Fmc Bergen

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 51227 Based on two of eight staff members observed for hand hygiene opportunities, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that hand hygiene is performed to prevent cross contamination in accordance with facility policy. Findings include: On 05/07/25 at 10:20 AM, in Station 24, S4 (Registered Nurse [RN]) was observed assisting a patient into the recliner chair. S4 removed his/her gloves and without the benefit of hand hygiene, donned (put on) a new pair of gloves. S4 then proceeded to enter Station 8 and touched the dialysis machine. During an interview at 11:00 AM, S4 stated, that he/she should have cleansed his/her hands after the removal of gloves and before going to another Station. On 05/07/25 at 10:25 AM, in Station 24, S3, a RN initiated hemodialysis through an Arteriovenous Fistula (AVF, a type of vascular access used for hemodialysis). S3 assessed the patient then removed his/her gloves and, without the benefit of hand hygiene, donned a new pair of gloves entered the laboratory area to obtain a cloth soaked with soap and water to cleanse the patient’s access site. During an interview at 11:15 AM, S3 stated he/she should have washed his/her hands after removing his/her gloves and exiting the Station. On 05/07/25 at 10:45 AM in Station 9, S4 a RN initiated hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis). S4 removed the old dressing of the CVC and then removed his/her gloves. S4 donned a new pair of gloves and cleansed the exit site. S4 removed his/her gloves and donned a new pair of gloves before he/she applied a new dressing onto the exit site. S4 then removed his/her gloves, donned a new pair of gloves and proceeded to wipe the catheter hubs with an alcohol preparation (prep) pad. S4 connected a pre-filled saline syringe and injected the fluid into each CVC line. S4 then removed his/her gloves and donned a new pair of gloves before he/she connected the patient to the hemodialysis machine. S4 did not perform hand hygiene between any glove changes during the above observation, as required by facility policy. During an interview at 11:00 AM, S4 stated, that he/she should have cleansed his/her hands after the removal of gloves. 48966 On 05/07/25 at 12:31 PM in Station 2, during an observation of the termination of hemodialysis through a CVC, S3 (RN), with gloved hands, discontinued dialysis and returned the patient’s blood through the CVC. S3 clamped the arterial (red) and venous (blue) CVC limbs of the catheter and then, with the same gloves on, touched the machine and typed on the keyboard. Wearing the same gloves, S3 disconnected the arterial bloodline from the catheter limb and proceeded to use an alcohol prep pad for 20 seconds to scrub the threads and the end of hub and then attached a prefilled saline syringe to the catheter limb. During an interview on 05/07/25 at 12:55 PM, S3 stated he/she should have changed his/her gloves after touching the keyboard and perform hand hygiene. A review of S3’s “Certificate Of Completion” indicated that his/her “Annual Clinical Skills Validation” on hand hygiene and discontinuation of dialysis with a CVC was completed on March 24, 2025. Facility policy titled, “Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer” published 11/04/24, stated, “ ... Termination: Returning Blood from Arterial Segment Step 5 ... return blood through the arterial line ... 7 close the arterial blood line clamp and the arterial catheter limb clamp ... Termination: Returning the Blood from Venous Segment Step 2 Start the blood pump and increase speed to 150-200 ml [milliliters]/min [minute]. Step 6 Stop the blood pump. Close venous line clamp and the venous catheter limb clamp ... Termination: Disinfection of Catheter and Disconnecting the Patient ... Step 1 For Inpatients: Obtain and document vital signs ... prior to disconnecting patient. Step 2 Discard gloves and perform hand hygiene. Don clean gloves. ...” Facility policy titled, “Hand Hygiene,” published 11/06/23, stated, “ ... Policy ... When ... Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medication, immediately after removing gloves ... after contact with other objects within the patient station or treatment space ...” N.J.A.C 8:43A-24.8(d)”

“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: 51227 Based on one of one observation of initiation of hemodialysis using a Central Venous Catheter (CVC, a type of access used for hemodialysis), staff interviews, and review of facility policies, it was determined that the facility failed to implement infection control practices for cleansing the CVC access site and limbs prior to initiating hemodialysis. Findings include: On 05/07/25 at 10:45 AM, in Station 9, Staff (S)4, a (Registered Nurse [RN]), initiated hemodialysis through a CVC. S4 cleansed the CVC exit site using a 2% Chlorhexidine Gluconate prepackaged swab for four seconds, this was 26 seconds less than required by facility policy. S4 then used one alcohol preparation (prep) pad to scrub the hub for two seconds. S4 proceeded to scrub the venous hub for two seconds. S4 did not clean and disinfect the arterial and venous hub for 10-15 seconds and did not clean the sides/threads in accordance with facility policy. During an interview at 11:00 AM, S4 stated, he/she should clean the exit site for 60 seconds. S4 stated, he/she should have cleaned the sides/threads of the CVC and scrubbed the hub for 30 seconds. Facility policy titled, “Initiation of Treatment using a Central Venous Catheter (CVC) and Optiflux Single Use Ebeam Dialyzer,” published 05/06/24, stated, “ ... Preparing the catheter: Disinfection of the Catheter Connections, Heparin Removal, Flushing the Catheter and Heparin Administration ... Step ... 3. Using a sterile alcohol pad scrub the sides (threads) and end of the hub thoroughly with friction. Makings sure to remove any residue. 4. Using the same sterile alcohol pad applying friction to remove any blood or residue, move from the hub at least several centimeters towards the body of the catheter. (Steps 3 and 4 should take 10-15 seconds. ... “ Facility policy titled, “Changing the Catheter Dressing Procedure,” published 02/05/24, stated, “ ... Cleaning the Site ... Steps ... 2. 2 % Chlorhexidine and 70 % alcohol: Using gentle back and forth friction, clean the exit site beginning in the center and continuing outward the area of the size of the dressing to be applied (2 inches) in a concentric circle for 30 seconds and allow to dry a minimum of 30 seconds ... “ N.J.A.C. 8:43A-24.8(b)”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 51227 Based on two of three observations of Central Venous Catheter (CVC, a type of access used for hemodialysis) care, staff interview, and review of facility documents, it was determined that the facility failed to ensure each patient’s right to privacy. Findings include: On 05/07/25 at 10:45 AM in Station 9, the initiation of hemodialysis through a right chest wall CVC was observed. The patient’s T-shirt was fully opened in the middle during the procedure, exposing his/her chest. The curtains were drawn on both sides of Station 9, however a two- foot opening was visible towards the right side of the patient. Also, the curtain was not fully extended in the front of the station, leaving an additional two-foot opening. The patient’s exposed chest was visible to patients and staff walking past Station 9. This surveyor was able to visualize staff members who walked past from inside Station 9 during the procedure. 48966 On 05/07/25 at 12:06 PM, a discontinuation of dialysis via a left chest CVC was performed by Staff (S)3 (Registered Nurse [RN]) in Station 2. The curtain on the left side was drawn in Station 2 fully extending to ensure patient privacy on the left of the patient, however, the curtain did not fully extend in the front of the station, leaving a two-foot opening. The patient’s exposed chest was visible to any staff members that walked by, as well as to the staff sitting at the desk in front of Station 2 and to patients using the scale to weigh themselves. This surveyor was able to visualize staff members who walked past from inside Station 2 during the procedure and sitting at the desk. During an interview at 12:45 PM, S3 confirmed the curtains should be fully around the patient sitting in Station 2 during discontinuation of dialysis. Facility document titled, “FMCNA Patient Rights” dated 06/28/18, stated, “ ... Privacy and confidentiality Privacy and confidentiality in all aspects of treatment. This includes ... the right to privacy during activities that may require exposure of body part while in the dialysis facility. Privacy screens, curtains, or blankets that do not cover your face or access, may be used to provide privacy ...” N.J.A.C. 8:43A-16.2(a)(10)”

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 39223 Based on medical record review, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that patients are encouraged to participate in planning their care for one of seven in-center hemodialysis patient medical records reviewed (Patient (P)8). Failure to encourage participation could deny patients the right to be informed about care, to make changes or to refuse any aspect of care. Findings include: A review of Medical Record (MR)8 revealed a plan of care dated 04/30/25. The ‘Patient Approval Signature’ section was left blank. There was no documented evidence that the patient was encouraged to participate in his/her plan of care. Upon request for documented evidence that the patient participated in the plan of care meeting or was invited to participate in the development of his/her plan of care at 05/09/25 at 11:30 AM, Staff (S)1 (Charge Nurse II) was unable to provide. Facility policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care,” revised 07/03/23, stated, “ ... The Comprehensive Interdisciplinary Assessment and Plan of Care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the patient or patient’s designee, a registered nurse, the patient’s attending physician (or physician extender where allowed by State regulations), qualified master’s degree level social worker and qualified registered dietitian. ... Patient Participation in Plan of Care ... The following recommendations for involving the patient in the development and review of the Plan of Care: Provide appropriate patient education to enable the patient to participate in the development of the Plan of Care. Encourage both patient and family to participate in the Plan of Care discussions in whatever format the facility and attending physician develop. Notify the patient in writing of the time and date of the Plan of Care review. Review expectation for participation in the Plan of Care with each patient. Review this expectation again when Rights and Responsibilities are reviewed. ... “ N.J.A.C. 8:43A-24.13(c)”

“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: 49828 Based on medical record review, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that: 1) post-hemodialysis nursing assessments are completed according to facility policy for two of seven In-Center Hemodialysis (ICHD) medical records reviewed (Patient [P]1 and P6); 2) the Registered Nurse (RN) re-evaluates the patient for one of one patient experiencing intradialytic cramping (P6); and 3) the prescribed blood flow rate (BFR) for two of six hemodialysis treatment sheets reviewed for P8 is implemented. Findings include: 1. A review of P1’s plan of care, dated 11/26/24, stated, “Area of Focus: ... Intervention(s): Hospitalization within last 90 days ... Monitor parameters that may lead to hospitalization (albumin, fluid overload, vascular access, anemia, and medications, In Progress ... Area of Focus: BP [blood pressure] and Fluid Management ... Intervention (s): ... Re-evaluate/Assess dry weight, In Progress ...” A review of the “Treatment Sheet For Facility” from 04/14/25 through 05/07/25 in P1’s medical record revealed the following: On 04/14/25, the pre-treatment (before treatment) “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 2+ [two plus]: 2-4 mm [millimeter] indent, disappears in 10-15 seconds, Ankle - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds. The post (after)-treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a Registered Nurse (RN). On 04/16/25, the pre-treatment “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds, Ankle - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds. The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 04/21/25, the pre-treatment “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds, Ankle - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds. The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 04/23/25, the pre-treatment “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 1+ [one plus]: 2 mm or less, disappears rapidly, Ankle - Severity [edema/swelling], 1+: 2 mm or less, disappears rapidly.” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 04/25/25, the pre-treatment “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds, Ankle - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds.” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 04/28/25, the pre-treatment “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 1+: 2 mm or less, disappears rapidly, Ankle - Severity [edema/swelling], 1+: 2 mm or less, disappears rapidly.” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 04/30/25, the pre-treatment “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 1+: 2 mm or less, disappears rapidly, Ankle - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds.” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 05/02/25, the pre-treatment “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 1+: 2 mm or less, disappears rapidly, Ankle - Severity [edema/swelling], 1+: 2 mm or less, disappears rapidly.” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 05/05/25, the pre-treatment “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds, Ankle - Severity [edema/swelling], 2+: 2-4 mm indent, disappears in 10-15 seconds.” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 05/07/25, the pre-treatment “Nursing Evaluation” section stated, “... Lower Leg - Severity [edema/swelling], 1+: 2 mm or less, disappears rapidly, Ankle - Severity [edema/swelling], 1+: 2 mm or less, disappears rapidly.” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. During an interview on 05/09/25 at 10:00 AM, Staff (S)1 (Charge Nurse II) confirmed the above findings that edema was not reassessed post-treatment on the above dates. S1 stated that if edema is noted pre-treatment, it should be reassessed post-treatment. 51227 A review of Patient (P)6’s medical record revealed the following: A Plan of Care, dated 03/26/25, stated “Area of Focus BP and Fluid Management ... Bp [blood pressure] elevated at times ... continue to monitor patient ...” A review of P6’s hemodialysis “Treatment Sheets For Facility” from 04/21/25 through 05/05/25, revealed the following: On 05/02/25, the pre-treatment “Nursing Evaluation” section stated, “ ... Bilateral [affecting both sides] lower leg/ankle edema, 1+:2 mm (millimeters) or less, disappears rapidly ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a Registered Nurse (RN). On 05/03/25, the pre-treatment “Nursing Evaluation” section stated, “ ... Bilateral lower leg/ankle edema, 1+:2 mm (millimeters) or less, disappears rapidly ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. On 05/05/25, the pre-treatment “Nursing Evaluation” section stated, “ ... Bilateral lower leg/ankle edema, 1+:2 mm (millimeters) or less, disappears rapidly ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the patient’s edema by a RN. During an interview on 05/09/25 at 10:00 AM, S1 confirmed the above treatment sheets lacked documented evidence of post treatment re-assessment of edema. S1 also stated he/she expects to see a RN reevaluate edema in the post treatment notes. Facility policy titled, “Patient Assessment and Monitoring,” published 05/01/23, stated, “ ... Pre-Treatment ... 2 ... Edema (As indicated by patient condition) Assess the patient for edema: [bullet] Location: foot, ankle, lower leg and sacrum. [bullet] Right, Left or Bilateral [bullet] Severity (None, 1+, 2+,3+ or 4+) 3 Document findings and interventions in the medical record. ... Post-Treatment ... 1 ... Edema ... The registered nurse will assess/re-assess post treatment as indicated. 2 Document findings in the patient’s record. ...” 2. A review of Patient (P)6’s medical record revealed the following: A Plan of Care dated 03/26/25, stated, “ ... Area of Focus BP and Fluid Management ... Change patient’s dry weight ... eval [evaluate] edw [Estimated Dry Weight] weekly ... “ An order by the physician, dated on 04/28/25, stated, “Special Attentions ... For cramps give 200 ml [milliliters] of NS [normal saline], max [maximum] 500 ml, if no relief notify MD [Medical Doctor].” A review of P6’s hemodialysis “Treatment Sheets For Facility” from 04/21/25 through 05/05/25, revealed the following: On 04/21/25 at 4:44 PM, documentation by the RN indicated that P6 complained of severe cramping, no bolus given. At 4:46 PM, the RN documented “little better,” no bolus given. At 4:53 PM, P6 requested to end treatment early due to severe cramping. There was no numerical pain scale documented by the RN. On 04/25/25 at 3:20 PM, documentation by the RN indicated that P6 complained of severe cramping of the left leg, no bolus given. At 4:24 PM], the RN reassessed P6 documenting no complaints. On 04/28/25 at 3:49 PM, documentation by the Patient Care Technician (PCT) indicated that P6 complained of leg cramping at a rate of 10, no bolus given. At 4:55 PM, the RN assessed P6 documenting no complaints. On 04/30/25 at 4:26 PM, documentation by the PCT indicated that P6 complained of leg cramps, no bolus given. The treatment sheet lacked documention that the RN assessed the patient for cramping. On 05/02/25 at 4:18 PM, documentation by the RN indicated that P6 complained of severe cramping and a NS bolus was given. At 4:26 PM, P6 continued to complain of cramps. There was no numerical pain scale documented by the RN. The above treatment sheets lacked documentation that the physician was made aware of P6’s cramping. During an interview on 05/09/25 at 10:00 AM, S1 stated that cramping could be a sign of too much fluid removal and that he/she would have expected to see documentation that the physician was made aware and that there was a need to re-evaluate the patients EDW. Facility policy titled, “Muscle Cramping,” published 09/07/21, stated, “ ... Treating Muscle Cramps while on Hemodialysis ... Step ... 8. Reassess EDW or dialysate if indicated and contact the patient’s physician for EDW order changes ... “ N.J.A.C. 8:43A-24.4(a) 39223 3. A review of medical record (MR)8 revealed a plan of care meeting dated 04/30/25, that stated, “ ... Area of Focus BP [Blood Pressure] and Fluid Management ... Goal Achieve BP Control as specified by the patient’s physician ... “ Further review of MR8 revealed the following: A physician’s order for hemodialysis treatments three days per week, with a blood flow rate (BFR) of 400 was started on 05/02/25. The Treatment Sheet, dated 05/02/25, documented a BFR of 350 from 11:52 AM, when hemodialysis treatment started, until 1:47 PM, one hour and 55 minutes later, when treatment ended. A physician’s order for hemodialysis treatments three days per week with a BFR of 400 was started on 05/05/25. The Treatment Sheet, dated 05/07/25, documented a BFR of 300 starting mid-treatment at 12:01 PM by the Patient Care Technician, until 1:56 PM, one hour and 55 minutes later, when treatment ended. This was not in accordance with physician orders. There was no documented evidence of the reason why the ordered BFR was not met, or that the physician was notified of the change. Facility policy titled, “Physician Order Documentation,” revised 07/03/23, stated, “ ... Nurse practice acts require nurses to carry out treatment care, medication administration, lab tests, procedures, and other treatments, based on physician orders. ... “ N.J.A.C. 8:43A-8.4(a)”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 51227 Based on one of two observations of the initiation of hemodialysis through an arteriovenous fistula (AVF, a type of vascular access used for hemodialysis), staff interview, and review of facility documents, it was determined that the facility failed to ensure that staff clean and disinfect the patient’s vascular access site prior to initiating hemodialysis treatment in accordance with facility policy. Findings include: On 05/07/25, at 10:25 AM, in Station 24, Staff (S)3, a (Registered Nurse [RN]), initiated hemodialysis through an AVF on the right forearm. S3 cleansed the first site of the AVF with an alcohol preparation (prep) pad in a circular motion for 15 seconds. This was 15 seconds less than the 30 seconds required by facility policy. S3 proceeded to clean the second site with an alcohol prep pad for 15 seconds, this is 15 seconds less than required per facility policy. During an interview at 11:15 AM, S3 stated he/she should clean the AVF access site for 30 seconds with an alcohol prep pad. Facility policy titled, “Access Assessment and Cannulation,” published 05/05/2025, stated, “ ... Skin Disinfection ... Step ... 1. Disinfect cannulation site as follows using any of the disinfectants below: 70% isopropyl alcohol pad: Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulating ...” N.J.A.C. 8:43A-24.8(b)”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 49828 Based on one of one medical record reviewed for peritonitis (inflammation of the peritoneum, the thin membrane that lines the abdominal cavity and cover the abdominal organs), interviews and review facility documents, it was determined that the facility failed to track and trend all cases of peritonitis during Outpatient Dialysis Quality Assessment and Performance Improvement (QAPI) meetings. Findings include: A review of Patient (P)10’s medical record indicated treatment for peritonitis infection in November 2024 and January 2025. After peritoneal fluid was drawn in November 2024, the patient received a course of Keflex (antibiotic medication used to treat infection). In January 2025, after hospitalization on 01/28/25 with a diagnosis of peritonitis, P10 received a course of Vancomycin (antibiotic medication used to treat infection) that completed on 02/06/25. During a review of the facility’s QAPI, it was revealed that P10’s peritonitis was not documented for the November 2024, or January 2025 data. There was no documented evidence the peritonitis cases were tracked and reviewed for trends in the facility’s QAPI program until the day of survey review on 05/09/25. The “Note” section revealed a note dated 05/09/25 which stated the facility had treated a patient for suspected peritonitis in November of 2024, and a positive case of peritonitis in January of 2025. This was six months after the patient was treated in November of 2024, and three months after the patient was diagnosed with peritonitis and began treatment in January of 2025. On 05/09/25 at 12:00 PM, Staff (S)22 (Facility Administrator) and S8 (PD Nurse) confirmed that the note was dated 05/09/25 and that the incident of peritonitis in November of 2024, and January of 2025 should have been reflected in the facility’s QAPI for the months the incidences had occurred, where it can be tracked and reviewed for trends. N.J.A.C. 8:43A-24.18(c)”

“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: 48966 Based on observation, staff interview, and review of facility documents, it was determined that the Medical Director failed to: 1) ensure that heparin is administered in accordance with the facility policy in one of one observation of medication administration; 2) patients are assessed for pre (before)- and post (after)-treatment pain in four of 10 medical records reviewed (Patient (P)1, P4, P7 and P8); and 3) implementation of the policy and procedure for the labeling of medications for one of two bottles of heparin and 15 of 15 pre-filled medication syringes observed. Findings include: 1. On 05/07/25 at 10:15 AM in Station 7, Staff (S)7 (Patient Care Technician [PCT]) initiated hemodialysis through an left lower arm graft. The following was observed: S4 (Registered Nurse [RN]) attached a pre-filled heparin syringe to the venous access line and slowly injected the heparin bolus with a back-and-forth motion. After waiting for two minutes, S7 then initiated the hemodialysis treatment. This was one minute less than required by facility policy. During an interview at 10:31 AM, S7 stated that after the administration of the heparin bolus, he/she should wait three to five minutes before initiating the hemodialysis treatment. S7 confirmed he/she did not wait the three to five minutes to initiate hemodialysis treatment. Facility policy titled, “Initiation of Treatment Using Arteriovenous Graft or Fistula and Optiflux Single Use Ebeam Dialyzer,” published 05/05/2025 stated, “ ... Prior to Initiation: Heparin Administration ... Step 4. Wait at least 3-5 minutes prior to initiation of dialysis to allow time for the protein-binding to occur, prevent loss of heparin through the dialyzer, and provide full anticoagulation as soon as treatment starts ...” N.J.A.C. 8:43A-9.3(a) 2. A review of P4’s “Nursing Evaluation,” on the “Treatment Sheet For Facility” dated 04/14/25 through 05/07/25, revealed the following: The post-treatment pain assessment was not documented on the following treatment dates: 04/16/25 and 05/07/25. The pre and post-treatment pain assessment was not documented on the following treatment dates: 04/14/25, 04/18/25, 04/21/25, 04/23/25, 4/25/25, 04/28/25, 05/02/25 and 05/05/25. During an interview on 05/08/25 at 11:56 AM, Staff (S)1 (Charge Nurse) stated that pain should be assessed pre- and post-treatment. S1 stated “It’s good nursing practice to assess for pain.” 39223 A review of P7’s “Nursing Evaluation,” on the Treatment Sheets dated 03/26/25 through 04/21/25, revealed that pain assessments were not documented in accordance with facility policy as follows: The pre and post-treatment pain assessment was not documented on the following treatment date: 03/26/25. The post-treatment pain assessment was not documented on the following treatment dates: 04/11/25 and 04/21/25. A review of P8’s “Nursing Evaluation,” on the Treatment Sheets dated 04/14/25 through 05/07/25, revealed that pain assessments were not documented in accordance with facility policy as follows: On 05/02/25 there lacked documented evidence of a pre-treatment pain assessment. The post-treatment assessment, timed for 14:46 (2:46 PM) stated, “ ... Notes: tx [treatment] ended early per patient request due to back pain. ... “ There was no documented evaluation of the patient’s reported back pain. The pre and post-treatment pain assessment was not documented on the following treatment dates: 05/05/25 and 05/07/25. 49828 A review of P1’s “Nursing Evaluation,” on the Treatment Sheets dated 04/14/25 through 05/07/25, revealed the following: The pre and post-treatment pain assessment was not documented on the following treatment dates: 04/14/25, 04/16/25, 04/18/25, 04/21/25, 04/28/25, 04/30/25, 05/02/25, 05/05/25 and 05/07/25. The post-treatment pain assessment was not documented on 04/25/25. During an interview on 05/09/25 at 10:00 AM, S1 (Charge Nurse) confirmed pain should be assessed by the Registered Nurse pre and post-treatment for patients. Facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, stated, “... Pre-Treatment ... Step 1 ... General Observation: ... Record any changes in overall condition. Some examples include: ... Is the patient experiencing any pain? ... Post-Treatment ... State of well-being/Reported by the patient/General observation, Ask the patient if he or she has anything more to report or any additional observations prior to discharge ...” Facility policy titled, “Pain Assessment and Management,” revised 07/03/23, stated, “ ... All patients will be assessed for pain using a 0 [zero] - 10 [ten] scale for adults or a 0 [zero] - 10 [ten] Wong-Baker faces pain scale tool for children, elderly, or cognitive impaired, and documented in the patient’s electronic medical record ... Procedure: Assessing a Patient for Pain Step 1. ... Action / Rationale The patient will be assessed for pain at the following times: ... When the patient complains of pain. Determine the following: Location, character, onset, duration, frequency (constant vs. [versus] intermittent), causative mechanism of pain and pain control. ... “ N.J.A.C 8:43A-16.2(a)(14) 3. On 05/07/25 at 10:27 AM, in the left top cabinet above Clean Sink 5, two bottles of heparin (blood thinning medication) were observed with 15 pre-filled syringes containing medications. One of the two bottles of heparin were opened. The opened heparin bottle did not contain an opened date, time, or initial of the teammate who opened it. 12 of the 15 syringes contained heparin, two contained doxercalciferol (used to treat secondary hyperparathyroidism), and one contained Retacrit (used to treat anemia/low red blood cell). All 15 syringes lacked a time prepared, and initial of the teammate who prepared them. The was not in accordance with facility policy which stated once IV medications are drawn, they are to be labeled with the time of preparation and an initial of the preparer. During an interview at 10:39 AM, Staff (S)4 (Registered Nurse) stated that he/she prepared the heparin, doxercalciferol, and Retacrit “around 9:00 AM.” S4 confirmed he/she did not initial or add the time the medication was prepared, as per facility policy. Facility policy titled, “Medication Preparation and Administration”, published 02/06/23, stated, “ ... Labeling Vials, When preparing medications if the vial is not used immediately in entirety, the nurse or PCT [patient care technician] (if allowed by state regulations), must place the date and time the vial was opened on the medication label along with their initials. Note: To ensure all open vials are properly marked, the nurse must never walk away from an opened multi-dose vial without writing the date and time the vial was opened. Label any open multi-dose vial the is not used immediately and store vial accordingly. ... “ N.J.A.C. 8:43A-9.3(a)”