Davita Dialysis at Deborah

“CFC-WATER & DIALYSATE QUALITY CFR(s): 494.40 This Condition is not met as evidenced by: 39223 Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the quality of water and dialysate provided to hemodialysis patients is within the Association for the Advancement of Medical Instrumentation’s (AAMI’s) standards by failing to ensure testing for residual disinfectant after monthly disinfection is performed using unexpired test strips (Tag V-219). Cross reference: 494.40 (a)(7) - ANSI (American National Standards Institute)/AAMI RD 52:2004 Requirements as Adopted by Reference Strategies for bacterial control”

“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: 39228 Based on observations, staff interview, and review of facility documents, it was determined that the facility failed to ensure staff perform hand hygiene in accordance with facility policy for two of four staff members observed. Findings include: On 10/28/24 at 11:12 AM, in Station 6, Staff (S) 6, a Registered Nurse, was observed initiating dialysis on a patient with a CVC (Central Venous Catheter-a type of access used for hemodialysis). S6 was observed wearing gloves and cleaning both limbs of the catheter with alcohol preparation (prep) pads. S6 removed his/her gloves, donned (put on) new gloves, and then applied a new gauze dressing to the CVC exit site on the upper right chest wall. S6 did not perform hand hygiene before donning new gloves. Once the dressing was applied, S6 removed his/her gloves and donned new gloves. S6 then removed the red colored cap from the CVC limb and proceeded to clean the hub with an alcohol prep pad before attaching a 10 milliliter syringe. S6 did not perform hand hygiene before donning new gloves. At 11:25 AM, upon completion of the initiation of dialysis through a CVC, S6, with gloved hands, exited the station with used supplies and two syringes that contained a small amount of blood. S6 discarded the supplies in a trash receptacle and the syringes in a red sharps container located outside of the station. S6 then removed his/her gloves, reached into a box of clean gloves located on a countertop next to the medication preparation area. S6 donned the new gloves, and re-entered Station 6. He/she proceeded to touch the chairside keyboard and the dialysis machine. S6 did not perform hand hygiene before donning new gloves and re-entering the dialysis station. 51227 On 10/28/24 at 10:55 AM, S5, a Registered Nurse, entered Station 11 with gloved hands. S5 then touched the hemodialysis machine, and removed his/her gloves while exiting Station 11. S5 proceeded to don new gloves, and entered Station 14 to set up tubing on the hemodialysis machine. S5 did not perform hand before donning new gloves. S5 did not perform hand hygiene upon exiting Station 11 and entering Station 14. S5 then exited Station 14 and removed his/her gloves without the benefit of performing hand hygiene upon exiting the station. S5 entered the medication preparation area and prepared two syringes of one milliliter (ml) of Heparin 1,000 units per ml. While in the medication preparation area, S5 touched his/her personal cell phone. Without performing hand hygiene first, S5 then donned a new pair of gloves and placed the prepared syringes in Station 14. Review of facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2024, stated, “ ... Policy: ... Hand Hygiene 1. All teammates ... will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact ... f. between patients even if the contact is casual g. before touching clean areas such as ... chairside keyboard/mouse ... “ N.J.A.C. 8:43A-24.8(b)”

“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 the initiation of hemodialysis using a central venous catheter (CVC), staff interviews, and facility policy, it was determined that the facility failed to ensure the staff perform skin disinfection of the access site prior to initiating the dialysis treatment, in accordance with facility policy. Findings include: On 10/28/24 at 11:11 AM, in Station 6, Staff (S) 6, a Registered Nurse (RN), was observed initiating hemodialysis through a CVC (a type of access used for hemodialysis). S6 cleansed the CVC exit site using a Hypochlorite (ExSept) saturated gauze with for six seconds. Then, with a second ExSept saturated gauze, S6 cleansed the exit site for 22 seconds. The total contact time with an ExSept saturated gauze was 32 seconds less than required per facility policy. During an interview on 10/28/24 at 12:45 PM, S6 stated he/she used ExSept instead of betadine due to the patient’s sensitivity. S6 said the procedure is to wipe the site for 15 seconds and allow the site to dry for two minutes. During an interview on 10/29/24 at 1:40 PM, with S1, the Clinical Coordinator (CC), this surveyor requested a CVC policy that discussed the cleansing of the exit site with ExSept. S1 stated the facility uses the Arteriovenous Fistula (AVF) policy regarding the contact time for ExSept use for cleansing a CVC site (referenced below). A review of the facility policy titled, “AV Fistula or Graft Cannulation With Nipro Or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised October 2022, stated, “... Skin Antiseptic ... Hypochlorite (ExSept Plus) ... Effective Contact Time ... 60 seconds ... Procedure: ... 11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. (For contact and dry time refer to table above) ...” N.J.A.C. 8:43A-24.8(b)”

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 39223 Based on observation, facility document review, and staff interview, it was determined that the facility failed to ensure testing for residual disinfectant after monthly disinfection was performed using two of four unexpired test strips. Findings include: During a tour of the Hemodialysis Treatment Floor on 10/28/24 starting at 10:00 AM, two used bottles of Minncare HD Residual Test Strips were available for staff use. One of the two bottles contained a manufacturer’s expiration date of 10/17/24. During an interview on 10/28/24 at 10:18 AM, Staff (S) 10, a Patient Care Technician, stated that he/she was the person who tested the water for residual of Minncare on 10/25/24, after the CWP Reverse Osmosis Unit was disinfected the previous night. S10 stated that he/she should check the expiration date on the bottle prior to use in order to ensure that it is not past the expiration date. S10 was unable to determine if he/she had used the expired bottle of test strips on 10/25/24. A review of S10’s personnel file revealed that on 5/06/24, S10 completed “Basic Components and Monitoring of Dialysis Quality Water Systems” training. During a tour of the Water Treatment Room on 10/28/24 starting at 10:30 AM, two used bottles of Minncare HD Residual Test Strips were available for staff use. One of the two bottles contained a manufacturer’s expiration date of 09/22/24. During an interview on 10/28/24 at 10:34 AM, S9, the Area Technical Operations Manager, confirmed that one of the two bottles of test strips were beyond the manufacturer’s expiration date. A review of the CWP Daily Water Log for the month of October 2024 indicated that the CWP Reverse Osmosis Unit was chemically disinfected on: 10/3, 10/10, 10/17, and 10/24/24. Documentation on 10/4, 10/11, 10/18, and 10/25/24 of the test results for chemical residual after disinfection did not indicate the expiration date for the test strips utilized. Therefore, it was unable to be determined if the test strips utilized on the documented dates were beyond the manufacturer’s expiration date. Facility procedure titled, “Residual Minncare HD Testing Using Residual Minncare HD Acid Test Strips,” revised April 2021, stated, “... Procedure ... 2. Verify that the test strip vial has been tightly capped and is not beyond the manufacturer’s expiration date. ... Rationale ... 2. Test strips stored in open vials or used beyond their expiration date may give inaccurate test results. ...” N.J.A.C. 8:43A-24.10(a)”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 33556 Based on observation of the hemodialysis treatment floor and support space, it was determined the facility failed to ensure that a safe environment is maintained for patients, staff, and the general public. Findings include: Reference: OSHA (The Occupational Safety and Health Administration) 29 CFR 1910.151(c), specifies that, “... where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use ...” During a tour conducted on 10/29/24 at 10:45 AM with Staff (S) 9, the Area Technical Operations Manager (ATOM), the following were noted: Inside the Water Treatment Room within the acid mixing area, there was no drench shower installed. In the event staff are exposed to corrosive materials, a drench shower would not be available for use. On the Treatment Floor, a door adjacent to the Biomedical Technicians Office, which was identified by signage as an “exit” was found to be locked. The designated “exit” could only be used by someone knowing the correct numerical code in the event of an emergency. S9 confirmed the above findings upon discovery.”

“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: 39228 Based on one of one observation of a patient’s initiation of dialysis (Patient [P] 7) via a central venous catheter (CVC), review of facility policy, and staff interview, it was determined that the facility failed to ensure each patient’s right to privacy. Findings include: On 10/28/24 at 11:12 AM, Staff (S) 6, a Registered Nurse, entered Station 6 and pulled the privacy curtains located on each side of the station fully extending to ensure patient privacy on the left and right side of the patient. S6 did not pull a privacy curtain in the front of the station which allowed for staff, and patients on the treatment floor to have a direct view of P7’s care. S6 then proceeded to expose P7’s CVC access site (a type of access used for hemodialysis) located on the right upper chest wall and began to remove the CVC exit site dressing. There was no privacy curtain across the front of the station throughout the duration of the initiation of the CVC. During an interview on 10/29/24 at 11:55 AM, S1, the Clinical Coordinator, confirmed that the privacy curtains located in the station should be fully closed during CVC care. Review of facility policy titled, “Patient Rights,” last revised October 2021, stated, “Your Rights As A Patient: ... 4. The right to privacy and confidentiality in all aspects of treatment. ...” N.J.A.C. 8:43A-24.15(a)”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 49828 Based on two of two medical records (MR) reviewed (Patient [P] 6, and P8), review of facility policy, and staff interview, it was determined that the facility failed to ensure that the patient’s comprehensive assessment includes an evaluation of nutritional status by a Registered Dietitian. Findings include: A review of the medical record for P6 revealed the following: A “Patient Plan of Care” dated 07/17/24, indicated that the patient was designated as “unstable.” The medical record lacked documented evidence of monthly comprehensive nutrition assessments for August, September, and October 2024. On 10/29/24 at 1:05 PM, Staff (S) 1, the Clinical Coordinator, confirmed that there were no monthly comprehensive nutrition assessments for August, September, and October of 2024. A review of the medical record for P8 revealed the following: P8 was admitted to the facility on 8/7/24. There was no documented evidence of a comprehensive nutrition assessment as of the day of survey, 10/30/24. This was 54 days after the required timeframe that a comprehensive nutritional assessment should be completed 30 days after admission, as per facility policy. On 10/29/24 at 1:05 PM, S1 confirmed that there were no monthly comprehensive nutrition assessments for August, September, and October of 2024. Facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised October 2024 stated, “... Assessment: The facility’s interdisciplinary (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP), if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social worker and a qualified renal dietitian per CMS ... 2. Assessment criteria will include, but not be limited to, evaluation of: ... Nutritional status by dietician ... 4. A comprehensive assessment will be conducted on all new patients within 30 calendar days [or 13 outpatients for hemodialysis] beginning with the first outpatient dialysis treatment or per state guidelines ... 7. A comprehensive reassessment of each patient and a revision in the plan of care will be conducted: ... At least monthly for unstable patients ...” N.J.A.C 8:43A-24.13(c)”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 39223 Based on two of two medical record reviewed of unstable patients (Medical Record (MR) 4 and MR 6), review of facility policy, and staff interview, it was determined that the facility failed to ensure a comprehensive reassessment and revision of the plan of care (PoC) is conducted at least monthly for a patient designated as “unstable.” Findings include: A review of Patient (P) 4’s medical record revealed the following: A Patient Plan of Care meeting, conducted on 7/10/24, determined that the patient’s status was “unstable.” There was no documented evidence of an interdisciplinary plan of care meeting or update to the patient’s plan of care during the following months of August, September, and October 2024. A review of the medical record for P6 revealed the following: A Patient Plan of Care meeting, conducted on 07/17/24, determined that the patient’s status was “unstable.” There was no documented evidence of an interdisciplinary plan of care meeting during the following months of August, September, and October 2024. During an interview on 10/29/24 at 12:07 PM, Staff (S) 1, the Clinical Coordinator, stated that the facility did not have the regular Registered Dietitian (RD) working at the facility since he/she went on a leave of absence in July. S1 stated that the facility had hired another RD to help with patients during this time, but he/she did not assess all the patients. S1 stated that Registered Nurse, Social Worker, and the Nephrologist continued to meet for Patient Plan of Care meetings during this time, but did not sign off on a new or updated Patient Plan of Care due to the lack of a RD at the meetings. Upon request for documented evidence of the meetings, S1 was unable to provide. Facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised October 2024, stated, “... Assessment: The facility’s interdisciplinary (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP), if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social worker and a qualified renal dietitian per CMS ... 7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: ... At least monthly for unstable patients ...” N.J.A.C. 8:43A-24.13(b)”

“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: 39223 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to manage the patient’s elevated blood pressure for three of six hemodialysis treatments reviewed. Findings include: A review of Patient (P) 4’s medical record revealed the following: The Plan of Care Meeting, dated 7/10/24 stated, “... Fluid/BP [Blood Pressure] Maintain post weight compared to target weight. Blood pressure within range. ...” The Patient Summary report indicated a medication order, dated 12/18/23, “... Clonidine [medication used to treat high blood pressure] 0.2 Milligram Oral Every 4 hours as needed ...”. A review of the hemodialysis treatment flowsheet, dated 10/11/24, indicated the following: 05:52 AM BP 184/104, a RN noted, “... High BP noted Pt [patient] asymptomatic; monitoring ...” 06:22 AM BP 180/99 06:52 AM BP 176/100 07:22 AM BP 177/93 07:52 AM BP 148/100 08:22 AM BP 130/111 08:52 AM BP 172/91 09:16 AM BP 176/131, a RN noted, “... Treatment terminated ...” Clonidine was not administered during the treatment. There was no documented evidence that the physician was notified of the elevated blood pressures, or the reason Clonidine was not administered. A review of the hemodialysis treatment flowsheet, dated 10/16/24, indicated the following: 06:04 AM BP 190/106, a RN noted, “... Treatment started without complications ...” 06:33 AM BP 193/104 07:03 AM BP 177/109, a PCT noted, “... bp elevated ...” 07:33 AM BP 193/106, a RN noted, “... BP remains elevated ...” 08:03 AM BP 194/108 08:33 AM BP 191/107 09:03 AM BP 193/126 09:33 AM BP 191/107, a RN noted, “... BP remains elevated; pt asymptomatic; denies headache; chest pain; dizziness; monitoring closely ...” 09:44 AM BP 187/97, a RN noted, “... Treatment terminated ...” Clonidine was not administered during the treatment. There was no documented evidence that the physician was notified of the elevated blood pressures, or the reason Clonidine was not administered. A review of the hemodialysis treatment flowsheet, dated 10/19/24, indicated the following: 06:14 AM BP 175/107, a Registered Nurse (RN) noted, “... Treatment started without complications ...” 06:45 AM BP 207/186, a RN noted, “... Patient blood pressure is elevated ... rechecking bp ...” 06:45 AM BP 179/104, a RN noted, “... readjusting bp cuff ...” 06:46 AM BP 179/104, a RN noted, “... bp stable ...” 07:14 AM BP 182/103, a PCT noted, “... bp remains elevated; will continue to monitor ...” 07:44 AM BP 171/105 08:14 AM BP 189/112 08:44 AM BP 167/99 09:14 AM BP 183/104, a RN noted, “... Patient appears to be tolerating treatment well at this time; bp elevated; pt asymptomatic. no sign of distress ...” 09:46 AM BP 190/103, a RN noted, “... Treatment terminated ...” Clonidine was not administered during the treatment. There was no documented evidence that the physician was notified of the elevated blood pressures, or the reason Clonidine was not administered. The above hemodialysis treatment flowsheets were reviewed with Staff (S) 1, the Clinical Coordinator, on 10/29/24 at 1:00 PM. S1 confirmed that the above blood pressures were elevated, that the order for Clonidine lacked a specific range of blood pressure that would indicate when to administer the medication, and that the physician was not notified of the elevated blood pressures. S1 confirmed that Clonidine was not administered to the patient during hemodialysis treatment. Facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, stated, “... ABNORMAL FINDINGS ... Blood Pressure Intradialytic: Systolic greater than 180 mm/Hg [millimeters of mercury] or less than 90 mm/Hg. Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg ...” N.J.A.C. 8:43A-24.13(b)”

“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 one observation of initiation of hemodialysis through an arteriovenous fistula (AVF), staff interview, and a review of facility documentation, it was determined that the facility failed to ensure that the staff perform skin disinfection of the access site prior to initiating the dialysis treatment in accordance with facility policy. Findings include: On 10/28/24 at 10:10 AM, Staff (S) 7, a Patient Care Technician (PCT), was observed entering Station 11 to initiate dialysis through an AVF (a connection that is made between an artery and a vein for dialysis access). S7 cleansed the site of the AVF with an alcohol preparation (prep) pad in a circular motion for 60 seconds and allowed it to air dry. S7 then cleansed the same site again with povidone iodine in a circular motion for 10 seconds. This was 20 seconds less than required per the facility policy. S7 proceeded to clean the second site with povidone iodine for seven seconds. This was 23 seconds less than the required time per the facility policy. During an interview at 10:35 AM, S7 stated, “I believe the policy is to clean the site with alcohol for 10 seconds and then 20 seconds with betadine with a dry time of two minutes, but I would have to double check.” A review of the facility policy titled, “AV Fistula or Graft Cannulation With Nipro Or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised October 2022, stated, “Skin Antiseptic ... Povidone Iodine ...Effective Contact Time ... 30 seconds ...Procedure: ...11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. (For contact and dry time refer to table above) ...” N.J.A.C. 8:43A-24.8(b)”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 49828 Based on one of one medical record (MR) reviewed (Patient [P] 8), review of facility policy, and staff interview, it was determined that the facility failed to ensure that the patient’s interdisciplinary team (IDT) developed an initial plan of care (PoC) within 30 calendar days of admission. Findings include: A review of the medical record for P8 revealed the following: P8 was admitted to the facility on 8/7/24. There was no documented evidence that an initial PoC was developed 30 calendar days after the patients first treatment on 8/7/24. From the day of survey, 10/30/24, 84 calendar days had passed from P8’s admission date. On 10/29/24 at 1:05 PM, the above findings were confirmed with Staff (S) 1, the Clinical Coordinator. S1 stated the initial PoC was not completed. During an interview at 1:46 PM with S11, a Facility Administrator (FA) at another clinic, he/she stated that the covering RD (Registered Dietician) did not contribute the patients PoC therefore they were incomplete. S11 continued that the IDT, apart from the RD, held a PoC meeting on 9/25/24 to discuss P8. Upon request for documented evidence of the meeting, S11 was not able to provide. On 10/30/24 at 9:30 AM, S1 provided, “Draft Patient Plan of Care” for P8 which lacked evidence of a RD contribution rendering the provided draft PoC incomplete. Facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised October 2024 stated, “... Assessment: The facility’s interdisciplinary (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP), if allowed by state ESRD [end-stage renal disease] licensure regulations, treating the patient for ESRD, a social worker and a qualified renal dietitian per CMS ... Plan of Care: ... New Patient: ... Plan of Care: Within 30 days of admission to facility (or within 13 treatments) ...” N.J.A.C 8:43A-24.13(b)”

“QAPI-ONGOING;USES INDICATORS=IMPROVEMENT CFR(s): 494.110(a)(1) The program must include, but not be limited to, an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors. This Standard is not met as evidenced by: 49828 Based on a review of the facility’s Quality Assurance and Performance Improvement (QAPI) and staff interview, it was determined that the facility failed to develop measurable interventions to achieve improvement in the health outcome of Mineral Bone Disease (MBD) and Nutrition Management for increased phosphorous (Phos) levels. Findings include: A review of the facility’s QAPI documentation from May 2024 through October 2024 revealed the following: In June 2024, the percentage of patients with a Phosphorus greater than seven was 7.3%, which met the facility’s goal of 12.6%. During July 2024, the percentage of patients with a Phosphorus greater than seven was 16.4%. Due to this increase the facility was no longer meeting their Phosphorus goal. During August 2024, the percentage of patients with a Phosphorus greater than seven increased to 19.2%. This continued trend remained outside of the Phosphorus goal. There was no documented evidence within the facility’s QAPI of a measurable intervention for the increased Phosphorus percentages. During an interview on 10/30/24 at 10:30 AM, Staff (S) 1, the Clinical Coordinator, stated that there is no current action plan for the increase in Phosphorus percentage. N.J.A.C 8:43A-24.18(b)(5)”

“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: 39223 Based on the review of medical records, facility documents, and staff interview, it was determined that the facility failed to ensure that: 1) progress notes are documented in seven of seven medical records (MR) reviewed (Patient [P] 3, P4, P5, P6, P7, P8 and P9) by the registered dietitian (RD) monthly and; 2) pre and post-treatment pain assessments are documented with a numerical value (0-10). Findings include: 1. A review of medical records revealed the following: MR3 lacked documented evidence of monthly RD (Registered Dietician) progress notes for August, September, and October of 2024. MR4 lacked documented evidence of monthly RD progress notes for August, September, and October 2024. MR5 lacked documented evidence of a monthly RD progress note for August 2024. MR6 lacked documented evidence of monthly RD progress notes for August, September, and October 2024. MR7 lacked documented evidence of monthly RD progress notes for August, September, and October of 2024. MR8 lacked documented evidence of monthly RD progress notes for August, September, and October 2024. MR9 lacked documented evidence of monthly RD progress notes for June, August, and October 2024. During an interview on 10/29/24 at 12:08 PM, Staff (S) 1, the Clinical Coordinator, explained that RD is on maternity leave and the facility has had a covering RD since July 2024. During a follow up interview at 1:10 PM, S2, Administrative Staff, stated that the Manager of Clinical Services had confirmed to him/her that the covering RD should be following the duties outlined on his/her signed job description, which indicated that the RD must document nutrition progress at least monthly. S2 provided a job description signed by the covering RD on 02/14/22, that stated, “... Essential Duties and Responsibilities ... Documents nutrition progress at least monthly ...” Facility policy titled, “Progress Note Policy,” revised October 2024, stated, “... Dietician: Dieticians are required to document patient progress notes at a minimum of every 90 days or more frequently as needed per state regulations ...” N.J.A.C 8:43A-24.13(d) 39228 2. On 10/29/24, a review of P3’s hemodialysis “Treatment Nurse Assessment” on the “Treatment Details Report,” from 10/07/24 through 10/25/24, revealed the following: The post-treatment pain assessment was documented as “N/A [not applicable]” on the following treatment dates: 10/09/24, 10/14/24, 10/16/24. On three of the nine treatment dates, the medical record for P3 lacked documentation of post-treatment pain assessments. On 10/29/24, a review of P5’s hemodialysis “Treatment Nurse Assessment” on the “Treatment Details Report,” from 10/07/24 through 10/25/24, revealed the following: The pre-treatment pain assessment was documented as “No” on the following treatment dates: 10/09/24, 10/11/24, 10/14/24, and 10/16/24. The post-treatment pain assessment was documented as “N/A” on the following treatment dates: 10/09/24, 10/16/24, and 10/21/24. On four of the nine treatment dates, the medical record for P5 lacked documentation of pre-treatment pain assessments. On three of the nine treatment dates the medical record lacked documentation of post-treatment pain assessments. 49828 A review P6’s of the hemodialysis “Treatment Nurse Assessment” on the “Treatment Details Report,” from 10/07/24 through 10/25/24, revealed the following: The pre-treatment pain assessment was documented as “No” on the following treatment dates: 10/09/24, 10/16/24, and 10/21/24. The post-treatment pain assessment was documented as “N/A” on the following treatment dates: 10/14/24, and 10/16/24. On three of the nine treatment dates, the medical record for P6 lacked documentation of pre-treatment pain assessments. On two of the nine treatment dates the medical record lacked documentation of post-treatment pain assessments. 51227 On 10/29/24 at 12:03 PM, an interview was conducted with Staff (S) 1, the Clinical Coordinator. S1 explained that the pre- and post-treatment pain assessments by the Registered Nurse should be documented in the comments section of the Treatment Nurse Assessment and that a numeric pain score should be documented for both pre- and post-assessments. S1 further stated that if the patient has no pain, it should be documented as a 0 out of 10. A review of the facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” last revised April 2024, stated, “... Policy: ... 2. The Nursing assessment will be performed an documented by a licensed nurse ... a. The assessment includes the following components: ... vi. A physical assessment of the patient which includes ... 5. Patient statement of well-being, level of pain or discomfort ...” N.J.A.C. 8:43A-24.4(a)”