Usrc Gloucester

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 39223 Based on observations, review of medical records (MRs), review of facility documents, and interview with staff, it was determined that the facility failed to ensure: 1) proper infection control practice is maintained by returning dirty supplies to a clean supply area (V-111); 2) hand hygiene is performed to prevent cross contamination (V-113); 3) transducer protectors are inspected to prevent blood contamination of the dialysis machines’ pressure monitor (V-120); 4) all surfaces of the hemodialysis station are cleaned and disinfected in accordance with facility policy and manufacturers’ instructions for use (MIFU) (V-122); 5) staff perform skin disinfection of the access site prior to initiating dialysis treatment in accordance with facility policy (V-132); and 6) CVC (Central Venous Catheter) care is provided in accordance with facility policy (V-147). On 08/13/25 at 12:28 PM, an Immediate Jeopardy (IJ) was identified for the facility’s failure to ensure that transducer protectors are inspected to prevent blood contamination of the dialysis machines’ pressure monitor. On 08/13/25 at 4:02 PM, the IJ template was presented to the Facility Administrator (FA), and a Removal Plan was requested. On 08/14/25 at 10:56 AM, an acceptable Removal Plan was received. The facility implemented the following: observation of transducer protectors and staff assessments of patients during patient chairside rounds; interviews with staff revealed staff was educated and all verbalized the correct procedure for inspecting transducer protectors and what to do if it becomes wetted with blood; review of staff education and sign in records; and review of the BMT (Biomedical Technician) documentation of the Visual Check-off of the Transducer. The IJ was removed on 08/14/25 at 11:33 AM, after the State Survey Agency verified full implementation of the Removal Plan, and Condition Level non-compliance remains (V-120). Cross Reference: 494.30 - IC- Sanitary environment 494.30(a)(1)(i) - IC-Wear gloves/hand hygiene 494.30(a) (1)(i) - IC-Transducer protectors - not wetted/changed 494.30(a)(4)(ii) - IC-Disinfect surfaces/equip/written protocols 494.30(a)(1)(i) - IC-Training & Education 494.30(a)(2) - IC-Staff education-catheters/catheter care”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 44833 Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to maintain proper infection control practice by returning dirty supplies to a clean supply area. Findings include: On 08/14/25 at 9:50 AM, Staff (S)10 obtained a clean roll of paper tape from the clean supply cart located in the center of the dialysis treatment floor. S10 used the roll of tape to apply additional pieces of tape directly onto the patient’s vascular access to reinforce the dressing present, before the patient left the hemodialysis treatment floor. S10 applied several pieces and then placed the roll of remaining tape back onto the clean supply cart. On 08/14/25 at 9:56 AM, S10 confirmed that the used roll of tape would have been considered dirty after being used to tape a patient’s arm. S10 also confirmed that the supply cart was considered a clean area and that he/she placed the roll of tape back onto the cart because he/she got “distracted by talking to the patient and forgot.” S10 further stated he/she would have thrown out that roll of tape later, but it should have been thrown out immediately and not placed back on the clean supply cart. On 08/15/25 at 9:47 AM, S1 stated, that the remaining unused portion of paper tape would have been considered dirty once used on a patient and should have been thrown out and not placed back on the clean supply cart. S1 stated that doing so could potentially contaminate the clean supplies and that it was “not acceptable” for S10 to have done that. Facility policy titled, “Infection Control and Precautions at the Dialysis Facility,” revised August 2025 stated, “... Procedure: ... 14. Supplies: Items taken into the dialysis station will either be disposed of, dedicated for use only on a single patient or cleaned and disinfected before being taken to a common clean area or used on another patient ...””

“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: 52927 Based on two of four staff members observed for hand hygiene, staff interview, and review of facility documents, it was determined that the facility failed to ensure that hand hygiene is performed to prevent cross contamination. Findings include: On 08/13/25 at 9:53 AM, Staff (S)5, was observed initiating hemodialysis through a left lower arm arteriovenous graft (AVG, a type of vascular access used for hemodialysis). With gloved hands, S5 cannulated (the process of inserting a catheter into the body for medication administration or other medical treatments) the patient and then touched the hemodialysis machine. S5 then removed his/her gloves, and without the benefit of performing hand hygiene first, donned (put on) a new pair of gloves. S5 proceeded to touch the hemodialysis machine and then without removing his/her gloves, performing hand hygiene, donned a new pair of gloves, and connected the patient’s access to the hemodialysis machine to initiate treatment. During an interview on 08/13/25 at 10:42 AM, S5 stated that he/she did not need to wash his/her hands between glove changes. A review of S5’s personnel file indicated his/her “Clinical Orientation Checklist- Annual,” which included hand hygiene, was completed and satisfactory on 06/10/25. 49828 On 08/14/25 at 10:00 AM, S5 was observed providing care to a patient in the Isolation Room. S5 confirmed that the patient utilizing this room was not on isolation precautions. While providing care to the patient, S5 touched the patient and hemodialysis machine with gloved hands. S5 exited the Isolation Room and then exited the Hemodialysis Treatment Area into the Patient Waiting Area through the door directly across from the Isolation Room without the benefit of removing his/her gloves and performing hand hygiene first. Still wearing the same gloves, S5 re-entered the Hemodialysis Treatment Area escorting a patient onto the unit. S5, with the same gloved hands, entered Station 9 and touched the hemodialysis machine within the station. S5 exited Station 9, with the same gloves on. He/she entered Station 8 and touched the hemodialysis machine within the station. Upon exiting Station 8, S5 removed his/her gloves and performed hand hygiene. S5 did not remove or change his/her gloves or perform hand hygiene upon exiting the Isolation Room, exiting and re-entering the Hemodialysis Treatment Area, entering and exiting Station 9, and upon entering Station 8. During an interview at 10:10 AM, S5 stated he/she was unaware he/she did not remove his/her gloves and perform hand hygiene during the observation explained above. S5 stated, “I didn’t change my gloves?” Facility policy titled, “Hand Hygiene,” revised August 2020, stated “HAND HYGIENE will be performed: 1. Before and after touching a patient 2. Prior to entering and on exiting station to provide care to patient ... 8. After touching patient surroundings (e.g., dialysis machine, any items in the dialysis area or chairside computers) 9. After gloves are removed. ... 12. Before entering and on exiting the patient treatment areas ...” Facility policy titled, “Infection Control and Precautions for All Patients,” revised July 2023, stated, “... PROCEDURE: ... 10. Hand Hygiene ... b. Staff will perform hand hygiene: i. Using soap and water or antibacterial hand sanitizer before/after all patient contact and before donning and after doffing [removing] PPE [personal protective equipment], including gloves. ii. After contact with integrated keyboard or chairside computer, regardless of whether contact occurred through gloves or ungloved hands ...””

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 39223 Based on two of three observations of a wetted external transducer protector, staff interview, and document review, it was determined that the facility failed to ensure that the transducer protector is inspected to prevent blood contamination of the dialysis machines’ pressure monitor. Findings include: On 08/13/25 at 10:25 AM in Station 2, the venous transducer was noted to be wet with blood. At 1:28 PM, Staff (S)3 disconnected the patient from the hemodialysis machine. S3 then removed and discarded the tubing from the machine without inspecting the side of the transducer that faces the machine. At that time, S3 and this surveyor inspected the venous external transducer protector, confirming that the external transducer protector had become wet with blood. During interview at the time of discovery, S3 stated that he/she clamps the line to prevent fluid or blood from backing out of the tubing. He/she then inspects the metal connector on the hemodialysis machine. When asked if he/she should inspect the side of the transducer protector that faces the machine, S3 stated, “No.” At 12:28 PM in Station 1, the venous transducer was noted to be wet with blood. S2 disconnected the patient from the hemodialysis machine. S2 then removed and discarded the tubing from the machine without inspecting the side of the transducer protector that faces the machine. During an interview at the time of discovery, S2 stated that he/she didn’t see it (blood) back up into the transducer. S2 and this surveyor were able to confirm that the venous transducer had become wet with blood by inspecting the discarded tubing together. He/she stated that when he/she pulled the transducer protector off, he/she clamped the line to prevent fluid and blood backing out of it. He/she then stated that he/she did not see any blood on, “the white part.” A review of the Fresenius Medical Care 2008T Hemodialysis Machine Operator’s Manual (490122 Rev AB) stated, “... General Warnings ... Warning! Transducer protectors should be used between pressure ports and each pressure monitor line of the extracorporeal system to prevent the internal transducer protectors from getting wet. Wet transducer protectors must be replaced, as they will cause inaccurate pressure readings. If the external transducer protector and the internal transducer protector become contaminated with blood, the transducer protectors must be replaced and the transducer, pressure ports, internal tubing and valve must be disinfected or replaced to prevent cross-contamination between patients. ...” Facility policy on Intradialytic Monitoring of Patient stated, “... Delivery System Monitoring ... NOTE: If transducer filter becomes wet, replace immediately. Inspect the side of the protector that faces the machine. If fluid is visible, biomed [biomedical] technician will be notified and machine taken out of service after dialysis treatment is completed. ...””

“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: 52927 Based on observation, staff interview, review of facility documents, and review of manufacturer’s instructions for use (MIFU), it was determined that the facility failed to ensure: 1) all surfaces of the hemodialysis station are cleaned and disinfected in accordance with facility policy and MIFU for one of two observations of the cleaning and disinfection of a hemodialysis station; and 2) the policy and procedure for the labeling of chlorine (bleach) solution for disinfecting of two of two containers of bleach solution is implemented. Findings include: 1. On 08/13/25 at 10:16 AM, in Station 7, Staff (S)5 was observed cleaning and disinfecting the hemodialysis station after the patient was discharged. S5 used a bleach-soaked cloth to clean and disinfect the top, left side, right side, front, back and tubing of the hemodialysis machine. S5 did not wipe the IV (intravenous) pole or the prime bucket located on the right side of the machine. S5 used a new bleach-soaked cloth to clean the hemodialysis chair. S5 placed the chair in the reclining position, opened the chair arms and wiped the seat, footrest, backrest, armrest, chair arms and side tray tables. S5 closed the arms of the chair immediately and did not allow the surfaces to air dry. S5 used the same bleach-soaked cloth to wipe the TV (television) remote and the blood pressure (BP) cuff. S5 did not use a new bleach-soaked cloth to clean the TV remote and BP cuff as required by facility policy. S5 did not wipe the cords connected to the TV remote or the BP cuff and the countertop behind the recliner, as required by facility policy. During an interview at 10:20 AM, the above findings were discussed with S5 and he/she stated, “I should have cleaned the IV pole, cords, countertops, and prime bucket.” When questioned about closing the arms of the recliner immediately, S5 stated, “I am not privy to knowing a dry time before closing the chair, maybe 30 seconds.” S5 proceeded to clean the IV pole, TV remote and BP cuff cords, countertop and prime bucket. On 08/14/25 during an interview at 2:10 PM, S6 explained the five minute contact time in the policy refers to the time it takes to clean the recliner and letting the bleach solution to air dry. At 2:20 PM, S6 provided the MIFU for the bleach solution used to clean and disinfect stations. On 08/15/25 during an interview at 9:29 AM, S1 stated, “Closing a recliner immediately does not allow it to air dry.” A review of S5’s personnel file indicated his/her “Clinical Orientation Checklist- Annual,” which included disinfection and cleaning of equipment and station, was demonstrated and satisfactory on 06/10/25. A review of the MIFU for the Pure Bright Germicidal Ultra Bleach, stated, “... Work surfaces ... Instructions ... cover surface with bleach solution for at least 2 minutes, drain, let air dry. ...” Facility policy titled, “Disinfection and Cleaning of Dialysis Machine Equipment,” revised July 2023 stated, “POLICY: 3. The bleach solution will have at least 5 minute contact time as per manufacturer’s recommendation for external disinfection of non-disposable items, dialysis machines, dialysis chars and related surfaces ... DISINFECTION PROCEDURE: 2. Follow manufacturer’s instructions for disinfection of the dialysis machine, chair and related equipment. Follow instructions for appropriate disinfectant and appropriate contact time ... 6. Obtain at least one (1) clean moistened 1:100 [one part bleach to 100 parts water] bleach cloth for the machine, one (1) for the chair and one (1) for ancillary equipment (oxygen concentrator/acid jig/TV/TV remote) 7. Clean all external surfaces of the dialysis machine to include top, sides, front and back, BP cuffs and basket; dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on pole ... 8. Disinfect all surfaces of the prime waste container, inside and out, with a moistened 1:100 bleach cloth. 9. Clean counter tops behind patient station ... 11. Clean chair by placing in the reclining position and swing arms out (if applicable) to clean seat, footrest, backrest and sides, armrest, inside of chair arms and chair frame and side tray tables. Return chair to its upright position when cleaning is complete.” 2. On 08/13/25 at 9:50 AM, the following was observed during a tour of the Hemodialysis Treatment Area: A clear, rectangular plastic box that contained a clear, yellow solution was present in the designated dirty area located across from Station 2. It did not contain a label indicating the contents of the plastic box. A clear, rectangular plastic box that contained a clear, yellow solution was present in the designated clean area located across from Station 6. It did not contain a label indicating the contents of the plastic box. During an interview at 10:09 AM, S4, stated the containers were bleach solutions that were made this morning. S4 stated the containers needed to have a label in place to reflect the type of solution, date and time of when the solution was prepared and the initials of who prepared it. At 10:49 AM, S4 labeled both containers. Facility policy titled, “Disinfection and Cleaning of Dialysis Machine Equipment,” revised 07/2023 stated, “ POLICY: ... 2. Label each bleach container with concentration, date, time and initials of individual mixing the bleach solution.””

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 52927 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 the staff perform skin disinfection of the access site prior to initiating dialysis treatment in accordance with facility policy. Findings include: On 08/13/25 at 9:53 AM, Staff (S)5 was observed entering Station 6 to initiate hemodialysis through an AVF. S5 cleansed both sites of the AVF with one alcohol preparation (prep) pad in a circular motion for 18 seconds. This was 12 seconds less than required by facility policy. S5 proceeded to cleanse the second site with a new alcohol prep pad for four seconds. This was 26 seconds less than required by facility policy. A review of S5’s personnel file revealed the “Clinical Orientation Checklist-Annual,” which included access preparation/disinfection, was completed and satisfactory on 06/10/25. During an interview at 10:00 AM, S5 stated “I use one alcohol pad to clean the whole site for 30 seconds and the second alcohol pad to clean the second site for a few seconds. I allow the alcohol to dry for five to 10 seconds.” Facility policy titled, “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation,” revised on July 2025, stated, “... Access Preparation: ... c. Disinfect each access site separately with one of the below options: Cleansing Agent ... Alcohol Prep Pad ... Cleaning Process and Contact Time ... Utilize a rubbing motion for at least 30 seconds ... Dry Time and Cannulation ... Needle insertion can be done immediately. ...””

“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: 52927 Based on one of one observation of the initiation of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis) and review of facility documents, it was determined that the facility failed to perform skin disinfection of the CVC exit site in accordance with facility policy. Findings include: On 08/13/25 at 10:32 AM, in Station 6, Staff (S)4 started the process of initiating dialysis by removing a right chest wall CVC dressing. S4 removed his/gloves, performed hand hygiene and donned (put on) a new pair of gloves. S4 held the patient’s shirt back with his/her hand and cleansed the exit site for 45 seconds with ChloraPrep. S4 then released the patient’s shirt. This allowed the shirt to touch the exit site before drying was complete. S4 did not secure the patient’s clothing to allow for the area to remain clean as required by facility policy. S4 did not re-clean the exit site after the patient’s clothing touched the area. A review of S4’s personnel file revealed that the “Clinical Orientation Checklist-Annual,” which reviews dressing changes was demonstrated and satisfactory on 04/25/25. Facility policy titled, “Dialysis Catheter Dressing Change Procedure,” revised February 2023, stated, “ PROCEDURE: ... 3. Secure clothing away from dressing/exit site. ...””

“H-HOME PT PLAN OF CARE DEV/UPDATED CFR(s): 494.100(b)(1)(iii) Services include, but are not limited to, the following: (iii) Development and periodic review of the patient’s individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs and meets the measurable and expected outcomes as specified in §494.90 of this part. This Standard is not met as evidenced by: 49828 Based on one of one medical record reviewed (Patient [P]3) for peritonitis, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that a home Peritoneal Dialysis (PD) patient with a change in mental status did not have a delay in care for suspected peritonitis. Findings include: A review of P3’s Plan of Care, dated 05/23/25, stated, “... HOSPITALIZATIONS ... Goal: Return pt [patient] to optimal functionality ... Comments: Prevention of peritonitis, aseptic techniques ... DIALYSIS ACCESS ... Access Actions: Educate pt on signs/symptoms infection to report [sic] ... Mental Cognitive Status ... Pt exhibits long term memory problems? No, Pt exhibits short term memory problems? No, Pt’s ability to make decisions regarding? Independent ...” A review of the “History and Physical,” completed 07/06/25 by the patients’ medical doctor (MD), Staff (S)14, stated, “... REVIEW OF SYSTEMS ... NEUROLOGICAL: no FND [Functional Neurologic Disorder] ...” A review of a phone call transcript from 08/02/25 between the on-call nurse (S13) and P3 revealed the following: P3 called the facilities on-call nursing line on 08/02/25 at 6:35 PM. S13 documented that P3 complained of belly pain and was confused, “HAS NO IDEA OF DATED [sic] OR TIME.” S13 also documented, “... INITIALLY SAID HE/SHE HAD PAIN IN ABDOMEN BUT NO IDEA OF FEVER SINCE HE/SHE LOST THERMOMETER. ALSO SAID HE/SHE HAD NOT DONE DIALYSIS FOR 2+ DAYS. PT ALSO STATES HE/SHE THINKS DRAIN IS CLOUDY. -HE.SHE DOES NOT HAVE DRAIN BAGS. HE/SHE SOMETIMES DRAINS INTO SINK OR INTO A BUCKET. ADVISED WHY THIS IS NOT SAFE AND WE ARE WORRIED ABOUT POSSIBLE PERITONITIS ... CALLED [Nephrologist] - HE/SHE ADVISED ... DISCUSSED ABOVE - IF FEVER - GO TO ER [Emergency Room]. IF STILL IN BAD PAIN, GO TO ER. IF OK, THEN GO TO CLINIC ON MONDAY. ...” Following the conversation with the nephrologist, S13 spoke to P3 again and relayed what the nephrologist had stated. S13 documented, “... PT STARTED TALKING ABOUT BLUE SOLUTION BAGS - AND HAD TO USE PLYERS [sic] TO BREAK FRANGIBLES. PT SAID HE/SHE THINKS ABDOMINAL PAIN BETTER AND WANTED TO WALK TO SEE IF PAIN NEAR BELLY BUTTON [SIC]. PT WALKED AWAY FROM PHONE AND I COULD NO LONGER HEAR HIM/HER - BUT COULD HEAR TV. WAITED OVER 5 MIN. ...” S13 then called the patients emergency contacts who stated they would not be available to check on the patient on 08/02/25. P3’s family member stated that he/she, “will try to stop by tomorrow.” P3 then called S13 again. S13 documented, “... I ASKED WHERE HE/SHE WENT SINCE I WAS ON PHONE FOR OVER 5 MIN AND HE/SHE NEVER CAME BACK. HE/SHE COULD NOT RECALL, BUT STATES HE/SHE IS OK NOW. ADVISED PT IF FEVER, CHILLS OR PAIN RETURN - TO GO TO ER. IF NOT, PT IS TO DO DIALYSIS TONIGHT AND SUNDAY. ... HE/SHE IS TO COME TO CLINIC ON MONDAY WITH FILL. ... THIS WAY WE CAN RULE OUT PERITONITIS ...” During an interview on 08/13/25 at 1:25 PM, with S12 and S15, S12 stated that P3 was normally oriented to date and time. On Monday 08/04/25, he/she called P3’s family member who informed that he/she never checked on P3 and was not sure where he/she was. The clinic was then able to get into contact with P3 who had gone to the hospital and was admitted for Peritonitis. S15 stated that the facility could have called to have a wellness check done on the patient on 08/02/25. Per S15, “it would’ve been good nursing judgement,” in regard to calling for a wellness check. During a phone interview on 08/13/25 at 1:54 PM, with S13, he/she stated that he/she had spoken to P3 several times and was sometimes “lucid” and sometimes “not.” S13 continued that he/she had discussed with S14 (the nephrologist) the patient’s presentation, and both agreed the patient could wait until Monday for follow-up. S13 also stated that when the patient called back, he/she sounded at baseline again despite being unable to articulate where he/she had gone previously. S13 stated, “if I didn’t speak to [P3] again I would’ve called for a wellness check, and I had spoken to the MD several times who said it was ok for [P3] to wait until Monday.” During a phone interview on 08/13/25 at 2:18 PM, with S14, he/she stated that P3 had called with symptoms of abdominal pain and confusion, as well as admitting to dumping drainage into a bucket. S14 stated, “[P3] was sounding pretty confused at the time.” Per S14, he/she would have recommended a wellness check on P3 if they had not shown up to the clinic on Monday 08/04/25, two days later. S14 explained that he/she feels the patient had been showing signs of dementia that were worsening and had been discussing with the team how P3 may no longer be a good home PD candidate, however, the patient was adamant about not getting evaluated for dementia. During a follow up interview on 08/15/25 starting at 12:30 PM, S15 stated that P3 did not have an official diagnosis of dementia and the physician did not inform the home therapy nurses of a diagnosis of dementia. S15 stated that while the patient’s behavior was bizarre at times, P3 was oriented and the patient was not normally confused. S15 stated that he/she thought P3 was possibly septic. Review of P3’s medical record did not indicate that P3 had episodes of confusion or decreased mentation at baseline prior to the phone call on 08/02/25. Facility policy titled, “Suspected Peritonitis 1 of 2: Management Protocol,” revised November 2024 stated, “DEFINITION, Peritonitis is an urgent to emergent situation requiring immediate treatment with antibiotic therapy. Peritonitis is one of the leading complications of peritoneal dialysis and can result in hospitalization, loss of therapy, or death, Prevention or early treatment of peritonitis is key. ... 2. Clinical triage. Most patients can be managed as outpatients. Consider ER triage for uncontrollable pain, severe nausea and vomiting, signs and symptoms of septicemia [serious blood infection] (fever and chills, hypotension, tachycardia, rapid breathing, and/or mental status change) or suspected intestinal perforated viscus [sic] [intestinal tract rupture] ...””