Davita Catawba County Dialysis

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 35306 Based on policy and procedure review, medical record reviews and staff interviews the facility staff failed to include an evaluation of the current health status and medical condition in the patient’s comprehensive assessment in 1 of 10 sampled records (Patient #5) and failed to complete a comprehensive medical History and Physical (H&P) for 4 of 10 sampled records (Patient #2, #9, #4, and #8). Findings included: 1. Review on 02/16/2024 of the facility’s policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” Revision Date: July 2023, revealed, “... 3. Assessment criteria will include, but not be limited to, evaluation of: Current health status and medical condition, including co-morbid conditions...” Medical record review on 02/16/2024 for Patient #5 revealed a 43-year-old-male was admitted to the facility on 05/13/2022 for ICHD. Review of the initial comprehensive assessment completed on 02/12/2024 failed to reveal a documented evaluation of the current health status and medical condition, including co-morbid conditions per facility policy. Interview on 02/16/2024 at 1220 with the facility’s Medical Director (MD) revealed that the comprehensive assessment should include evaluation of the patient’s current health status and medical condition, including co-morbid conditions. Interview on 02/16/2024 at 1645 with the Manager of Clinical Services (MCS) during review of Patient #5’s initial comprehensive assessment on 02/12/2024, confirmed there was no documented evaluation of Patient #5’s health status and medical condition, including co-morbid conditions. The interview revealed the comprehensive assessment did not meet facility policy requirements. 2. Review on 02/16/2024 of the facility’s policy titled, “History and Physical (H&P) Policy” Revision Date: October 2021, revealed “1. Within 30 days of admission, a comprehensive medical history and physical that addresses the patient’s current presentation and health status, including the patient’s medical condition related to his or her renal disease, will be obtained for all new admissions. 2. An H&P from another provider may be designated as the admission history and physical if it was completed within the last year of patient admission and is reviewed, signed, and dated by the attending nephrologist including a brief note that he/she agrees with statements in the H&P. 3. H&Ps will be filed in the medical record.” a. Medical record review on 02/16/2024 for Patient #2 revealed a 38-year-old-female was admitted to the facility on 08/24/2023 for ICHD and subsequently admitted to the facility’s HHD program on 11/13/2023. Review of the “Nephrology Progress Note” dated 08/21/2023 from an outside hospital revealed the patient was admitted for COVID-19, diarrhea, and dehydration on 08/16/2023. Review of the Nephrology Progress Note failed to reveal documentation indicating the note was reviewed by the attending nephrologist. Further review of the medical record revealed that there was no H&P on file for the patient. Interview on 02/16/2024 at 1220 with the facility’s MD revealed that an H&P should be maintained on the patient’s medical record. Interview revealed that the Home Training Program FA had informed the MD that a H&P was not found in Patient #2’s medical record and that “one will be completed as soon as possible. It was an oversight on my part and I accept full responsibility.” Interview confirmed that the facility nephrologist failed complete a H&P within 30 days of admission for Patient #2 per policy. Interview on 02/16/2024 at 1630 with the Home Training Program Facility Administrator (FA) confirmed there was no documented H&P in Patient #2’s medical record. The interview revealed the facility policy requires completion of an H&P within 30 days of admission. b. Medical record review on 02/15/2024 for Patient #9 revealed 72-year-old-male was admitted to the facility’s Home Training Peritoneal Dialysis (PD) program on 02/15/2021. Record review failed to reveal an H&P in the patient’s medical record for review. Interview on 02/16/2024 at 1630 with the facility’s Home Training Program Facility Administrator (FA) revealed that she was unable to find an H&P for Patient #9 filed in the medical record. Interview on 02/16/2024 at 1220 with the facility’s MD revealed that a H&P should be maintained on the patient’s medical record and that in review of the available documentation, one was not present on Patient #9’s chart. Interview revealed that an H&P from an outside provider is acceptable; however, the MD stated that the information should be reviewed, signed, and dated by the attending nephrologist, along with notation of agreement and/or updates to the H&P. 49003 c. Medical record review on 02/16/2024 for Patient #4 revealed a 75-year-old-female was admitted to the facility on 07/10/2020 for ICHD. Record review revealed Patient #4 was admitted at a local hospital from 01/13/2024 through 01/17/2024 for pneumonia and again from 01/20/2024 through 01/27/2024 for respiratory issues. On 01/30/2024, Patient #4 received a Lifevest (vest to perform electrical shocks to a patient when in a lethal heart rhythm is detected) and resumed ICHD at the facility. Review of hospital notes failed to reveal documentation indicating that the outside provider notes, including the patient’s current health status and medical condition, were reviewed by the attending nephrologist. Further review revealed that there was no H&P on file for the patient. Interview on 02/16/2024 at 1220 with the facility’s MD revealed that History and Physical’s (H&P) from an outside provider should be reviewed, signed, and dated by the attending nephrologist, along with notation of agreement and/or updates to the H&P. The facility’s MD stated that it was an oversight and accepted full responsibility. d. Medical record review on 02/16/2024 for Patient #8 revealed a 52-year-old-female was admitted to the facility on 03/09/2020 for ICHD. Review of the chart revealed that there was no H&P recognized or signed off by the attending nephrologist within the last year of treatment. Interview on 02/16/2024 at 1220 with the facility’s MD revealed that an updated H&P should be completed by either the attending nephrologist or Patient #8’s Primary Care Physician and should be maintained in the patient’s medical record. Interview revealed that an H&P from an outside provider is acceptable; however, the MD stated that the information should be reviewed, signed, and dated by the attending nephrologist, along with notation of agreement and/or updates to the H&P. Interview revealed, the facility’s MD stated that it was an oversight and accepted full responsibility.”

“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: 35306 Based on facility policy review, medical record review, and staff interview, the facility staff failed to follow the established notification and assessment guidelines and standing prn Clonidine orders for ICHD patients with elevated blood pressures for 2 of 2 sampled records (Patient #5 and #6). Findings included: Review on 02/15/2024 of the facility’s policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” Revision Date: October 2023, revealed “...1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes ... ii. Measurement of Blood Pressure (BP) ... 2. The Nursing assessment will be performed and documented by a licensed nurse ... a. The assessment includes the following components: i. ... data collection ... v. Review of documentation for accuracy, completion, and patient data ... PRE-TRETMENT DATA COLLECTION/ASSESSMENT 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre, intra, or post treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). INTRADIALYTIC DATA COLLECTION /ASSESSMENT ... 11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record. POST TREATMENT DATA COLLECTION/ASSESSMENT 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings. 16. If abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse ... ABNORMAL FINDINGS Unless other abnormal parameters are established by the facility Governing Body ....the following are considered abnormal findings and should be reported to the licensed nurse whenever there is concern for the patient’s condition ... Blood pressure: Pre-dialysis: *Systolic greater than 180 ... or less than 90 * Diastolic greater than or equal to 100 ... Blood Pressure-Intradialytic: * Difference of 20 .... increase or decrease from patient’s last intradialytic treatment BP reading ... Blood Pressure Post Treatment: ... Standing systolic BP greater than 140 .... or less than 90 * Standing diastolic BP greater than 90 .... or less than 50 ... Sitting systolic BP greater than 140 .... or less than 90 ... Sitting diastolic BP greater than 90 .... or less than 50 ...” Review on 02/15/2024 of the “Facility Hemodialysis Standing Orders” Dated 2021, revealed, “ ... 36. HYPERTENSION: Clonidine 0.1MG [milligram] systolic blood pressure > [greater than] 180. Re-adjust blood pressure cuff and retake blood pressure to ensure accuracy prior to administering medication. May repeat x1 ...” 1. Medical record review on 02/16/2024 for Patient #5 revealed the patient was admitted to the facility on 05/13/2022 for ICHD treatment. Review of the “Patient Summary Report” for Patient #5 revealed a physician’s order with a start date of 04/25/2023 for Clonidine 0.1 mg [milligram] every 4 hours as needed. Review of the treatment flowsheet dated 01/29/2023 revealed the treatment started at 1101 and ended at 1501 for a duration of 240 minutes. Review of the treatment flowsheet revealed Patient #5’s blood pressures were as follows: BP of 156/91 at 1241, BP of 161/109 at 1301 (20 minutes later), BP of 175/112 at 1321 (20 minutes later), BP of 166/107 at 1322 (1 minute later), BP of 170/102 at 1341 (19 minutes later), and BP of 175/203 at 1401(20 minutes later). Further review of the treatment flowsheet revealed post-treatment BPs of 182/104 Standing and 175/102 Sitting at 1502. The review revealed no documentation of nursing notification by the patient care staff of the elevated blood pressures. Review of the post-treatment nursing assessment at 1556 (54 minutes post-treatment vital signs) revealed no documentation related to Patient #5’s intra- or post-dialytic hypertension, administration of Clonidine per physician orders, or notation indicating why prn Clonidine was not administered. Review of the treatment flowsheet dated 01/31/2024 revealed the treatment started at 1030 and ended at 1432 for a duration of 242 minutes. Review of the treatment flowsheet revealed Patient #5’s blood pressures were as follows: BP of 166/98 at 1222, BP of 182/100 at 1242 (20 minutes later), and 169/94 at 1302 (20 minutes later). BP of 161/94 at 1342, BP of 179/103 at 1402 (20 minutes later), BP of 167/102 at 1422 (20 minutes later), BP of 172/102 at 1432 (10 minutes later). Further review of the treatment flowsheet revealed post-treatment BPs of 183/105 Standing and 182/116 Sitting at 1433. The review revealed no documentation of nursing notification by the patient care staff of the elevated blood pressures. Review of the post-treatment nursing assessment at 1450 (18 minutes post-treatment vital signs) revealed no documentation related to Patient #5’s intra- or post-dialytic hypertension, administration of Clonidine per physician orders, or notation indicating why prn Clonidine was not administered. Review of the treatment flowsheet dated 02/02/2024 revealed the treatment started at 1033 and ended at 1432 for a duration of 239 minutes. Review of the treatment flowsheet revealed Patient #5’s blood pressures were as follows: BP of 173/102 at 1034, BP of 166/104 at 1041 (7 minutes later), and BP of 148/92 at 1101 (20 minutes later). BP of 160/91 at 1241, BP of 163/104 at 1301 (20 minutes later). BP of 172/89 at 1421 and BP of 175/100 at 1432 (1 minute later). Further review of the treatment flowsheet revealed post-treatment BPs of 180/104 Standing and 185/105 Sitting. The review revealed no documentation of nursing notification by the patient care staff of the elevated blood pressures. Review of the post-treatment nursing assessment at 1459 (27 minutes post-treatment vital signs) revealed no documentation related to Patient #5’s intra- or post-dialytic hypertension, administration of Clonidine per physician orders, or notation indicating why prn Clonidine was not administered. Interview on 02/16/2024 at 1220 with the Medical Director (MD) revealed, “We have to be careful and judicious [{exercise good judgment}] when treating known hypertensive patients on dialysis]. My expectation would be for the PCT [patient care technician] to tell the nurse, ‘Do you think we need to try prn Clonidine.’ At some point, [continued blood pressure control issues] the issue should be escalated to me so that changes to medications can be considered and not just use prn Clonidine [on an ongoing basis for control]. I will review his [Patient #5] blood pressures and it sounds like I may need to adjust his medications.” Interview revealed the MD expected facility staff to follow physician orders and to document justification for any deviations from the prescribed treatment regimen. Interview revealed the MD was not aware of Patient #5’s ongoing hypertension issues pre, intra, and post-dialysis treatments. Interview on 02/16/2024 at 1438 with the Register Nurse (RN) who cared for Patient #5 on 01/31/2024 and 02/02/2024 (RN #1) revealed, “He [Patient #5] probably told me that he would take his blood pressure medicine when he got home.” Interview revealed the Electronic Health Record (EHR) “flags [the nurse] for high blood pressure, we put it in the rounding folder for review [by the provider] and consideration of medication changes, if needed.” Interview on 02/16/2024 at 1450 with the Assistant Facility Administrator (AFA) revealed the RN who cared for Patient #5 on 01/29/2024 was not available for interview. Interview revealed, “There should be a documented nursing assessment of the patient’s vital signs, if abnormal during treatment in the post-treatment nursing assessment at a minimum.” Interview on 02/16/2024 at 1510 with the MCS revealed the staff were expected to monitor the patients and notify the nurses of any abnormal findings such as elevated blood pressures. Interview revealed the staff failed to notify the nurses of abnormal values per policy. 39307 2. Medical record review on 02/14/2024 for Patient #6 revealed the patient was admitted to the facility on 08/01/2023 for ICHD treatment. Review of the treatment flowsheet dated 02/01/2024 revealed pre-treatment blood pressure of 168/109 at 1136, the treatment started at 1200 and ended at 1535 for a duration of 212 minutes. Review of the treatment flowsheet revealed Patient #6’s blood pressures were as follows: at 1200 BP of 159/105 and at 1201 BP of 152/107 (1 minute after the start of dialysis. Further review revealed at 1224 BP of 164/111 and at 1241 BP of 205/139 and at 1249 BP of 183/113 with a note by the Patient Care Technician (PCT) stating “RN aware” (with no intervention documented) and at 1304 BP of 170/112. Further review revealed at 1441 BP of 144/102 and at 1501 BP of 161/104 and at 1534 BP of 171/117 and at 1535 BP of 164/116. Review revealed post-treatment BP of 183/117, noted “ ...BP elevated, pt takes BP medications after tx. Review of the treatment flowsheet dated 02/03/2024 revealed the treatment started at 0923 and ended at 1259 for a duration of 212 minutes with a pre-treatment blood pressure of 159/108 noted at 0910. Further review of the treatment flowsheet revealed Patient #6’s blood pressures were as follows: at 0923 BP of 159/109 and at 0945 BP of 138/101 and at 1004 BP of 140/102 without noted documentation of notification to the licensed RN or intervention for the elevated BP. Post-treatment nursing assessment revealed documentation of “Tolerated tx with no issues. DC home” Review of the treatment flowsheet dated 02/07/2024, the treatment started at 1214 and ended at 1545 for a duration of 203 minutes with a pre-treatment BP of 172/119 at 1152. Review of the treatment flowsheet revealed Patient #6’s blood pressures were as follows: at 1214 BP of 180/120 with “RN notified” documented by the PCT, and at 1225 BP of 178/106, and at 1245 BP of 191/122, and at 1305 BP of 177/119 ,and at 1325 BP of 167/114, and at 1345 BP of 153/105, and at 1405 BP of 166/113, and at 1425 BP of 181/118 with “RN notified” documented by the PCT, and at 1445 BP of 168/114, and at 1505 BP of 168/114, and at 1524 BP of 163/110, and at 1545 BP 181/119 without noted documentation of intervention for the elevated BP by the RN. Review revealed post-treatment BP of 174/118. Review of the treatment flowsheet dated 02/09/2024 revealed the treatment started at 1215 and ended at 1552 for a duration of 211 minutes, with a pre-treatment BP of 165/112 at 1206. Review of the treatment flowsheet revealed Patient #6’s blood pressures were as follows: at 1220 BP of 179/121 and at 1224 BP of 176/117 and at 1244 BP of 164/109 without noted documentation of notification to the licensed RN or intervention for the elevated BP. Interview on 02/16/2024 at 1000 with the Facility Administrator (FA) from a sister facility assisting during the survey revealed Patient #6 should have had the RN provide the ordered Clonidine 0.1 mg orally administered as per physician order. Interview on 02/16/2024 at 1400 with the facility Registered Nurse revealed Patient #6 had a physician order on 10/23/2023 for Clonidine 0.1mg prn (as needed) medication available for administration for elevated blood pressure. Interview revealed RN had communicated in the past to the ordering MD Patient #6 had refused his prn medication. RN stated the facility MD had informed RN, as long as Patient #6 was asymptomatic, it should be communicated to Patient #6 to take his medications when he returned home. Interview on 02/16/2024 at 1220 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the patient had elevated blood pressure, there should be documentation available supporting the deviation from the administration of the PRN protocol.”

“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: 39307 Based on policy review, medical record review and staff interview, the facility’s patient care staff failed to dialyze a hemodialysis patient according to a physician ordered dialysis prescription for 3 of 10 records sampled (Patient #3, #6, and #7) Findings included: Review on 02/14/2024 of the facility’s policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” Revision Date: October 2023, revealed “ ...POLICY ...3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along. Prescription components include...f. Blood flow rate ... INTRADIALYTIC DATA COLLECTION/ASSESSMENT ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed...” 1. Medical record review on 02/14/2024 for Patient #3 revealed the patient was admitted to the facility on 12/08/2023 for ICHD treatment. Review of treatment flowsheet created on 01/22/2024 with physician signature on 01/23/2024 revealed the prescription was for BFR of “400” ordered by the physician. Review of the treatment flowsheet 02/01/2024 revealed Patient #3 dialyzed from 0629 - 0959 with a documented BFR of 350 (50 less than the prescribed rate) with a documented “NURSE PRESCRIPTION VERIFICATION” stating, “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” by the RN at 0632. Review revealed at 0632 the RN documented verification of the prescription for dialysis treatment. Review of treatment flowsheet on 02/06/2024 revealed Patient #3 dialyzed from 0631-1000 with a documented BFR of 350 (50 less than the prescribed rate) with a documented “NURSE PRESCRIPTION VERIFICATION” stating, “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” by the RN at 0634. The review in the clinical record revealed no documented complications or issues for the reason the facility staff did not dialyze the patient at the ordered BFR. No physician order was found in the medical record to indicate the patient’s physician was aware of the BFR changes. Interview on 02/16/2024 at 1000 with the Facility Administrator (FA) from a sister facility assisting during the survey revealed the RN staff were expected to document the reason the dialysis was not provided as the written prescription and notification to the Medical Provider. Interview on 02/16/2024 at 1220 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the patient was unable to reach the prescribed BFR, there should be documentation available supporting the need to deviate from the patient’s prescription. 2. Medical record review on 02/14/2024 for Patient #6 revealed the patient was admitted to the facility on 08/01/2023 for ICHD treatment. Review of the treatment flowsheet on 01/29/2024 revealed the prescription was for BFR of “400” ordered by the physician. Review revealed that the dialysis treatment started at 1223 with BFR 300, then at 1304 BFR of 350 through 1601 and treatment ended at 1614 with BFR 250. Review revealed at 1239 the RN documented verification of the prescription for dialysis treatment. Interview on 02/16/2024 at 1000 with the FA from a sister facility assisting during the survey revealed review of Patient #3, Patient #6 and Patient #7 should have had each patient’s BFR at the prescribed BFR as per physician orders. Interview on 02/16/2024 at 1220 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the patient was unable to reach the prescribed BFR, there should be documentation available supporting the need to deviate from the patient’s prescription. 3. Medical record review on 02/14/2024 for Patient #7 revealed the patient was admitted to the facility on 04/04/2023 for ICHD treatment. Review of the treatment flowsheet on 02/10/2024 revealed the prescription was for BFR of “350” ordered by the physician. Review revealed that the dialysis treatment started at 0804 with BFR 350 then at 1005 BFR dropped to 320 and at 1006 BFR dropped to 300 with notation of “BFR dropped to 300 due to AP. At 1021 RN noted recheck b/p 55/43 and BFR 300, at 1024 RN noted b/p improved, patient denies any distress, continue to monitor 114/37 BFR remained at 300 through 1134 when treatment ended. Review revealed at 0914 the RN documented verification of the prescription for dialysis treatment. Interview on 02/16/2024 at 1000 with the FA from a sister facility assisting during the survey revealed review of Patient #3, Patient #6 and Patient #7 should have had each patient’s BFR at the prescribed BFR as per physician orders. Interview on 02/16/2024 at 1220 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the patient was unable to reach the prescribed BFR, there should be documentation available supporting the need to deviate from the patient’s prescription.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 39307 Based on policy review, medical record review and staff interview, the facility’s medical director failed to assure facility policy and procedures were adhered to by the facility’s patient care staff failing to dialyze ICHD patients with the prescribed machine temperatures in 3 of 6 sampled records (Patient #3, #6 and #5). Findings included: Review on 02/14/2024 of the facility’s policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” Revision Date: October 2023, revealed “ ...INTRADIALYTIC DATA COLLECTION/ASSESSMENT ... 2. The Nursing assessment ... a. The assessment includes the following components ... iii. Verification of prescription including machine parameters ... 3. Patient identity. Prescription and machine settings are verified by teammate prior to initiation of treatment ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment ... Prescription components include by are not necessarily limited to ...i. Correct dialysate composition ...and settings ...” 1. Medical record review on 02/14/2024 for Patient #3 revealed the patient was admitted to the facility on 12/08/2023 for ICHD treatment. Review of treatment flowsheet on 01/30/2024 the Dialysate temperature prescribed was 37.0 degrees Celsius, Machine Temperature was 36.0. Review of the treatment flowsheet on 02/06/2024 the Dialysate temperature prescribed was 37.0 degrees Celsius, Machine Temperature was 35.1. Review of the treatment flowsheet on 02/10/2024 the Dialysate temperature prescribed was 37.0 degrees Celsius, Machine Temperature was 36.0. Interview on 02/16/2024 at 1000 with the Facility Administrator (FA) from a sister facility assisting during the survey revealed review of Patient #3 and Patient #6 treatment flowsheets, the staff should have waited for the Machine temperature to reach the prescribed temperature prior to the initiation of the dialysis treatment. Interview on 02/16/2024 at 1220 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the staff were unable to meet the prescribed temperature for the Machine temperature, there should be documentation available supporting the need to deviate from the patient’s prescription. 2. Medical record review on 02/14/2024 for Patient #6 revealed the patient was admitted to the facility on 08/01/2023 for ICHD treatment. Review of the treatment flowsheet on 02/05/2024 the Dialysate temperature prescribed was 37.0 degrees Celsius, Machine Temperature was 36.0. Interview on 02/16/2024 at 1000 with the Facility Administrator (FA) from a sister facility assisting during the survey revealed review of Patient #3 and Patient #6 treatment flowsheets, the staff should have waited for the Machine temperature to reach the prescribed temperature prior to the initiation of the dialysis treatment. Interview on 02/16/2024 at 1220 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the staff were unable to meet the prescribed temperature for the Machine temperature, there should be documentation available supporting the need to deviate from the patient’s prescription. 35306 3. Medical record review on 02/16/2024 for Patient #5 revealed the patient was admitted to the facility on 05/13/2022 for ICHD treatment. The review of the patient’s dialysis prescription dated 12/27/2023 revealed the patient had a Machine Temperature of “36.0” degrees Celsius ordered by the physician. Review of treatment flowsheets from 01/29/2024 to 02/09/2024 revealed the facility patient care staff documented the machine temperature as “36.7” (0.7 degrees higher than the prescribed temperature) on 02/05/2024 and “37.1” (1.1 degrees higher than the prescribed temperature) with “NURSE PRESCRIPTION VERIFICATION” documented by the RN stating, “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” The review in the clinical record revealed no documented complications or issues for the reason the facility staff did not set the machine up with the prescribed machine temperature. No physician order was found in the medical record to indicate the patient’s physician was aware of the machine temperature changes. Interview on 02/16/2024 at 1220 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the staff were unable to meet the prescribed temperature for the Machine temperature, there should be documentation available supporting the need to deviate from the patient’s prescription. Interview on 02/16/2024 at 1450 with the Assistant Facility Administrator (AFA) revealed patient care staff’s entry of incorrect machine temperatures in the Electronic Health Record (EHR) was a “new opportunity” for the facility. Interview revealed education would be provided to all staff regarding the need to allow the machine time to reach the programmed temperature before documenting in the EHR and the importance of assuring machine settings align with the patient’s prescribed orders.”