Fresenius Kidney Care West Johnston

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 38766 Based on a review of policy and procedures, medical records review, and staff interviews, the facility staff failed to perform and/or document patient monitoring every 30-45 minutes during dialysis treatments for four (4) of seven (7) in-patient records reviewed (Patient #5 and #1). Findings included: A review on 07/22/2025 of the facility’s policy and procedure, “Patient Assessment and Monitoring,” published 05/01/2023, revealed “...During Treatment: Obtaining blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 minutes or more often as needed, but not to exceed 45 minutes per state regulations...” 1. An open medical record review on 07/23/2025 for Patient #5 revealed that a 60-year-old female had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 09/16/2024. A review of the treatment flowsheet dated 07/09/2025 revealed the treatment started at 0730 and concluded at 1130 (lasting a total of 240 minutes). The treatment flowsheet revealed no documented vital signs from 0931 through 1031 (60 minutes). A review of the treatment flowsheet on 07/16/2025 revealed the treatment started at 0743 and ended at 1143 (lasting a total of 240 minutes). The treatment flowsheet revealed no documented vital signs from 0904 through 1004 (60 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment, as required by policy. An interview on 07/24/2025 at 0930 with PCT/CCHT #1 revealed that the facility’s patient care technicians were responsible for monitoring patients, which included checking vital signs and conducting safety checks. The interview confirmed that these tasks should be performed and documented every 30 minutes, or more frequently if needed. 2. An open medical record review on 07/22/2025 for Patient #1 revealed that a 56-year-old male had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 05/30/25. A review of the treatment flowsheet dated 07/12/2025 revealed the treatment started at 0723 and concluded at 1123 (lasting a total of 240 minutes). The treatment flowsheet revealed no documented vital signs from 1005 through 1100 (55 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment, as required by policy. An interview on 07/24/2025 at 0930 with PCT/CCHT #1 revealed that the facility’s patient care technicians were responsible for monitoring patients, which included checking vital signs and conducting safety checks. The interview confirmed that these tasks should be performed and documented every 30 minutes, or more frequently if needed.”

“PA-DIALYSIS ACCESS TYPE & MAINTENANCE CFR(s): 494.80(a)(8) The patient’s comprehensive assessment must include, but is not limited to, the following: (8) Evaluation of dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts and peritoneal catheters). This Standard is not met as evidenced by: 38766 Based on policy and procedure review, medical record review, and staff interview, the facility staff failed to follow the dialysis prescription for one (1) of four (four) patients dialyzing via a central venous catheter (CVC) (Patient #1). The findings include: A review on 07/22/2025 of the facility policy titled “Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer” published 11/04/2024 revealed “... Prior to Termination: Preparation Follow the steps below to prepare for the termination of dialysis: 1. Check volume of each catheter limb to determine the amount of heparin or other locking solution to be instilled into each catheter lumen. 2. Draw up heparin or other locking solution as prescribed for each catheter lumen... Termination: Preparing Catheter for Patient Discharge: ...3. Open Catheter limb clamp and gently flush limb with heparin or other prescribed locking agent...” An open medical record review on 07/22/2025 for Patient #1 revealed that a 56-year-old male had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 05/30/2025 via a CVC. A review of the patient’s Current Orders Report under Patient Management Services indicated Patient #1 had an order for Heparin Sodium (an anticoagulant medication used to prevent blood clots) 1,000 Units/ml (milliliter) Catheter Lock Venous (blue Port) and Arterial (Red Port) at 1,800 units after every treatment. Review of the Treatment Flowsheet on 07/08/2025 revealed Patient #1’s hemodialysis treatment was initiated at 0718 and ended at 1115 (237 minutes). Review of the Flowsheet revealed Patient #1 received 1,800 units of catheter lock through the venous port at 1119. Review of the Treatment Flowsheet dated 07/12/2025 revealed Patient #1’s hemodialysis treatment was initiated at 0723 and ended at 1123 (240 minutes). Review of the Flowsheet revealed Patient #1 received 1,800 units of catheter lock through the venous port at 1125. Review of the Flowsheet from 07/08/2025 through 07/19/2025 (a total of 6 treatment records) revealed that the staff failed to lock the patient’s catheter lumens as per policy. An interview on 07/24/2025 at 0930 with PCT/CCHT #1 revealed that the facility’s patient care technician was responsible for injecting Heparin into each lumen before capping the lumen after every treatment. The staff indicated that if there were orders to inject Heparin into only one lumen, the patient care technician would inform the RN to review the orders. The interview revealed that the Heparin in the lumen was to prevent blood clots and to extend the life of the catheter. An interview on 07/24/2025 at 1235 with the CM revealed that the Haperin lock in the lumens was to prevent clotting. The CM added that the staff had reported that she did put Heparin into both lumens, but did not document on the treatment record. The interview confirmed the findings.”