Fresenius Kidney Care - Wheatfield

“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: 40430 Based on policy review, observation, and interview, the facility does not ensure that staff follow standard infection control practices regarding the use of gloves and hand hygiene. Findings include: Review of the policy “Hand Hygiene,” published 11/06/23, revealed hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water; before and after direct contact with patients; before performing any invasive procedure such as vascular access cannulation; immediately after removing gloves; and after contact with other objects within the patient station or treatment space. Review of the policy “Personal Protective Equipment,” published 11/06/23, revealed staff must remove gloves and wash hands after patient care, exposure to blood and body fluids, and touching surfaces within the patient station. If hands are not visibly soiled, alcohol-based hand sanitizer may be used. Always perform hand hygiene after glove removal. Review of the policy “Central Venous Catheter (CVC-tube inserted into a large vein in the body to provide access for dialysis) Dressing Change,” published 05/06/24, revealed the following steps will be followed for CVC dressing change: perform hand hygiene, apply gloves, remove and discard the old dressing, remove gloves, and perform hand hygiene. Observation on 01/27/25 at 10:00 AM at Station #2 for Patient #10 revealed Staff (P), Registered Nurse (RN) returned Patient #10’s blood to discontinue their dialysis treatment. Staff (P) removed their gloves, but did not perform hand hygiene prior to applying a new pair of clean gloves to disconnect the blood lines from the CVC ports. At 10:05 AM Staff (P) completed post CVC care, disposed of used syringes, removed their gloves but did not perform hand hygiene prior to exiting Station #2 to walk with Patient #10 to the scale and discharge from the treatment area/unit. Observation on 01/27/25 at 10:20 AM at Station #8 for Patient #7 revealed Staff (L), Patient Care Technician (PCT) disconnected Patient #7’s blood lines from their fistula (access used for dialysis) needles and removed their gloves, but did not perform hand hygiene prior to applying a new pair of clean gloves. Staff (L) removed the used blood lines from the machine and discarded but did not perform hand hygiene prior to applying a new pair of clean gloves and proceeded to wipe down/disinfect the dialysis machine. Staff (L) removed their gloves, but did not perform hand hygiene, prior to exiting Station #8. Staff (L) entered Station #5, applied clean gloves without performing hand hygiene, and reset a machine alarm. Staff (L) removed their gloves, exited Station #5, returned to Station #8, applied a clean pair of gloves, but did not perform hand hygiene and proceeded to tape the gauze to Patient #7 needle sites. Observation on 01/28/25 at 09:30 AM at Station #10 for Patient #27 revealed Staff (Q), Licensed Practical Nurse (LPN) grabbed the sharps container (used to dispose of used needles) to move it closer to Station #10. Staff (Q) removed their gloves, but did not perform hand hygiene prior to applying a new clean pair of gloves and disconnected Patient #27s blood lines from their CVC ports. Observation on 01/28/25 at 11:30 AM at Station #13 for Patient #12 revealed Staff (Q), LPN preformed CVC exit site (site where the catheter exits the body) care/dressing change. Staff (Q) removed the old dressing from Patient #13’s CVC exit site, removed their gloves but did not perform hand hygiene. Staff (Q) applied a new clean pair of gloves and proceeded to cleanse the exit site and apply a new dressing to the site. Observation on 01/28/25 at 11:40 AM at Station #7 for Patient #22 revealed Staff (P), RN performed CVC exit site care/dressing change. Staff (P) removed the old dressing from Patient #22’s CVC exit site but did not remove gloves or perform hand hygiene prior to cleansing the exit site. Staff (P) removed their gloves but did not perform hand hygiene prior to applying a new dressing to the CVC exit site. Observation on 01/28/25 at 11:50 AM at Station #1 for Patient #24 revealed Staff (R), RN performed CVC exit site care/dressing change. Staff (R) removed the old dressing from Patient #24’s CVC exit site, removed their gloves but did not perform hand hygiene prior to cleansing the exit site. Staff (R) cleansed/scrubbed and then aspirated/flushed the catheter ports. Staff (R) removed their gloves, but did not perform hand hygiene prior to applying a new dressing to the CVC exit site. Interview on 01/29/25 at 11:00 AM with Staff (B), Clinical Manager verified these findings.”

“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: 40430 Based on policy review, observation, and interview, staff do not ensure that the patient station is vacant prior to disinfecting/setting up the hemodialysis machine for the next patient. Findings include: Review of the policy “Cleaning and Disinfecting the Dialysis Station,” published on 09/05/23 indicated to prevent cross contamination between patients, the previous patient must completely vacate the station before the dialysis machine can be externally disinfected, allowed to dry, and set up for the next patient treatment. Observation on 01/27/25 at 10:20 AM at Station #8 for Patient #7 revealed Staff (L), Patient Care Technician (PCT) discontinued treatment and removed the fistula (access used to deliver dialysis treatments) needles from Patient #7. At 10:30 AM Staff (L) removed the used blood lines from the machine, externally disinfected the machine, and proceeded to set up the machine/lines/dialyzer for the next scheduled patient, while Patient #7 remained in the chair at Station #8. At 10:45 AM Staff (I), Registered Nurse, verified this finding. Interview on 01/29/25 at 10:45 AM with Staff (B), Clinical Manager, verified this finding.”

“IC-HBV-ISOLATION (EXISTING FACILITY) CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, designate a separate room for their treatment. For existing units in which a separate room is not possible, HBsAg positive patients should be separated from HBsAg susceptible patients in an area removed from the mainstream of activity. This Standard is not met as evidenced by: 34528 Based on interview and document review, the facility does not have a transfer agreement with a local chronic dialysis facility and/or a protocol for Hepatitis B positive patients of the change in treatment facility location. Findings include: Interview on 01/28/25 at 11:30 AM with Staff (M) Director of Operations, indicated the facility has an isolation room and the ability to treat Hepatitis B positive patients. However, due to the need to change the staffing structure to treat a Hepatitis B positive patient, an existing clinic with the ability to treat Hepatitis B positive patients could be utilized. There is not a transfer agreement or written process for the transfer of Hepatitis B positive patients to an alternative dialysis facility. This situation has not occurred at the facility. Review on 01/29/25 of the facility contract binder (no date) revealed no evident of a transfer agreement with an alternative dialysis facility that has the capacity to treat Hepatitis B positive patients. Interview on 01/29/24 at 02:45 PM with Staff (M) Director of Operations, verified findings.”

“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: 40430 Based on policy review, medical record review, and interview, in four of six medical records review, the facility does not ensure pre-treatment central venous catheter (CVC-tube inserted into a large vein in the body to provide access for dialysis) assessments are documented and/or completed by a registered nurse (Patient #10, Patient #14, Patient #17, and Patient #20). Findings include: Review of the policy “Nursing Supervision and Delegation,” published 11/06/23, revealed the registered nurse (RN) must perform an assessment of each patient, including their vascular access (surgically created access used to deliver hemodialysis treatment), preferably within an hour or according to state requirements (New York State requires an evaluation within 45 minutes of treatment initiation for CVC patient’s). Review of the policy “Initiation of Treatment Using a CVC and Optiflux Single Use Ebeam Dialyzer,” published 05/06/24, indicated the catheter exit site (site where the catheter exits the body) must be examined for signs and symptoms of infection, dislodgement of catheter or other problems prior to accessing the bloodstream. Review on 01/28/25 of the medical record treatment flowsheets for Patient #10, dated 12/27/24 to 01/17/25, revealed a CVC was used to deliver the hemodialysis treatment. On 01/06/25 treatment was initiated at 06:11 AM, but there is no RN assessment of the CVC and/or exit site assessment documented in the medical record. Review on 01/28/25 of the medical record treatment flowsheets for Patient #14, dated 01/04/25 to 01/25/25, revealed a CVC was used to deliver the hemodialysis treatment. On 01/07/25 treatment was initiated at 11:53 AM, but there is no RN assessment of the CVC and/or exit site documented in the medical record. Review on 01/28/25 of the medical record treatment flowsheets for Patient #17, dated 01/06/25 to 01/27/25, revealed a CVC was used to deliver the hemodialysis treatment. On 01/24/25 treatment was initiated at 05:58 AM, but there is no RN assessment of the CVC and/or exit site documented in the medical record. Review on 01/28/25 of the medical record treatment flowsheets for Patient #20, dated 11/13/24 to 12/02/24, revealed a CVC was used to deliver the hemodialysis treatment. On 11/18/24 treatment was initiated at 05:50 AM, but there is no RN assessment of the CVC and/or exit site documented in the medical record. On 11/26/24 treatment was initiated at 05:54 AM, but there is no RN assessment of the CVC and/or exit site documented in the medical record. Interview on 01/29/25 at 10:45 AM with Staff (B), Clinical Manager verified these findings.”

“MIX SYS-DFU/MONITOR/PM/LOG/SANITIZE CFR(s): 494.40(a) 5.4.4.1 Mixing systems: follow DFU/monitor/PM/log/sanitization If a concentrate mixing system is used, the preparer should follow the manufacturer’s instructions for mixing the powder with the correct amount of water. If a concentrate mixing system is used, the number of bags or the weight of powder added should be determined and recorded. Manufacturer’s recommendations should be followed regarding any preventive maintenance and sanitization procedures. Records should be maintained indicating the date, time, person performing the procedure, and results (if applicable). 6.4.1 Mixing systems: Systems for preparing either bicarbonate or acid concentrate from powder should be monitored according to the manufacturer’s instructions. This Standard is not met as evidenced by: 16136 Based on policy review, document review, and interview, the facility does not ensure that the one-micron filter (to remove micron size particles) on the acid mixing tank is replaced after six batches of acid has been mixed. Findings include: Review of the policy “ Acid Concentrate Mixing and Handling,” published 09/05/23, indicated the acid mixing tank be operated in accordance with the manufacturer printed instructions. The manufacturer operator’s manual “Granuflo Concentrate Dissolution Unit,” recommendations indicated “the one-micron filter should be changed after mixing six batches of acid concentrate.” Review on 01/28/25 of the “Granuflo Mixing Log (acid mixing log),” dated 08/2024 through 01/2025, revealed the following: -In 08/2024, the one-micron filter was not changed after mixing eight batches of acid. -In 09/2024, the one-micron filter was not changed after mixing seven batches of acid. -On 10/22/54, the one-micron filter was changed after mixing 19 batches of acid. -On 01/14/25, the one-micron filter was changed after mixing nine batches of acid. Interview on 01/28/25 at 12:15 PM with Staff (M), Director of Operations, verified this finding.”

“MIXING SYSTEMS-PERM RECORD/VERIF TEST CFR(s): 494.40(a) 5.4.4.1 Mixing systems: perm record/verification testing In addition to container labeling, there should be permanent records of batches produced. These records should include the concentrate formula produced, the volume of the batch, the lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, the date and time of mixing, any test results, the person performing the mixing, the person verifying mixing and test results, and the expiration date (if applicable). 6.4.1 Mixing systems Acid and bicarbonate concentrates may be tested by using conductivity or by using a hydrometer. Concentrates should not be used or transferred to holding tanks or distribution systems until all tests are completed. The test results and verification that they meet all applicable criteria should be recorded and signed by the individuals performing the tests. This Standard is not met as evidenced by: 16136 Based on document review and interview, the facility does not ensure all batches of acid are documented when mixed/prepared. Findings include: Review on 01/28/25 of the “Granuflo Mixing Log (acid mixing log),” from 11/2024 to 01/2025, revealed in December 2024, only four batches of acid concentrate were documented. Interview on 01/28/25 at 12:15 PM with Staff (M), Director of Operations, verified these findings and stated the facility prepares seven to eight batches of acid concentrate per month.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 16136 Based on document review, observation, and staff interview, the facility does not ensure that the regulated medical waste was secured/covered in the regulated medical waste storage room. Findings include: Review of the service contact “Daniels Service Agreement,” dated 03/04/22, revealed the use of collection bins for regulated medical waste. The service contractor will remove the filled containers from the designated soiled utility room and replace the containers of equal size and quantity. Both parties agree to handle all waste in a safe, responsible manner, not jeopardizing human health and/or the environment. The customer will ensure the waste presented for collection will be properly segregated, packaged, and labeled. Observation on 01/27/25 at 10:05 AM in the regulated medical waste storage room revealed that four large regulated medical waste containers were not covered. The lids available for covering the containers were approximately one to two inches too small and would not secure the contents when moved for disposal. Interview on 01/27/25 at 11:00 AM with Staff (G), Area Technical Operations Manager, verified this finding.”

“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: 16136 Based on document review and interview, the facility does not ensure that the fire extinguishers are tested annually, fire doors are inspected annually, documentation of the level of milliamperes a ground fault circuit interrupter (GFCI) (protects against electric shock by cutting off electrical power) outlet becomes inactivated, and documentation of the location/quantity of the battery-operated emergency lighting. Findings include: Review on 01/29/25 of the “Portable Extinguisher Certification and Test Report,” revealed the facility has seven portable fire extinguishers. The last annual fire extinguisher testing occurred in 10/11/2023. Annual testing is required according to NFPA (National fire Protection Association)-10 , 2010 edition. Review on 01/29/25 of the “2024 Fire Inspection Reports,” revealed no evidence facility fire doors were inspected in 2024 to date. Inspections are required annually per NFPA 80, 2010 edition. Review on 01/29/25 of the “2024 GFCI’s Testing Reports,” dated 06/18/24 and 12/17/24, did not indicate the level of milliamperes (mA) the outlets become inactivated per NFPA 99, 2012 edition. Review on 01/29/25 of the “Exit Signs /Emergency Lighting Reports,” dated February 2024 through December 2024, did not provide evidence of the location or the quantity of the battery emergency lights within the facility per NFPA (National Fire Protection Association)- 2012 edition. Interview on 01/29/25 at 02:00 PM with Staff (G), Area Technical Operations Manager, verified these findings.”

“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: 16136 Based on document review, policy review, and interview, the facility does not ensure the documentation of daily acid cleaning solution batches (used for daily cleaning of the hemodialysis machines) and the correct expiration dates of the cleaning solution. The facility does not ensure the correct pressures are documented for readings in the water room. Findings include: Review of the “2008 T Operator’s Manual (for hemodialysis machines),” revealed that the 2008 T hemodialysis machines should undergo daily acid cleaning using bicarbonate concentrates. Review of the policy “Mixing Handling and Using 2% Citric Acid,” published 05/05/24, indicated once the 2% citric acid is mixed, it must be used or discarded within one month. Review on 01/28/25 of the “2% Citric Acid Solution Mixing Log,” November 2024 through 01/27/25 indicated no evidence the two percent citric acid solution was not mixed/prepared daily on 11/01/24, 11/04/24, 11/06/24, 11/15/24, 11/16/24, 11/22/24, 11/26/24, 11/30/24, 12/04/24, 12/16/24, 12/22/24, 12/23/24,12/24/24,12/30/24, 01/08/25, 01/11/25, and 01/18/25. The “Packet Use By Date” or expiration date of solution was the documented as the same date the solution was prepared/mixed. Interview on 01/28/25 at 01:30 PM with Staff (G), Area Technical Operations Manager and Staff (O), Facility Administrator, verified these findings and stated the “Packet Use Date” should be the date on the packet, not the date the solution was mixed. Review on 01/29/25 of the “Water Pre-Treatment Opening Log,” dated 11/2024, 12/2024, and 01/27/25, indicated the daily water system readings obtained for the pre and post sediment filters, pre and post softener, pre and post primary carbon filters, pre and post carbon polisher filters, and pre and post ultra filters (pressures for the components of the water system) were documented all the same as 60 PSI (pound per square inch). Interview on 01/29/25 at 12:30 PM with Staff (G), Area Technical Operations Manager, stated that the readings for each component of the water system from 11/2024 through 01/27/25 could not possibly have the same result of 60 PSI.”

“PR-INFORMED OF PT CARE POLICIES CFR(s): 494.70(a)(8) The patient has the right to- (8) Be informed of facility policies regarding patient care, including, but not limited to, isolation of patients; This Standard is not met as evidenced by: 34528 Based on policy review, document review, and interview, the facility does not have a process to inform Hepatitis B positive patients of the need to work with facility staff to transfer to another local facility. Findings include: Review of the policy “Patient Admission,” last published 04/24/19, revealed the patient shall be made aware of and afforded access to all treatment modalities provided by the facility as appropriately certified and applicable licensed by the state including In-center Hemodialysis, Self -Care Dialysis, Nocturnal In-Center Hemodialysis, Home Hemodialysis (Nocturnal and Daytime), Continuous Ambulatory Peritoneal Dialysis, Continuous Cycling Peritoneal Dialysis, and referral for Renal Transplantation. Additionally, the patient shall be provided with resource information for dialysis modalities not offered by the facility, including information about alternative scheduling options for working patients. This policy does not outline a procedure for notifying Hepatitis B positive patients of the option of treatment at another local facility. Review of the “New Patient Admission Packet” (no date) revealed no information was found related to the need to isolate and the possibly transfer Hepatitis B positive patients to another local clinic that has the capacity to care and provide treatment. Interview on 01/28/25 at 11:30 AM with Staff (M) Director of Operations, indicated the facility has an isolation room and the ability to treat Hepatitis B positive patients. Hepatitis B positive patients coming from the hospital or converting at our facility are always given the choice of a facility. However, due to the need to change the staffing structure to treat a Hepatitis B positive patient, an existing clinic with the ability to treat Hepatitis B positive patients could be utilized. There is not a transfer agreement or written process for the transfer of Hepatitis B positive patients to an alternative dialysis facility. This situation has not occurred at the facility. Interview on 01/29/25 with Staff (M), Director of Operations, verified this finding and confirmed there is not a specific process as to how a Hepatitis B positive patient would be informed there may be a time they are offered care at another local facility.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 40430 Based on policy review, medical record review, and interview, in six of seven medical records review, pre & post-treatment assessments were not completed timely by a registered nurse (Patient #5, Patient #10, Patient #15, Patient #17, Patient #19, and Patient #20). Findings include: Review of the policy “Nursing Supervision and Delegation,” published 11/06/23, revealed the registered nurse (RN) must perform an assessment of each patient to review the patient’s condition, preferably within an hour or according to state requirements. Prior to discharge, the RN must review the treatment record to confirm the patient is stable for discharge. Review on 01/28/25 of the medical record treatment flowsheets for Patient #5 from 01/06/25 to 01/27/25 revealed the following: -On 01/06/25, treatment was discontinued at 10:20 AM. There is no RN post-treatment assessment documented. -On 01/08/25, treatment was discontinued at 10:09 AM, but the RN post-treatment assessment was not completed until 01:58 PM. -On 01/13/25, treatment was discontinued at 10:00 AM, but the RN post-treatment assessment was not completed until 01:53 PM. -On 01/17/25, treatment was initiated at 06:19 AM but the RN pre-treatment assessment was not documented until 09:41 AM. Treatment was discontinued at 09:50 AM but the RN post-treatment was not completed until 12:50 PM. -On 01/20/25, treatment was discontinued at 09:59 AM, but the RN post-treatment assessment was not completed until 01:38 PM. -On 01/22/25 treatment was discontinued at 10:16 AM, but the RN post-treatment assessment was not completed until 04:30 PM. -On 01/24/25 treatment was discontinued at 10:11 AM, but the RN post-treatment assessment was not completed until 04:00 PM. Review on 01/28/25 of the medical record treatment flowsheets for Patient #10 from 12/27/24 to 01/17/25 revealed the following: -On 12/29/24, treatment was discontinued at 09:31 AM, but the RN post-treatment assessment was not completed until 11:33 AM. -On 01/06/25, treatment was discontinued at 09:28 AM, but the RN post-treatment assessment was not completed until 11:24 AM. -On 01/10/25 treatment was discontinued at 09:43 AM, but there is no RN post-treatment assessment documented. -On 01/13/25 treatment was discontinued at 09:49 AM, but the RN post-treatment assessment was not completed until 02:16 PM. -On 01/15/25 treatment was discontinued at 09:55 AM, but the RN post-treatment assessment was not completed until 01:26 PM. -On 01/17/25 treatment was discontinued at 09:51 AM, but the RN post-treatment assessment was not completed until 12:41 PM. Review on 01/28/25 of the medical record treatment flowsheets for Patient #15 form 12/30/24 to 01/18/25 revealed the following: -On 01/04/25 treatment was discontinued at 10:41 AM, but the RN post-treatment assessment was not completed until 01:53 PM. -On 01/07/25 treatment was discontinued at 10:39 AM but the RN post-treatment assessment was not completed until 12:26 PM. -On 01/09/25 treatment was discontinued at 10:37 AM but the RN post-treatment assessment was not completed until 01:29 PM. -On 01/11/25 treatment was discontinued at 10:35 AM but the RN post-treatment assessment was not completed until 12:52 PM. -On 01/14/25 treatment was discontinued at 10:32 AM but the RN post-treatment assessment was not completed until 11:47 PM. -On 01/16/25 treatment was discontinued at 10:42 AM but the RN post-treatment assessment was not completed until 01:13 PM. -On 01/18/25 treatment was discontinued at 10:37 AM but the RN post-treatment assessment was not completed until 02:54 PM. Review on 01/28/25 of the medical record treatment flowsheets for Patient #17 from 01/06/24 to 01/27/25 revealed the following: -On 01/08/25, treatment was discontinued at 11:11 AM, but the RN post-treatment assessment was not completed until 03:14 PM. -On 01/10/25, treatment was discontinued at 10:48 AM, but the RN post-treatment assessment was not completed until 01:15 PM. -On 01/13/25, treatment was discontinued at 11:29 AM, but the RN post-treatment assessment was not completed until 02:34 PM. -On 01/15/25, treatment was discontinued at 11:42 AM, but the RN post-treatment assessment was not completed until 01:46 PM. -On 01/22/25, treatment was discontinued at 12:18 PM but the RN post-treatment assessment was not completed until 04:59 PM. Review on 01/28/25 of the medical record treatment flowsheets for Patient #19 from 01/04/25 to 01/25/25 revealed the following: -On 01/09/25, treatment was discontinued at 02:00 PM, but the RN post-treatment assessment was not completed until 03:59 PM. -On 01/11/25, treatment was initiated at 10:42 AM, but the RN pre-treatment assessment was not completed until 12:20 PM. -On 01/16/25, treatment was initiated at 10:20 AM, but the RN pre-treatment assessment was not completed until 12:45 PM. The treatment was discontinued at 02:00 PM, but the RN post-treatment assessment was not completed until 03:15 PM. -On 01/18/25, treatment was discontinued at 01:59 PM, but the RN post-treatment assessment was not completed until 04:08 PM. Review on 01/28/25 of the medical record treatment flowsheets for Patient #20 from 11/13/24 to 12/02/24 revealed the following: -On 11/15/24, treatment was discontinued at 08:53 AM, but the RN post-treatment assessment was not completed until 03:18 PM. -On 11/18/24, treatment was discontinued at 09:10 AM, but the RN post-treatment assessment was not completed until 03:54 PM. -On 11/22/24, treatment was discontinued at 09:07 AM, but the RN post-treatment assessment was not completed until 10:56 AM. -On 11/25/24, treatment was discontinued at 09:08 AM, but the RN post-treatment assessment was not completed until 01:22 PM. -On 11/26/24, treatment was discontinued at 08:54 AM, but the RN post-treatment assessment was not completed until 10:21 AM. Interview on 01/29/25 at 10:45 AM with Staff (B), Clinical Manager, verified these findings.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 40430 Based on policy review, observation, medical record review, and interview, in four of eight medical records reviewed, nursing staff did not ensure dialysate flow rates (DFR-the rate fluid passes through a dialyzer or artificial kidney, to remove toxins from a patient’s bloodstream) are implemented and/or maintained per physician order (Patient #10, Patient #14, Patient #15, and Patient #21). Findings include: Review of the policy “Dialysate Flow Rate Guidance,” (no date) revealed if an adjustment in the dialysate flow rate is made, it should be reflected in the patient’s hemodialysis order. Observation on 01/28/25 at 12:30 PM at Station #2 for Patient #21 revealed a DFR of 800 ml/min on the dialysis machine. Review of the treatment flow sheet dated 01/28/25 revealed an ordered DFR of 500ml/min. There was no documentation in the medical record to indicate why the dialysate flow rate was not maintained as ordered. Review on 01/28/25 of the medical record treatment flowsheets for Patient #10 from 12/27/24 to 01/17/25 revealed an ordered/prescribed DFR of “autoflow 1.5 (DFR adjusts automatically depending on blood flow rate).” On 01/17/25, the autoflow 1.5 DFR was not implemented as ordered for the treatment and instead a constant rate of 800 milliliters per minute (ml/min) was utilized throughout treatment. There was no documentation in the medical record to indicate why the DFR was not maintained as ordered. Review on 01/28/25 of the medical record treatment flowsheets for Patient #14 from 01/04/24 to 01/25/25 revealed an ordered/prescribed DFR of 700 ml/min. The DFR was not maintained on 01/04/25, 01/07/25, 01/09/25, 01/14/25, and 01/21/25. There was no documentation in the medical record to indicate why the dialysate flow rate was not maintained as ordered. Review on 01/28/25 of the medical record treatment flowsheets for Patient #15 from 12/30/24 to 01/18/25 revealed an ordered/prescribed DFR of 800 ml/min. The DFR was not maintained on 01/04/25. There was no documentation in the medical record to indicate why the dialysate flow rate was not maintained as ordered. Interview on 01/29/25 at 10:45 AM with Staff (B), Clinical Manager, verified these findings.”