Davita Arden Dialysis Center

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 35306 Based on policy review, observations, and staff interview, the facility staff failed to prevent cross-contamination during CVC exit site care in 1 of 1 observations of CVC exit site care (PCT #1, Patient #9). Findings included: Review on 01/24/2024 of facility policy titled, “CENTRAL VENOUS CATHETER (CVC) WITH CLEARGUARD HD ANTIMICROBIAL END CAPS PROCEDURE” (Revision Date: October 2023), revealed “... clean the exit site.... in a “back and forth” pattern, using gentle friction progressing from the insertion site to the periphery using both sides of the swab. Observation on 01/24/2024 at 1210 in the patient treatment area revealed PCT #1 performed CVC exit site care for Patient #9. Observation revealed the PCT used a chlorhexidine (antimicrobial agent) swab in a back-and-forth motion, progressing from the exit site to the peripheral area and moved to the bottom of the exit site. Continued observation revealed the PCT failed to turn the swab over and used the same side of the swab that was used to clean the top of the exit site and peripheral area. Observation revealed the PCT failed to prevent cross-contamination when cleaning the CVC exit site by failing to use both sides of the swab per policy. Interview on 01/24/2024 at 1410 with the MCS revealed the PCT should have turned the swab over and cleaned the exit site with the unused side of the swab. The Ainterview confirmed the observation finding.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 35306 Based on policy review, observation, review of equipment logs and staff interview, the facility failed to ensure preventive maintenance for the eye/face wash station, drench shower and centrifuge was performed according to the facility’s protocol and manufacturer specifications. Findings included: 1. Review on 01/25/2024 of the facility’s policy titled, “EYEWASH STATION/SINK/DRENCH SHOWER/HOSE CHECKS” (Revision Date: October 2019), revealed “... 1. ... Self-contained stations are to be inspected according to the manufacturers’ specification... Annual inspections are documented on the Annual Eyewash and Drench Shower/Hoses Inspection log. Logs are maintained by the facility...” Review on 01/25/2024 of the “Guardian EMERGENCY EYEWASH & SHOWER TECHNOLOGY ANSI [American National Standards Institute (accrediting standards development organization)] / ISEA [International Safety Equipment Association] (establishes minimum performance and use guidelines for eyewash and shower equipment for the emergency treatment of the eyes or body of someone who has been exposed to hazardous materials) Z358.1-2014 Compliance Checklist” provided by the facility Biomedical staff revealed, “... Emergency Showers... Maintenance/Inspection... Inspect all emergency showers annually for compliance with standard... Eye/Face Washes... Maintenance/Inspection... Inspect all eye/face wash units annually for compliance with standard...” Observation on 01/23/2024 at 1300 in the treatment area of the facility revealed one (1) eye/face wash station. Observation on 01/25/2024 at 1044 in the supply storage area revealed one (1) emergency shower. Review of the preventive maintenance (PM) “Work Order Information” on 01/25/2024 revealed the last annual inspection for the “Emergency Wash Station, Eye-Shower” was 07/05/2022. Review of the PM log revealed an annual inspection was not performed in 2023. Interview on 01/25/2024 at 1610 with the facility’s Biomedical Operations Manager (BOM) revealed the annual inspection had been not entered into the facility’s electronic preventive maintenance system [BART] and was missed in 2023. The BOM confirmed there had been no annual inspection for the eye/face wash station or emergency shower since 07/05/2022. Interview on 01/25/2024 at 1645 with the facility’s Medical Director (MD) revealed that closer attention to manufacturer recommendations was indicated and that facility policy should reflect and align with maintenance specifications. Interview confirmed facility policy was not followed. 2. Review on 01/25/2024 of the facility’s contracted service for laboratory equipment policy titled, “Centrifuge Q/A [Questions/Answers] Inspection Policy and procedures V.3.1” revealed, “...8. Check condition of tubes. Replaced as needed per manufacturer PM [Preventive Maintenance] instructions...” Review of the “DaVita Model 755VES Operator’s Manual” revealed, “Care and Preventive Maintenance ... 6. Tube Carrier / Holder Replacement: It is recommended that the tube holders be replaced after 24 months of use...” Observation on 01/23/2024 at 1330 in the designated laboratory area of the facility revealed one (1) “DaVita Model 755VES Centrifuge.” Interview on 01/25/2024 at 1610 with the facility’s BOM and Manager of Clinical Services (MCS), revealed the BPM stated that he was not aware of the manufacturer’s recommendations for replacement of the tube holders after 24 months. Interview revealed the DaVita Model 755VES Centrifuge was installed 07/2020 and that preventive maintenance was performed by an outside, contracted agency. Interview revealed the MCS and BOM both stated the horizon Model 755VES Centrifuge, located in the designated laboratory area, had “most definitely” been used 24 months. The BOM confirmed that the tube holders had not been replaced on the Model 755VES Centrifuge since being purchased in 07/2020. Interview on 01/25/2024 at 1645 with the facility’s Medical Director (MD) revealed that closer attention to manufacturer recommendations was indicated and that facility policy should reflect and align with maintenance specifications. Interview confirmed facility policy was not followed.”

“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 patient care staff failed to notify the nurse of a elevated blood pressures in 2 of 4 sampled records (Patients #1 and #2) and the licensed nurse failed to administer Clonidine per the facility’s Blood Pressure Protocol for 1 of 4 records sampled (Patient #1). Findings included: 1. Review on 01/24/2024 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 ... 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. An assessment by the nurse prior to initiation of dialysis, during dialysis, and/or prior to discharge will be triggered by an abnormal finding. The medical record should indicate the finding, the intervention, physician notification, physician orders, and the patient response... 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) ...Abnormal Findings Job Aid ... INTRADIALYTIC Inform the nurse of any “abnormal findings” per policy or health concerns during dialysis...” a. Medical record review on 01/24/2024 for Patient #1 revealed the patient was admitted to the facility on 11/07/2023 for ICHD treatment. Review of the treatment flowsheet dated 12/19/2023 revealed the treatment started at 1113 and ended at 1420 for a duration of 187 minutes. Review of the treatment flowsheet revealed Patient #1’s blood pressures were as follows: At 1150 BP of 159/125 and 151/103 at 1251 (60 minutes later). Further review of the treatment flowsheet revealed at 1331, a BP of 168/112 and 153/136 at 1420. The review revealed no documentation of nursing notification by the patient care staff of the elevated blood pressures. Interview on 01/24/2024 at 1500 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. b. Medical record review on 01/24/2024 for Patient #2 revealed the patient was admitted to the facility on 11/01/2023 for ICHD treatment. Review of the treatment flowsheet dated 01/11/2024 revealed the treatment started at 1133 and ended at 1507 for a duration of 214 minutes. Review of the treatment flowsheet revealed Patient #2’s blood pressures were as follows: At 1257, a BP of 163/136 and 160/118 at 1357 (60 minutes later), with no documentation of nursing notification by the patient care staff of the elevated blood pressures. Interview on 01/24/2024 at 1500 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. 2. Review on 01/24/2024 of the facility’s Blood Pressure Protocol titled “Patient Assessment and Monitoring” no date, revealed “...HYPERTENSION PROTOCOL SBP >210 AND/OR DBP >110 Pretreatment 1. Initiate treatment and monitor vitals Q30 [every 30] mins. [minutes]. 2. At 60 mins. If over parameters administer clonidine [used to treat high blood pressure] 0.1 mg [milligram] 3. Monitor vitals Q30 mins. 4. At 60 mins after administration of clonidine if over parameters notify MD [doctor] Intradialytic 1. Repeat above starting at #2.” Medical record review on 01/24/2024 for Patient #1 revealed the patient was admitted to the facility on 11/07/2023 for ICHD treatment. Review of the treatment flowsheet dated 11/14/2023 revealed the treatment started at 1203 and ended at 1431 for a duration of 148 minutes. Review of the treatment flowhsheet revealed the licensed nurse noted Patient #1’s blood pressures as follows: At 1307, BP of 178/123 and 176/113 at 1408 (60 minutes later). The review revealed no documentation of administration of Clonidine per facility protocol or notation indicating why prn Clonidine was not administered. Interview on 01/24/2024 at 1500 with the MCS revealed the licensed nurse should have administered Clonidine when the blood pressure was rechecked at 1408 or documented the reason it was not given. Interview revealed the licensed nurse failed to follow the facility’s Hypertension [elevated blood pressure] 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: 35306 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 4 sampled records (Patients #1, #2 and #3). Findings included: Review on 01/24/2024 of the facility policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” (Revision Date: October 2023), revealed “... 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... Prescription components include... f. Blood flow rate ... i. Correct dialysate composition.... and settings... 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 01/24/2024 for Patient #1 revealed the patient was admitted to the facility on 11/07/2023 for ICHD treatment. The review of the patient’s dialysis prescription dated 12/16/2023 revealed the patient had a BFR of “400” ordered by the physician. Review of treatment flowsheets from 11/07/2023 to 12/15/2023 revealed the facility patient care staff failed to dialyze the patient at the prescribed BFR for two (2) of seven (7) treatments reviewed. The documentation from the treatment flowsheets revealed as follows: -11/07/2023: Dialyzed from 1337-1536 with a documented BFR of 350 (50 less), and - 12/19/2023: Dialyzed from 1150-1420 with a documented BFR of 300 (100 less). 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 01/25/2024 at 1015 with the FA revealed that if the patient is unable to obtain the prescribed BFR, the treatment flowsheet should include documentation from staff indicating the reason the prescribed order was not followed. Interview on 01/25/2024 at 1645 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the patient is 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 01/24/2024 for Patient #2 revealed the patient was admitted to the facility on 11/01/2023 for ICHD treatment. The review of the patient’s dialysis prescription dated 12/17/2023 revealed the patient had a BFR of “350” ordered by the physician. Review of treatment flowsheets from 01/09/2024 to 01/20/2024 revealed the facility patient care staff failed to dialyze the patient at the prescribed BFR for one (1) of six (6) treatments reviewed. The documentation from the treatment flowsheets revealed as follows: - 01/16/2024: Dialyzed from 1303-1610 with a documented BFR of 300 (50 less). 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 01/25/2024 at 1015 with the FA revealed that if the patient is unable to obtain the prescribed BFR, the treatment flowsheet should include documentation from staff indicating the reason the prescribed order was not followed. Interview on 01/25/2024 at 1645 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the patient is 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 01/24/2024 for Patient #3 revealed the patient was admitted to the facility on 10/06/2021 for ICHD treatment. The review of the patient’s dialysis prescription dated 12/12/2023 revealed the patient had a BFR of “350” ordered by the physician. Review of treatment flowsheets from 01/08/2024 to 01/22/2024 revealed the facility patient care staff failed to dialyze the patient at the prescribed BFR for two (2) of seven (7) treatments reviewed. The documentation from the treatment flowsheets revealed as follows: - 01/17/2024: Dialyzed from 1229-1459 with a documented BFR of 300 (50 less), and - 01/22/2024: Dialyzed from 1141-1256 with a documented BFR of 290 (60 less) and from 1306-1412 with a BFR of 300 (50 less). 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 01/25/2024 at 1015 with the FA revealed that if the patient is unable to obtain the prescribed BFR, the treatment flowsheet should include documentation from staff indicating the reason the prescribed order was not followed. Interview on 01/25/2024 at 1645 with the MD revealed that his expectation was that staff follow the prescribed orders for patients and that if the patient is unable to reach the prescribed BFR, there should be documentation available supporting the need to deviate from the patient’s prescription.”

“POC-OUTCOME NOT ACHIEVED-ADJUST POC CFR(s): 494.90(b)(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient’s current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section. This Standard is not met as evidenced by: 35306 Based on policy review, medical record review and staff interview, the facility staff failed to adjust the patient’s plan of care when desired outcomes were not met for 1 of 4 sampled records (Patient #3). Findings included: Review on 01/25/2024 of the facility’s policy titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE”, Revision Date: July 2023, revealed, “... 8. The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and will include measurable and expected outcomes and estimated timetable to achieve these outcomes... 13. In addition, if the expected outcome is not achieved, the interdisciplinary team (or individual IDT member) will adjust the patient’s plan of care to achieve the specified goal. When a patient is unable to achieve the desired outcomes, the team will: - Adjust the plan of care to reflect the patient’s current condition - Document in the patient’s medical record the reasons why the patient was unable to achieve the goals - Implement plan of care changes to address the issues identified.” 1. Medical record review on 01/24/2024 for Patient #3 revealed the patient was admitted to the facility on 10/06/2021 for ICHD treatment. Review of the Initial “Interdisciplinary Patient POC [Plan of Care] Meeting Report” dated 03/31/2024, revealed on 03/08/2023, a Plan of Care was implemented for “BP and Fluid Management Goal: To meet or trend toward goal of Pre-dialysis Blood Pressure of less than 140/90 ... Follow Up Time Frames: 60 [05/07/2023]” by the licensed nurse. Review of the POC failed to reveal nursing interventions, evidence that the POC was adjusted to reflect the patient’s current condition or changes in the POC to address and resolve the identified barriers. Interview on 01/24/2024 at 1330 with the MCS and Group FA revealed that interventions should be included in the patient’s POC when a problem is identified and that if the goal is not met within the follow up time frame, revision to the POC should occur. Interview revealed the nursing staff failed to adjust the patient’s POC when the expected outcome was not achieved. Interview on 01/25/2024 at 1610 with the MD revealed that when a POC is not met, information regarding patient’s current condition should be discussed by the IDT and that the POC should be adjusted to reflect the interventions in place to assist the patient in achieving the desired outcome. Interview revealed, “Half the battle was identifying this issue. We need to get this taken care of.” Interview confirmed findings.”

“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: 35306 Based on policy review, medical record review and staff interview, the facility’s medical director failed to assure facility staff adhered to policy and procedures for prescription verification of machine temperatures for 4 of 4 records sampled (Patients #1, #2, #3, and #4). Findings included: 1. Review on 01/24/2024 of the facility policy titled, “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” (Revision Date: October 2023), revealed “... 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... Prescription components include... i. Correct dialysate composition.... and settings... INTRADIALYTIC DATA COLLECTION/ASSESSMENT ... 10. If the dialysis prescription is not being met.... the reason will be documented and the licensed nurse informed...”2. The Nursing assessment ... a. The assessment includes the following components ... iii. Verification of prescription including machine parameters ...” Review on 01/25/2024 of the facility policy titled, “TESTING pH AND CONDUCTIVITY OF PROPORTIONED DIALYSATE AND VERIFICATION OF TEMPERATURE OF PROPORTIONED DIALYSATE” (Revision Date: April 2020), revealed “... 12. Verify dialysate temperature is set to prescribing physician’s order ...” 1. Medical record review on 01/24/2024 for Patient #1 revealed the patient was admitted to the facility on 11/07/2023 for ICHD treatment. The review of the patient’s dialysis prescription dated 12/16/2023 revealed the patient had a Dialysate temperature of “37.0” degrees Celsius ordered by the physician. Review of treatment flowsheets from 11/07/2023 to 12/15/2023 revealed the facility patient care staff failed to dialyze the patient at the prescribed Dialysate temperature for four (4) of seven (7) treatment flowsheets with “Nurse Prescription Verification: I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” noted by the RN on each of the treatment flowsheets reviewed. The documentation from the treatment flowsheets revealed as follows: - 11/07/2023: Machine temperature documented as 36.3 degrees Celsius (0.7 degree less), - 11/14/2023: Machine temperature documented as 36.3 degrees Celsius (0.7 degree less), - 11/28/2023: Machine temperature documented as 35.5 degrees Celsius (1.5 degree less), and - 12/19/2023: Machine temperature documented as 36.0 degrees Celsius (1 degree less). 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 Dialysate temperature. No physician order was found in the medical record to indicate the patient’s physician was aware of the Dialysate temperature changes. Interview on 01/25/2024 at 1530 with the BOM and MCS, the BOM revealed that the PCT staff were “checking the machine temperatures too early without giving the machine time to reach the prescribed temperature and since the nurse has an hour to verify the prescription, the machine has had enough time to reach the prescribed temperature. The BOM confirmed the findings during the interview. Concurrent interview on 01/25/2024 at 1530 with the MCS revealed staff should validate machine temperature settings during review of the current prescription and should not document machine temperatures in the patient’s medical record until the ordered temperature was achieved. Interview revealed staff should know that they have to give the machine time to reach the prescribed temperature. Interview confirmed findings. Interview on 01/25/2024 at 1645 with the MD revealed that he was not aware that prescribed machine temperatures were not being documented in the patient’s medical record. Interview revealed that when the Interdisciplinary Team met, individual patient treatment flowsheets were not routinely pulled and reviewed. Interview revealed, “Half the battle was identifying this issue, and we need to get these taken care of.” Interview revealed that it was the MD’s expectation that staff follow the prescribed orders for patients. 2. Medical record review on 01/24/2024 for Patient #2 revealed the patient was admitted to the facility on 11/01/2023 for ICHD treatment. The review of the patient’s dialysis prescription dated 12/17/2023 revealed the patient had a Dialysate temperature of “36.0” degrees Celsius ordered by the physician. Review of treatment flowsheets from 01/09/2024 to 01/20/2024 revealed the facility patient care staff failed to dialyze the patient at the prescribed Dialysate temperature for five (5) of six (6) treatments, with “Nurse Prescription Verification: I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” noted by the RN on each of the treatment flowsheets reviewed. The documentation from the treatment flowsheets revealed as follows: - 01/11/2024: Machine temperature documented as 36.9 degrees Celsius (0.9 degrees more), - 01/13/2024: Machine temperature documented as 35.6 degrees Celsius (0.4 degrees less), - 01/16/2024: Machine temperature documented as 36.6 degrees Celsius (0.6 degrees more), - 01/18/2024: Machine temperature documented as 36.7 degrees Celsius (0.7 degrees more), and - 01/20/2024: Machine temperature documented as 36.7 degrees Celsius (0.7 degrees more). 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 Dialysate temperature. No physician order was found in the medical record to indicate the patient’s physician was aware of the Dialysate temperature changes. Interview on 01/25/2024 at 1530 with the BOM and MCS, the BOM shared that the PCT staff were “checking the machine temperatures too early without giving the machine time to reach the prescribed temperature and since the nurse has an hour to verify the prescription, the machine has had enough time to reach the prescribed temperature. The BOM confirmed the findings during the interview. Concurrent interview on 01/25/2024 at 1530 with the MCS revealed staff should validate machine temperature settings during review of the current prescription and should not document machine temperatures in the patient’s medical record until the ordered temperature was achieved. Interview revealed staff should know that they have to give the machine time to reach the prescribed temperature. Interview confirmed findings. Interview on 01/25/2024 at 1645 with the MD revealed that he was not aware that prescribed machine temperatures were not being documented in the patient’s medical record. Interview revealed that when the Interdisciplinary Team met, individual patient treatment flowsheets were not routinely pulled and reviewed. Interview revealed, “Half the battle was identifying this issue, and we need to get these taken care of.” Interview revealed that it was the MD’s expectation that staff follow the prescribed orders for patients. 3. Medical record review on 01/24/2024 for Patient #3 revealed the patient was admitted to the facility on 10/06/2021 for ICHD treatment. The review of the patient’s dialysis prescription dated 12/17/2023 revealed the patient had a Dialysate temperature of “37.0” degrees Celsius ordered by the physician. Review of treatment flowsheets from 01/08/2024 to 01/22/2024 revealed the facility patient care staff failed to dialyze the patient at the prescribed Dialysate temperature for six (6) of seven (7) treatments, with “Nurse Prescription Verification: I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” noted by the RN on each of the treatment flowsheets reviewed. The documentation from the treatment flowsheets revealed as follows: - 01/08/2024: Machine temperature documented as 36.9 degrees Celsius (0.1 degrees less), - 01/10/2024: Machine temperature documented as 36.7 degrees Celsius (0.3 degrees less), - 01/12/2024: Machine temperature documented as 36.7 degrees Celsius (0.3 degrees less), - 01/15/2024: Machine temperature documented as 36.7 degrees Celsius (0.3 degrees less), - 01/17/2024: Machine temperature documented as 36.7 degrees Celsius (0.3 degrees less), and - 01/22/2024: Machine temperature documented as 36.2 degrees Celsius (0.5 degrees less). 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 Dialysate temperature. No physician order was found in the medical record to indicate the patient’s physician was aware of the Dialysate temperature changes. Interview on 01/25/2024 at 1530 with the BOM and MCS, the BOM shared that the PCT staff were “checking the machine temperatures too early without giving the machine time to reach the prescribed temperature and since the nurse has an hour to verify the prescription, the machine has had enough time to reach the prescribed temperature. The BOM confirmed the findings during the interview. Concurrent interview on 01/25/2024 at 1530 with the MCS revealed staff should validate machine temperature settings during review of the current prescription and should not document machine temperatures in the patient’s medical record until the ordered temperature was achieved. Interview revealed staff should know that they have to give the machine time to reach the prescribed temperature. Interview confirmed findings. Interview on 01/25/2024 at 1645 with the MD revealed that he was not aware that prescribed machine temperatures were not being documented in the patient’s medical record. Interview revealed that when the Interdisciplinary Team met, individual patient treatment flowsheets were not routinely pulled and reviewed. Interview revealed, “Half the battle was identifying this issue, and we need to get these taken care of.” Interview revealed that it was the MD’s expectation that staff follow the prescribed orders for patients. 4. Medical record review on 01/24/2024 for Patient #4 revealed the patient was admitted to the facility on 02/14/2022 for ICHD treatment. The review of the patient’s dialysis prescription dated 01/11/2024 revealed the patient had a Dialysate temperature of “37.0” degrees Celsius ordered by the physician. Review of treatment flowsheets from 01/08/2024 to 01/17/2024 revealed the facility patient care staff failed to dialyze the patient at the prescribed Dialysate temperature for two (2) of five (5) treatments, with “Nurse Prescription Verification: I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” noted by the RN on each of the treatment flowsheets reviewed. The documentation from the treatment flowsheets revealed as follows: - 01/12/2024: Machine temperature documented as 35.6 degrees Celsius (1.4 degrees less), and - 01/17/2024: Machine temperature documented as 36.6 degrees Celsius (0.4 degrees less). 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 Dialysate temperature. No physician order was found in the medical record to indicate the patient’s physician was aware of the Dialysate temperature changes. Interview on 01/25/2024 at 1530 with the BOM and MCS, the BOM shared that the PCT staff were “checking the machine temperatures too early without giving the machine time to reach the prescribed temperature and since the nurse has an hour to verify the prescription, the machine has had enough time to reach the prescribed temperature. The BOM confirmed the findings during the interview. Concurrent interview on 01/25/2024 at 1530 with the MCS revealed staff should validate machine temperature settings during review of the current prescription and should not document machine temperatures in the patient’s medical record until the ordered temperature was achieved. Interview revealed staff should know that they have to give the machine time to reach the prescribed temperature. Interview confirmed findings. Interview on 01/25/2024 at 1645 with the MD revealed that he was not aware that prescribed machine temperatures were not being documented in the patient’s medical record. Interview revealed that when the Interdisciplinary Team met, individual patient treatment flowsheets were not routinely pulled and reviewed. Interview revealed, “Half the battle was identifying this issue, and we need to get these taken care of.” Interview revealed that it was the MD’s expectation that staff follow the prescribed orders for patients.”