Meridian Fresenius Dialysis Red Bank

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 51990 Based on observation, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that one of one In-Center Hemodialysis (ICHD) emergency evacuation box contains supplies for every licensed patient station and contains a comprehensive checklist of all supplies/medications. Findings include: On 01/14/26 at 12:00 PM, the ICHD emergency evacuation box was reviewed in the presence of Staff (S)2. The checklist titled “Emergency Box Contents Log Incenter- Monthly” was checked on 01/02/26 and indicated the following supplies were present in the box: 12 Catheter caps, 12-10cc (cubic centimeter) syringes with needles and 12- three-ply 12x17 underpads. The ICHD emergency evacuation box did not have the amount of supplies needed for the above items for 15 licensed patient stations in the event of an emergency. Furthermore, the emergency box contained three tubes of Glutose15 (an oral gel used to treat low blood sugar) and two tubes of Triple Antibiotic Ointment. The checklist did not include the medications found in the evacuation box. During an interview on 01/14/26 at 12:15 PM, S2 confirmed that the facility had 15 licensed stations and stated that there should be enough supplies in the box for 15 patients. S2 also stated, “I don’t know why the medications are in the box.” Facility policy titled, “Emergency Medication Equipment and Supplies,” published 07/07/25, stated, “... Definitions ... Emergency Evacuation Box: An emergency evacuation box contains supplies primarily needed to emergently remove needles, cap catheters and provide saline as needed for every licensed station ... Emergency Evacuation Box ... An itemized log must be kept indicating the contents ...” N.J.A.C. 8:43A-15.1(a)”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 37656 Based on observation, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that potentially contaminated equipment is not stored in a designated clean area. Findings include: On 01/14/26 at 10:35 AM, the area across from Station 7 and Station 8 contained a dialysis chair, a gray rolling office chair, an O2 (oxygen) concentrator, two sets of dialysis initiation packages, and a patient’s wheelchair with the patient’s jacket and other belongings on it. The patient’s wheelchair was touching the dialysis chair. Upon interview on 01/14/26 at 10:40 AM, Staff (S)8 stated that the area indicated above was designated as a clean area and that the dialysis chair, the O2 concentrator, and the two sets of dialysis initiation packages, were all clean except for the patient’s wheelchair and the office chair. S8 confirmed that the patient’s wheelchair and the office chair should not be stored next to the clean supplies in the clean area. Facility policy titled, “Dialysis Precautions,” published 01/04/2012, stated, “... Clean Versus Dirty Areas Clean area: An area designated for clean and unused equipment, supplies and medications. ... Clean areas should be clearly separated from dirty areas where used supplies, equipment ... are handled ...” N.J.A.C. 8:43A-24.8(b)”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 37656 Based on two of two observations of the cleaning and disinfection of hemodialysis stations, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that all equipment and surfaces within the hemodialysis station is cleaned and disinfected in accordance with facility policy and that the hemodialysis station is completely cleaned and disinfected before preparing the hemodialysis machine for a new patient in accordance with facility policy. Findings include: On 01/14/26, during a tour of the Hemodialysis Treatment Floor, the following was revealed: At 9:55 AM, Staff (S)3 was observed during the cleaning and disinfection of Station 15. S3 obtained white cloth wipes soaked with 1:100 (one part bleach to 100 parts water) bleach solution then started cleaning the dialysis machine. He/she then took the BP (blood pressure) cuff and placed it flat on the surface of the unclean chase wall and wiped the BP cuff down with the bleach-soaked wipes then placed it into the holder mounted to the machine. S3 then cleaned the dialysis chair, opened the right side arm of the chair and cleaned only the upper half of the inside arm. S3 did not clean the TV (television) console and the chase wall. Upon interview at 10:00 AM, S3 stated he/she was finished cleaning the station. This surveyor asked about the cleaning of the BP cuff on the unclean chase wall, why only the upper half of the inside right side arm of the chair was cleaned, and not cleaning the TV and the chase wall. S3 did not respond, exited the station and obtained bleach-soaked wipes and wiped down the BP cuff again, wiped all the surfaces of the chair’s right side arm, the chase wall, and the TV console. A review of S3 Personnel file indicated that on 09/19/25, S3 completed the “Coaching Report ... Annual Skills...” which included training on Disinfection of the Dialysis stations. At 10:35 AM, S9, used a new bleach-soaked cloth to clean and disinfect the dialysis machine. After cleaning the dialysis machine, S9 placed a new dialysis tubing, dialyzer filter (a device that filters waste, toxins and excess fluids in the blood during hemodialysis), hung a one-liter normal saline bag on the machine, then proceeded to set up the dialysis machine. Once set up, S9 then proceeded to clean the recliner chair. S9 did not wait until the dialysis station was clean and disinfected before setting up the hemodialysis machine for the next patient to prevent cross contamination. At 10:39 AM, S9 used a new bleach-soaked cloth to clean and disinfect the hemodialysis recliner chair. S9 placed the chair in the reclining position, opened the left chair arm, cleaned the inside of the left arm, then wiped the seat of the chair, the back portion of chair, the footrest and then immediately closed the left chair arm. S9 continued to open the right chair arm, cleaning the inside of the right chair arm and then closed the right chair arm immediately. S9 did not allow the surfaces to air dry before closing the arms of the chair. S9 also did not clean the chase wall behind the patient recliner. During an interview at 10:45 AM, the above findings were discussed and confirmed with S9. S9 stated that the dialysis station, recliner chair and chaise wall should be completely cleaned and disinfected before setting up the dialysis machine for a new patient. A review of S9’s file revealed that he/she has completed the “Coaching Report” on 03/07/25 that includes education and training on “Patient Discharge: Disinfection of Dialysis Station”. Facility policy titled, “Cleaning and Disinfecting the Dialysis Station,” published 09/02/25 stated, “Procedure ... Step 3 ... Action ... Use a cloth wet with 1:100 bleach solution or EPA [Environmental Protection Agency] - approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff, hand sanitizer dispenser and holder, sharps container mounted to the machine, chaise wall behind chair). Place the chair in Trendelenburg [tilted, head-down] position and open side panels if chair has swing open sides so all surfaces of the chair are accessible ... Step 4 .... Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry ... “ N.J.A.C. 8:43A-24.8(b) 50912”

“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: 37656 Based on a review of facility documents and staff interview, it was determined that the facility failed to ensure testing for residual disinfectants is performed after monthly AmeriWater (reverse osmosis [RO] water system) disinfection with bleach (a chemical disinfectant) in two of six disinfections, in accordance with facility policy. Findings include: A review of the “Water Treatment - Central RO” logs revealed the following: On 08/22/25, the log stated, “PM: AME- MRO4x - Water loop Disinfect ... RO Disinfect ...” The “Post Loop Disinfection Residual Testing” log indicated that the residual testing was documented on 08/27/25, five days after disinfection. On 11/19/25, the log stated, “PM: AME- MRO4x - Water loop Disinfect ... RO Disinfect ...” The “Post Loop Disinfection Residual Testing” log indicated that the residual testing was documented on 11/25/25, six days after disinfection. Upon interview on 01/15/26 at 11:30 AM, Staff (S)5 confirmed the above findings and stated that the residual bleach testing should be done the next day before the patient treatments. Facility policy titled, “Testing for Residual Bleach Using WaterCheck RC Residual Chlorine Reagent Test Strips,” published 05/02/2024, stated, “... At a minimum, residual bleach must be tested: ... After a bleach disinfection of the Solution Delivery System ... Documentation Testing results for residual bleach must be documented in the approved electronic documentation system ...” N.J.A.C. 8:43A-24.10(a)”

“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: 50912 Based on review of facility documents and staff interview, it was determined that the facility failed to ensure that nine of 17 HD (Hemodialysis) machines are disinfected at the end of each treatment day and documented in accordance with the facility policy. Findings include: On 01/15/26 at 9:38 AM, a review of the 2008 Machine Heat Disinfection V3 logs for November revealed that the following HD machines lacked documentation of citric acid cleaning and heat disinfection on the following dates: HD machine 159035 had no documented disinfection on 11/05/25 and 11/14/25; HD machines 159465, 159609 and 159669 had no documented disinfection on 11/12/25; and HD machine 159694 had no documented disinfection on 11/14/25. A review of the 2008 Machine Heat Disinfection V3 logs for December revealed that the following HD machines lacked documentation of citric acid cleaning and heat disinfection on the following dates: HD machine 159559 had no documented disinfection on 12/03/25; HD machine 159463 had no documented disinfection on 12/10/25; and HD machines 159035 and 159733 had no documented evidence of disinfection on 12/12/25. During an interview on 01/15/26 at 1:34 PM, the above findings were reviewed with and confirmed by Staff (S)4. S4 stated that the machines would normally have been acid cleaned, and heat disinfected at the end of each treatment day and documented by staff. S4 further stated that staff should have written a note for each HD machine lacking documentation of disinfection stating the reason why it was not disinfected. Facility policy titled, “Hemodialysis Machines: Acid Clean, Chemical Rinse, and Heat Disinfection,” published 07/07/25, stated, “... Policy ... to define the minimum requirement for acid clean, chemical rinse and heat disinfection of the dialysis machine. ... At the end of each treatment day of use, the dialysis machine must be: ... Acid cleaned with a set of acid clean cycle of minimum of 15 minutes. Chemical rinse or heat disinfection must be performed before treatment ... Operation of the machine in rinse mode during loop disinfection does not substitute for the daily machine disinfection. ... Documentation: Clinical staff will document acid clean, chemical rinse with presence and residual chlorine testing results and heat disinfection using the log(s) in the company approved electronic CMMS [Computerized Maintenance Management System] system. ...” N.J.A.C 8:43A-24.11(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: 51990 Based on two of seven medical records reviewed (Patient [P]1 and P3), staff interview, and a review of facility documents, it was determined that the facility failed to ensure a comprehensive reassessment and a revision of the Plan of Care (POC) are conducted monthly by the IDT [Interdisciplinary Team, includes a Physician, a Registered Nurse (RN), a Social Worker (SW), and a Registered Dietitian (RD)] for unstable patients. Findings include: A review of P1’s medical record revealed the following: P1’s was deemed “Unstable” due to frequent hospitalizations on 03/31/25. There was no documented CIA by the physician for the March 2025 POC. The monthly “Unstable” POC meeting was held on 04/28/25. There was no documented CIA by the physician for the April 2025 POC. The monthly unstable Comprehensive Interdisciplinary Assessment (CIA) by the IDT for May 2025 was completed. There was no documented evidence of a completed POC by the IDT for May 2025. An unstable POC meeting was held by the IDT on 06/30/25. There were no documented CIAs by the IDT for the June 2025 POC. During an interview on 01/16/25 at 9:10 AM, Staff (S)1 explained that P1 was hospitalized on 05/10/25 and was discharged with family who lived out of state on 05/13/25. P1 returned to the facility on 06/06/25. A POC meeting was then held on 06/30/25. Furthermore, the medical record lacked documented evidence of a monthly unstable CIA and POC by the IDT for July, August, September, October and November of 2025. There was a completed CIA and POC by the IDT on 12/24/25 which further indicated that P1 remained unstable. During an interview on 01/15/26 at 11:15 AM, Staff (S)1 stated P1 is chronically unstable and confirmed the above findings of the missing documentation. A review of P3’s medical record revealed the following: P3’s was deemed “Unstable” on 12/15/25 due to a diagnosis of Liver Cirrhosis. The monthly “Unstable” POC meeting was held on 01/14/26. The CIA by the Physician was dated 01/16/26. This was two days after the POC meeting was held. During an interview on 01/16/26 at 10:05 AM, S1 confirmed the above findings. Facility policy titled, “... Comprehensive Interdisciplinary Assessment and Plan of Care,” published 07/02/23, stated, “... Background ...An Interdisciplinary Assessment and Plan of Care must be completed by the Interdisciplinary team members ... CIA/ POC for Unstable Patients ... Unstable patients must be reassessed by the IDT monthly ... Monthly reassessment and any POC updates related to the reason the patient is considered unstable must be documented until the issues have been resolved ...” N.J.A.C. 8:43A-24.4(a)”

“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: 50912 Based on medical record review, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that staff assess patients for edema (fluid build-up in the body tissues) post (after) hemodialysis treatment in accordance with facility policy in one of seven medical records reviewed (Patient [P] 6). Findings include: A review of P6’s Plan of Care (POC), dated 08/12/25, stated, “Area of Focus BP [blood pressure] and Fluid Management: Goal Achieve BP Control as specified by the patient’s physician ... Intervention (s): ... Re-evaluate/Assess dry weight: In Progress ... Use fluid volume algorithm (MD [Medical Doctor] order): In Progress ...” A review of the “Treatment Sheet for Facility” from 12/24/25 through 01/08/26 in P6’s medical record revealed the following: On 01/03/26, 01/06/26 and 01/08/26, the pre-treatment (before treatment) “Nursing Evaluation” indicated “bilateral [affecting both sides] ankle, 1+ [plus]: 2 mm [two millimeters] or less, disappears rapidly. ...” The post treatment “Nursing Evaluation” lacked documented evidence of a re-assessment of the bilateral ankle edema. During staff interview on 01/16/26 at 1:16 PM, the above treatment sheets were reviewed with Staff (S)1. S1 confirmed that the post hemodialysis re-assessment of edema were not documented on the above-mentioned hemodialysis flowsheet dates. S1 confirmed the above findings and agreed that if there were abnormal findings in the pre-assessment of the patient, the staff should document a re-assessment of the abnormal findings post treatment. Facility policy titled, “Patient Assessment and Monitoring,” published 05/01/23, stated, “... Purpose ... provide guidance to (facility name) direct patient care staff on assessment and monitoring patients before, during and after treatment ... Edema ... Assess the patient for edema ... Location ... Severity ... Post Assessment ... Post-Treatment Follow the steps below for obtaining post-treatment assessing data: ...1. The direct patient care staff may obtain the following: ... Edema ... The Registered Nurse will assess/re-assess post treatment as indicated ... 2. Document findings in the patient’s record ...” N.J.A.C. 8:43A-24.4(a)”

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 51990 Based on one of seven medical records reviewed (Patient [P]3), staff interviews and a review of facility documents, it was determined the facility failed to ensure that a treatment option is discussed to improve nutritional status for a patient with a chronically low albumin (Alb, protein level found in the blood). Findings include: A review of P3’s medical record revealed the following: The laboratory results for the Alb level from February 2025 to January 2026 were as follows: On 02/02/25, the Alb level was 2.5 g/dl (gram per deciliter); on 03/03/25, the Alb level was 2.4 g/dl; on 04/04/25 and 09/03/25, the Alb level was 2.0 g/dl; on 05/07/25, 06/04/25 and 11/05/25, the Alb level was 2.3 g/dl; on 07/02/25 and 12/03/25, the Alb level was 2.1 g/dl; on 08/06/25, the Alb level was 2.2 g/dl; and on 10/01/25 and 01/07/26, the Alb level was 1.9 g/dl. The above results were less than the goal of 4.0 g/dl. There was a decreased trend in Alb for the last 3 months, from November to January. P3’s Home Medication List reviewed by a Registered Nurse on 12/12/25 included LiquaCel (amino acids- protein hydrolys) at home in addition to ONSP (Oral Nutrition Supplements Program) 30ml (milliliters) twice a day. A review of the “Nutrition” portion of the physician’s orders section stated, “ ... Nutritional Supplement: LiquaCel- 1 oz [ounce] PO [by mouth] during Dialysis 3 X [three times] Week ... Start Date ... 01/12/26 ...” The “Nutrition History and Assessment- ESRD [end-stage renal disease]” by the RD [Registered Dietician] dated 01/12/26 stated, “... Nutrition History ... Appetite/current intake ... ...Fair: Appetite and intake decrease ... GI [gastrointestinal] symptoms ... Yes ... Symptoms experience ... Nausea [checked] ... Vomiting [checked] ... Frequency of symptoms affecting nutrient intake ... Some or all symptoms frequent/daily > [greater than] 2 weeks ... Other significant history ... Chronic Ascites decreased appetite r/t [related to] ascites and scheduled paracentesis ... Appetite variable noted decrease more ... N/V [nausea and vomiting] intermittent ... Nutrition Intake ... Oral Nutritional Supplement Program ... Active ... Home Supplements ... Yes ... Comments ... Patient having trouble chewing jimmy bar and want ot [sic] change back to LiquaCel at HD [hemodialysis] TIW [three times a week] ... Anthropometrics ... Estimated Caloric Intake ... Inadequate ... Estimated Protein Intake ... Inadequate ... Analysis of Nutrition Status ... Alb decrease to 1.9 ... Nutrition Related Labs ... Severe Depletion < [less than] 3.0 g/dl ... Malnutrition Risk Score ... Overall Nutrition status (score) ... 8.00 ... Malnutrition risk score ... 8-10 = Moderate malnutrition ...” During an interview on 01/15/26 at 11:15 AM, Staff (S)14 stated that P3 had chronically low Alb and was on ONS. S14 also stated that P3 was taking ‘Jimmy Bars’ and had difficulty chewing them and that the ONS was changed back to LiquaCel with hemodialysis. During an interview on 01/16/26 at 9:55 AM, S17 stated P3 was diagnosed with Liver Cirrhosis in October 2026 and undergoes a paracentesis weekly; and the underlying medical condition causes proteinuria (an abnormal, excess amount of protein in the urine). S17 added, P3 could be assessed for IDPN (Intradialytic Parenteral Nutrition) therapy option. P3’s medical record lacked documented evidence that a treatment option was discussed by the RD and Physician to improve P3’s albumin level. A policy for low albumin was requested from S1. A Hypoalbuminemia Algorithm was provided by S1 on 01/16/26. Facility algorithm titled, “Hypoalbuminemia Algorithm InCenter Version 1.0,” indicated, “... 7. ... RD to Evaluate Nutritional Intake ... Comorbid interferes with oral intake or absorption ... [Check] If albumin </= 3.5 g/dl Go to step 8. Indication for Treatment ... 8. Indication for Treatment ... Albumin </= (less than or equal to) 3.5 g/dl and patient unable to maintain adequate oral intake ... Discuss enteral nutrition (provide feeding through gastrointestinal tract via a feeding tube) as an option with Physician/ NP [Nurse Practitioner]/PA [Physician’s Assistant] and patient and care partner ...” 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: 39228 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 a review of facility documents, it was determined that the facility failed to ensure that staff perform skin disinfection of the access site prior to initiating the dialysis treatment in accordance with facility policy. Findings include: On 01/14/26 at 11:12 AM at Station 15, Staff (S)3 initiated dialysis through a patient’s left AVF. S3 cleansed the first site of the AVF with an alcohol pad in a circular motion for 18 seconds then cannulated (the act of inserting a needle into the vascular access) the site. S3 cleansed the second site of the AVF with an alcohol pad in a circular motion for 18 seconds then cannulated the site. During an interview on 01/14/26 at 11:30 AM, S4 stated each access site should be cleaned and disinfected for 30 seconds with an alcohol pad. Facility policy titled, “Access Assessment and Cannulation,” published 05/05/25, stated, “... Skin Disinfection: Step 1 Action 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-24.4(a)”

“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: 51990 Based on observation, staff interview, and a review of facility documents, it was determined that the Medical Director failed to ensure that the vascular clamp is used in accordance with facility policy in one of one patient (Patient [P]3), post (after) hemodialysis treatment. Findings include: On 01/14/26 at 10:10 AM, in Station 3, Staff (S)7 discontinued hemodialysis on P3 through a left arm Arteriovenous Fistula (AVF, a type of vascular access used for hemodialysis). S7 decannulated the venous needle and applied pressure on the clean gauze pad over the needle site. At 10:23 AM, S7 then placed a vascular clamp over the venous site. He/she then taped the clamp and secured it in place. At 10:50 AM, P3 reached hemostasis and S7 then removed the clamp and bandaged the venous site. The staff did not check for a thrill (palpable vibration over the AVF indicating good flow) on P3’s access while the vascular clamp was applied from 10:23 AM to 10:50 AM. Furthermore, this was seven minutes longer than what was recommended for the clamp to be in place. During an interview on 1/14/26 at 10:55 AM, S7 stated the access should have been checked for a thrill every 10 minutes and that the clamps should not have been on more than 20 minutes on P3’s site. A review of P3’s medical record lacked evidence of a physician’s order for the use of vascular clamps. Facility policy titled, “Venipuncture Site Clamps,” published 05/05/25, stated, “... Policy ... A physician’s order is required for clamp usage ... While the clamp remains on the access, check for thrill every 10 minutes ... It is recommended not to exceed clamps in place longer than 20 minutes ... Do not use tape to hold clamps in place ...Venipuncture Clamp Procedure ... Step ... 4 ... (If occurring post treatment, it is recommended to remove the arterial needle first to reduce the risk of the arterial needle protruding through the access ...) ...” N.J.A.C. 8:43A-24.4(a)”