14 revealed the patient was admitted to the facility on 11/25/2024 for ICHD treatment. Review of the patient’s “IMMUNOLOGY TEST” results revealed the patient was documented as Hepatitis B “Positive”. 5. Medical record review on 12/04/2024 for Patient #15 revealed the patient was admitted to the facility on 11/26/2014 for ICHD treatment. Review of the patient’s “IMMUNOLOGY TEST” results revealed the patient was documented as Hepatitis B “Positive”. 6. Medical record review on 12/04/2024 for Patient #16 revealed the patient was admitted to the facility on 02/15/2021 for ICHD treatment. Review of the patient’s “IMMUNOLOGY TEST” results revealed the patient was documented as Hepatitis B “Positive”. 7. Medical record review on 12/04/2024 for Patient #17 revealed the patient was admitted to the facility on 06/15/2021 for ICHD treatment. Review of the patient’s “IMMUNOLOGY TEST” results revealed the patient was documented as Hepatitis B “Negative”. 8. Medical record review on 12/04/2024 for Patient #18 revealed the patient was admitted to the facility on 02/08/2012 for ICHD treatment. Review of the patient’s “IMMUNOLOGY TEST” results revealed the patient was documented as Hepatitis B “Positive”. The review of Patients #11, #12, and #17 (susceptible to HBV) and patients #13, #14, #15, #16, and #18 (HBsAg Positive Patients) medical records revealed that patients were concurrently cared for by the same RN (#2) between 0940 and 1205 on 12/04/2024 and that the nursing staff failed to prevent potential Hepatitis B transmission. Interview on 12/04/2024 at 1140 with RN #2 revealed that he worked as a staff nurse at the facility. The interview revealed that he was the only nurse assigned to POD E, H, and I on 12/04/2024. During the interview, the RN was asked if he was aware that Patients #11, #12, and #17 were susceptible to HBV and RN #2 stated, “I wasn’t aware and should have been. I did not pay attention to the schedule.” Interview on 12/04/2024 at 1147 with the Clinical Coordinator (CC) revealed, “I don’t make the schedule.” Interview revealed Patients #11, #12, and #17 were previously in another area of the treatment area where susceptible patients received HD treatment and that schedules were currently made by the Facility Administrator (FA). Interview on 12/04/2024 at 1348 with the FA revealed, staff caring for confirmed or suspect hepatitis B surface antigen positive (HBsAg) positive patient(s) should not be assigned to care for surface antibody negative (susceptible) patients simultaneously. The interview revealed Patients #11, #12, and #17 were previously in another area of the treatment area where susceptible patients received HD treatment and that she did not think about them being moved to stations #18 and #20, diagonally across from the isolation room. Interview revealed patients assigned directly across from the isolation room are all hepatitis B positive patients. Interview on 12/04/2024 at 1618 with the medical director revealed that he was concerned that the susceptible patients to HBV received treatment by staff that concurrently provided care for isolated patients who were HBsAg positive. The interview revealed, “Hepatitis is such a bear. We need to follow those [policy] guidelines.” The interview revealed the facility needed to look at the system problem and remedy it as quickly as possible.”

“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: 35306 Based on observation, policy review, North Carolina Board of Nursing’s “DIALYSIS IN THE ACUTE CARE, COMMUNITY CENTERS, AND HOME SETTINGS POSITION STATEMENT for RN and LPN Practice” review, medical record reviews, and staff interview, the facility’s Registered Nurse (RN) failed to perform a patient’s pre-dialysis treatment assessment prior to start of treatment for 6 of 6 sampled in-center hemodialysis patient medical records (Patients #1, #2, #3, #4, #5, and #6). Findings included: Observation on 12/04/2024 at 1030 revealed hemodialysis treatment was initiated for Patient #12 at 1026 at Station #15. The pre-treatment nursing assessment was performed by RN #1 at 1030, 4 minutes after initiation of hemodialysis treatment. Observation on 12/04/2024 at 1042 revealed hemodialysis treatment was initiated for Patient #19 at 1208 at Station #10. The pre-treatment nursing assessment was performed by RN #1 at 1213, 5 minutes after initiation of hemodialysis treatment. Review on 12/04/2024 of the policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT”, Policy: 1-03-08, Revision Date: April 2024, revealed, “PRE-TREATMENT DATA COLLECTION/ASSESSMENT ... 4. ... If an abnormal findings is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. ... INTRADIALYTIC DATA COLLECTION/ASSESSMENT 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law. ...” Review on 12/04/2024 of the North Carolina Board of Nursing’s “DIALYSIS IN THE ACUTE CARE, COMMUNITY CENTERS, AND HOME SETTINGS POSITION STATEMENT for RN and LPN Practice”, revised: 09/2021, revealed “... RN Role in Dialysis: ...3. Client assessment prior to initiation of dialysis and prior to client’s discharge from facility. ...” 1. Medical record review on 12/03/2024 for Patient #1 revealed the patient was admitted to the facility on 10/29/2024 for ICHD treatments. Review of a “Treatment Details Report” dated 11/21/2024 revealed the patient received HD treatment from 1059-1332 for 2 hours and 33 minutes. A pre-dialysis assessment was performed by Registered Nurse (RN) #4 at 1224 (2 hours and 33 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/23/2024 revealed the patient received HD treatment from 0754-1155 for 4 hours and 01 minutes. A pre-dialysis assessment was performed by RN #2 at 0809 (3 hours and 43 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/26/2024 revealed the patient received HD treatment from 0903-1309 for 4 hours and 06 minutes. A pre-dialysis assessment was performed by RN #1 at 1136 (2 hours and 33 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/28/2024 revealed the patient received HD treatment from 0555-0855 for 3 hours. A pre-dialysis assessment was performed by RN #3 at 0612 (17 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/30/2024 revealed the patient received HD treatment from 0939-1344 for 4 hours and 05 minutes. A pre-dialysis assessment was performed by RN #6 at 1013 (17 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Interview on 12/04/2024 at 1348 with the Facility Administrator (FA) revealed pre-dialysis nursing assessments should be done prior to initiation of HD treatments, “but it sounds like they are not being done until afterward.” Interview revealed, “This is an opportunity for us going forward.” Interview on 12/04/2024 at 1502 with the Clinical Coordinator (CC) revealed the staff have a 30-minute window between patients to get treatments set-up and initiated. “We are horrible at getting it (the pre-dialysis nursing assessment) done and into the system within that 30-minute window but should do a late entry if it’s done prior to initiation of dialysis.” Interview revealed after sharing observations of pre-dialysis assessments being performed after initiation of HD, the CC stated, “Teaching has to be done to get everyone on board. I am not familiar with North Carolina nursing requirements and was not aware until today (that nursing assessments had to be performed prior to initiation of HD per NCBON) but we will get this resolved as soon as possible.” Interview on 12/04/2024 at 1618 with the Medical Director (MD) revealed after sharing the NCBON requirements for the RN’s role in dialysis and review of the facility’s PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT policy requirements, “Pre-treatment assessments should be done before treatments are actually initiated based on the information provided. It sounds like an opportunity for [Organization name], as a whole, to review the policy given the NC Board requirements, to add that verbiage to our policy. We will add that to our next Governing Body to ensure that it is addressed and communicated to our nurses.” 2. Medical record review on 12/03/2024 for Patient #2 revealed the patient was admitted to the facility on 02/04/2022 for ICHD treatments. Review of a “Treatment Details Report” dated 11/29/2024 revealed the patient received HD treatment from 1018-1412 for 3 hours and 54 minutes. A pre-dialysis assessment was performed by RN #4 at 1401 (3 hours and 43 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Interview on 12/04/2024 at 1348 with the FA revealed pre-dialysis nursing assessments should be done prior to initiation of HD treatments, “but it sounds like they are not being done until afterward.” Interview revealed, “This is an opportunity for us going forward.” Interview on 12/04/2024 at 1502 with the CC revealed the staff have a 30-minute window between patients to get treatments set-up and initiated. “We are horrible at getting it (the pre-dialysis nursing assessment) done and into the system within that 30-minute window but should do a late entry if it’s done prior to initiation of dialysis.” Interview revealed after sharing observations of pre-dialysis assessments being performed after initiation of HD, the CC stated, “Teaching has to be done to get everyone on board. I am not familiar with North Carolina nursing requirements and was not aware until today (that nursing assessments had to be performed prior to initiation of HD per NCBON) but we will get this resolved as soon as possible.” Interview on 12/04/2024 at 1618 with the MD revealed after sharing the NCBON requirements for the RN’s role in dialysis and review of the facility’s PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT policy requirements, “Pre-treatment assessments should be done before treatments are actually initiated based on the information provided. It sounds like an opportunity for [Organization name], as a whole, to review the policy given the NC Board requirements, to add that verbiage to our policy. We will add that to our next Governing Body to ensure that it is addressed and communicated to our nurses.” 3. Medical record review on 12/03/2024 for Patient #3 revealed the patient was admitted to the facility on 10/10/2022 for ICHD treatments. Review of a “Treatment Details Report” dated 11/18/2024 revealed the patient received HD treatment from 0725-1115 for 3 hours and 50 minutes. A pre-dialysis assessment was performed by RN #1 at 0740 (15 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/22/2024 revealed the patient received HD treatment from 0724-1052 for 3 hours and 28 minutes. A pre-dialysis assessment was performed by RN #2 at 0824 (1 hour after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/27/2024 revealed the patient received HD treatment from 0657-1045 for 3 hours and 45 minutes. A pre-dialysis assessment was performed by RN #1 at 0732 (35 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Interview on 12/04/2024 at 1348 with the FA revealed pre-dialysis nursing assessments should be done prior to initiation of HD treatments, “but it sounds they are not being done until afterward.” Interview revealed, “This is an opportunity for us going forward.” Interview on 12/04/2024 at 1502 with the CC revealed the staff have a 30-minute window between patients to get treatments set-up and initiated. “We are horrible at getting it (the pre-dialysis nursing assessment) done and into the system within that 30-minute window but should do a late entry if it’s done prior to initiation of dialysis.” Interview revealed after sharing observations of pre-dialysis assessments being performed after initiation of HD, the CC stated, “Teaching has to be done to get everyone on board. I am not familiar with North Carolina nursing requirements and was not aware until today (that nursing assessments had to be performed prior to initiation of HD per NCBON) but we will get this resolved as soon as possible.” Interview on 12/04/2024 at 1618 with the MD revealed after sharing the NCBON requirements for the RN’s role in dialysis and review of the facility’s PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT policy requirements, “Pre-treatment assessments should be done before treatments are actually initiated based on the information provided. It sounds like an opportunity for [Organization name], as a whole, to review the policy given the NC Board requirements, to add that verbiage to our policy. We will add that to our next Governing Body to ensure that it is addressed and communicated to our nurses.” 4. Medical record review on 12/03/2024 for Patient #4 revealed the patient was admitted to the facility on 06/09/2015 for ICHD treatments. Review of a “Treatment Details Report” dated 11/18/2024 revealed the patient received HD treatment from 0629-1031 for 4 hours and 2 minutes. A pre-dialysis assessment was performed by RN #1 at 0641 (12 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/20/2024 revealed the patient received HD treatment from 0619-1019 for 4 hours. A pre-dialysis assessment was performed by RN #3 at 0623 (4 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/22/2024 revealed the patient received HD treatment from 0626-1036 for 4 hours and 10 minutes. A pre-dialysis assessment was performed by RN #2 at 0653 (27 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/25/2024 revealed the patient received HD treatment from 0629-1026 for 3 hours and 57 minutes. A pre-dialysis assessment was performed by RN #2 at 0645 (16 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/27/2024 revealed the patient received HD treatment from 0644-1052 for 4 hours and 8 minutes. A pre-dialysis assessment was performed by RN #1 at 0735 (51 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/29/2024 revealed the patient received HD treatment from 0635-1040 for 4 hours and 5 minutes. A pre-dialysis assessment was performed by RN #1 at 0743 (1 hour and 8 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Interview on 12/04/2024 at 1348 with the FA revealed pre-dialysis nursing assessments should be done prior to initiation of HD treatments, “but it sounds like they are not being done until afterward.” Interview revealed, “This is an opportunity for us going forward.” Interview on 12/04/2024 at 1502 with the CC revealed the staff have a 30-minute window between patients to get treatments set-up and initiated. “We are horrible at getting it (the pre-dialysis nursing assessment) done and into the system within that 30-minute window but should do a late entry if it’s done prior to initiation of dialysis.” Interview revealed after sharing observations of pre-dialysis assessments being performed after initiation of HD, the CC stated, “Teaching has to be done to get everyone on board. I am not familiar with North Carolina nursing requirements and was not aware until today (that nursing assessments had to be performed prior to initiation of HD per NCBON) but we will get this resolved as soon as possible.” Interview on 12/04/2024 at 1618 with the MD revealed after sharing the NCBON requirements for the RN’s role in dialysis and review of the facility’s PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT policy requirements, “Pre-treatment assessments should be done before treatments are actually initiated based on the information provided. It sounds like an opportunity for [Organization name], as a whole, to review the policy given the NC Board requirements, to add that verbiage to our policy. We will add that to our next Governing Body to ensure that it is addressed and communicated to our nurses.” 5. Medical record review on 12/03/2024 for Patient #5 revealed the patient was admitted to the facility on 11/17/2020 for ICHD treatments. Review of a “Treatment Details Report” dated 11/04/2024 revealed the patient received HD treatment from 0624-0929 for 4 hours and 5 minutes. A pre-dialysis assessment was performed by RN #2 at 0636 (12 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/06/2024 revealed the patient received HD treatment from 0614-0818 for 2 hours and 4 minutes. A pre-dialysis assessment was performed by RN #2 at 0651(37 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/08/2024 revealed the patient received HD treatment from 0622-0926 for 3 hours and 4 minutes. A pre-dialysis assessment was performed by RN #3 at 0641 (19 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/11/2024 revealed the patient received HD treatment from 0612-0814 for 2 hours and 2 minutes. A pre-dialysis assessment was performed by RN #3 at 0632 (20 minutes after treatment start by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/22/2024 revealed the patient received HD treatment from 0615-0836 for 2 hours and 21 minutes. A pre-dialysis assessment was performed by RN #2 at 0720 (1 hour and 5 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Interview on 12/04/2024 at 1348 with the FA revealed pre-dialysis nursing assessments should be done prior to initiation of HD treatments, “but it sounds like they are not being done until afterward.” Interview revealed, “This is an opportunity for us going forward.” Interview on 12/04/2024 at 1502 with the CC revealed the staff have a 30-minute window between patients to get treatments set-up and initiated. “We are horrible at getting it (the pre-dialysis nursing assessment) done and into the system within that 30-minute window but should do a late entry if it’s done prior to initiation of dialysis.” Interview revealed after sharing observations of pre-dialysis assessments being performed after initiation of HD, the CC stated, “Teaching has to be done to get everyone on board. I am not familiar with North Carolina nursing requirements and was not aware until today (that nursing assessments had to be performed prior to initiation of HD per NCBON) but we will get this resolved as soon as possible.” Interview on 12/04/2024 at 1618 with the MD revealed after sharing the NCBON requirements for the RN’s role in dialysis and review of the facility’s PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT policy requirements, “Pre-treatment assessments should be done before treatments are actually initiated based on the information provided. It sounds like an opportunity for [Organization name], as a whole, to review the policy given the NC Board requirements, to add that verbiage to our policy. We will add that to our next Governing Body to ensure that it is addressed and communicated to our nurses.” 6. Medical record review on 12/03/2024 for Patient #6 revealed the patient was admitted to the facility on 02/15/2024 for ICHD treatments. Review of a “Treatment Details Report” dated 11/18/2024 revealed the patient received HD treatment from 0637-1110 for 4 hours and 33 minutes. A pre-dialysis assessment was performed by RN #4 at 0723 (46 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Review of a “Treatment Details Report” dated 11/25/2024 revealed the patient received HD treatment from 0633-1048 for 4 hours and 15 minutes. A pre-dialysis assessment was performed by RN #4 at 0647 (14 minutes after treatment was started by a PCT). Review failed to reveal any available documentation indicating the pre-treatment dialysis assessment was performed by the RN prior to treatment start by the PCT. Interview on 12/04/2024 at 1348 with the FA revealed pre-dialysis nursing assessments should be done prior to initiation of HD treatments, “but it sounds like they are not being done until afterward.” Interview revealed, “This is an opportunity for us going forward.” Interview on 12/04/2024 at 1502 with the CC revealed the staff have a 30-minute window between patients to get treatments set-up and initiated. “We are horrible at getting it (the pre-dialysis nursing assessment) done and into the system within that 30-minute window but should do a late entry if it’s done prior to initiation of dialysis.” Interview revealed after sharing observations of pre-dialysis assessments being performed after initiation of HD, the CC stated, “Teaching has to be done to get everyone on board. I am not familiar with North Carolina nursing requirements and was not aware until today (that nursing assessments had to be performed prior to initiation of HD per NCBON) but we will get this resolved as soon as possible.” Interview on 12/04/2024 at 1618 with the MD revealed after sharing the NCBON requirements for the RN’s role in dialysis and review of the facility’s PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT policy requirements, “Pre-treatment assessments should be done before treatments are actually initiated based on the information provided. It sounds like an opportunity for [Organization name], as a whole, to review the policy given the NC Board requirements, to add that verbiage to our policy. We will add that to our next Governing Body to ensure that it is addressed and communicated to our nurses.” NC00201471”