Fms-Irondequoit Bay Dialysis

“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: 40430 Based on policy review, observation, and interview, the facility does not ensure staff follow the facility process for verification of emergency equipment. This has the potential to cause a delay in responding to a medical emergency and/or lead to an adverse patient outcome. Findings Include: Review on 06/14/24 of policy “Emergency Medications, Equipment, and Supplies”, dated 05/01/23, revealed the emergency cart (crash cart-contains emergency equipment and medications for medical emergencies such as cardiac arrest) must be locked when not in use, checked monthly or after use for contents, expiration dates, cleanliness, proper functioning of all equipment, and be equipped with a dedicated oxygen tank. Staff must check the pressure gauge on the oxygen cylinder weekly. The emergency evacuation box (a box that contains supplies primarily needed to emergently remove needles, cap catheters, and provide saline, as needed, for every licensed station, once the patient is in a secure location in the event of facility evacuation) must contain all patient and staff emergency contact information and be checked monthly or after use for contents, expiration dates and cleanliness. An itemized log for the emergency cart and evacuation box must be kept indicating contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date. Observation on 06/12/24 at 10:55 AM revealed the emergency cart was not locked. An itemized log of contents located on top of the emergency cart was dated 05/03/23. There was no documented monthly check of contents from June 2023 until May 2024. Interview on 06/12/24 at 11:10 AM, Staff (L), Registered Nurse verified the findings and stated the automatic external defibrillator (AED- used to monitor heart rates and treat cardiac arrest) on the emergency cart was checked daily to confirm the green check mark, indicating power, and that defibrillator pads were available and not expired. Staff (L) stated that verification of the log of contents was signed off electronically on the facility computer system (TMS- The Maintenance System) dashboard. Observation and interview on 06/12/24 at 01:30 PM, Staff (L) and Staff (K), Registered Nurses stated emergency cart and evacuation box checks are signed off on the computer system (TMS) dashboard when it lights up red on the screen, indicating the checks are required to be completed. Staff (L) brought up the dashboard screen with emergency code cart and medication checklist (monthly) highlighted red dated 05/03/23. Staff (L) and Staff (K) verified the emergency cart check was highlighted red and overdue, with the last sign off date as 05/03/23. Staff (L) then brought emergency evacuation box contents log (quarterly) up on the screen with last sign off date of 01/17/24. Staff (L) and Staff (K) stated the emergency evacuation box check was not required to be completed because it was not highlighted red, it was still white in color indicating it was not due to be completed/signed off. They stated staff are alerted to tasks requiring completion when they are highlighted red. When the task is not highlighted red it indicates the task/check was not due. Observation on 06/12/24 at 01:55 PM, revealed the emergency evacuation box was stored in the back nursing station. The evacuation box lacked all patient and staff emergency contact information and an itemized log of contents with expiration dates of the contents. The evacuation box contained expired supplies including: three corroded AA batteries, contained in ziplock bag, with an expiration date of 03/2023; six intravenous administration sets/lines with an expiration date of 03/31/2022; one liter bag of normal saline (intravenous solution for fluid and electrolyte replacement) expiration date 12/2022; two chlora-prep single swab sticks (antiseptic solution used to cleanse skin) expiration date 04/2021; and three chloral-prep single swab sticks expiration date 06/2021. Staff (L), Registered Nurse verified the findings. Interview on 06/12/24 at 02:33 PM with Staff (B), Nurse Manager verified these findings.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 34528 Based on policy review, documentation review and interview the facility did not have evidence of performing the correct type of consecutive Emergency Preparedness drills for 2 of 2 years. (2022,2023) Findings Include: Review on 06/13/24 of policy, “Guidelines for Emergency Preparedness”, last revised 07/03/23, revealed annually each facility must participate in a community-based disaster drill. If the Emergency operations Center or similar agency has not performed a community based drill, or it was missed for a particular year, the Director of operations should coordinate a dialysis facility area-based drill. Review on 06/13/24 of Emergency Preparedness drills revealed the following: - On 06/16/22 an active shooter table- top exercise was completed. - On 06/15/23 a blizzard table- top exercise was a completed. There is no documentation of a facility drill being completed or an actual facility event occurring in either year. Interview on 06/13//24 at 02:30 PM with Staff (B), RN Nurse Manager verified these findings.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 40430 Based on observation, interview and policy review, the facility did not ensure expired medication and supplies are not available for use and that aseptic technique was used to prepare intravenous medications, as required. This practice could result in adverse patient outcome. Findings Include: Observation on 06/12/24 at 11:40 AM in the lab/supply area revealed the following expired supplies: - two cases (100 tubes/case) of red top tubes that expired 04/30/24 and 02/29/24. - 17 cases (50 tubes/case) of green/yellow top tubes expired 01/31/24 and one case expired 12/01/23; - One case (100 tubes/case) of purple top tubes expired 03/31/24; - Two cases(100 tubes/case) of light green top tubes expired 03/31/24; - One case (100 rubes/case) of yellow top tubes expired 12/31/23. - 17 STARSWAB II (orange cap) expired 02/09/23 - 8 STARSWAB II (orange cap) expired 10/28/23 - 6 BBL Culture Swab Plus expired 10/31/23 Observation on 06/12/24 at 12:00 PM in the front nursing station, medication storage/prep area, revealed the following expired medications: - Three cases, containing 24 bottles each, of oral calcitriol (vitamin D) 0.25 microgram (mcg) capsules with expiration dates of 06/2023, 10/2023 and 12/2023. - 23 vials of adrenalin (medication for emergency treatment of severe allergic reaction)1 milligram (mg)/milliliter (ml) with an expiration date of 04/2024. - 18 vials of two-gram cefepime (antibiotic) powder with an expiration date of 05/2024. Interview on 06/12/24 at 12:20 PM with Staff (G), Director of Operations and Staff (K), Registered Nurse verified the findings. Observation on 06/13/24 at 08:45 AM at the front nursing station, medication storage/prep area, revealed Staff (K), Registered Nurse, did not cleanse the diaphragm (rubber material used to seal a vial), of a multi dose vial of Epogen (medication used to help produce red blood cells in the body) 20,000 units/ml and single dose vial of diphenhydramine 50 mg/ml, with alcohol prior to puncturing and withdrawing the medication into two syringes. Observation on 06/13/24 at 08:50 AM in the front nursing station, medication storage/prep area, revealed four vials of diphenhydramine (Benadryl- used for allergic reaction) 50 mg/ml with an expiration date of May 2023. Interview on 06/13/24 at 08:50 AM with Staff (N), Registered Nurse, verified the findings. Review on 06/14/24 of policy, “Medication Preparation and Administration”, dated 02/6/2023, revealed expiration dates for all medications are to be monitored monthly. Expired medications are to be discarded. Aseptic technique (practice used to avoid introduction and transfer of germs) will be used to prepare and administer intravenous medications. Cleanse the diaphragm of a vial with alcohol prior to accessing the vial. If the vial is a multidose vial, cleanse the diaphragm with a new alcohol pad each time the vial is accessed using friction and 70% alcohol. Review on 06/14/24 of policy, “Storage of Supplies”, last reviewed 04/05/21 revealed to appropriately dispose of items that have reached the expiration date. Interview on 06/14/24 at 10:00 AM with Staff (B), Nurse Manager, verified these findings.”

“ACID BULK STORAGE TANKS-SAFETY CONTROLS CFR(s): 494.40(a) 5.4 Concentrate preparation 5.4.3 Bulk storage tanks (acid concentrate): safety controls Procedures should be in place to control the transfer of the acid concentrate from the delivery container to the storage tank to prevent the inadvertent mixing of different concentrate formulations. If possible, the tank and associated plumbing should form an integral system to prevent contamination of the acid concentrate. The storage tanks and inlet and outlet connections, if remote from the tank, should be secure and labeled clearly. This Standard is not met as evidenced by: 16136 Based on document review, policy review and staff interview, the facility does not ensure that separate staff review the log when acid solution is prepared. Findings Include: Review on 06/13/24 of the Granuflo Mixing Log, from 02/2024 thru 06/06/24, revealed that the batch acid solution was not reviewed and verified by two qualified staff members at the end of each batch. Review of this log indicated that two staff members did not verify the prepared acid solution on 02/19/24, 03/11/24, 03/14/24 and on 06/06/24. Review on 06/13/24 of policy, “Acid Concentrate Mixing and handling: Dry Acid Dissolution Unit”, last reviewed 09/05/23, revealed that “each batch record must be reviewed and verified as complete by two qualified staff members at the end of batch preparation.” Interview on 06/13/24 at 3:15 PM with Staff (B), Nurse 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 observation and staff interview, the facility did not ensure that the hot water at two of two clean hand wash sinks did not exceed 110 degrees Fahrenheit. (Across from Station 10 and across from Station 17) Findings Include: Observation on 06/14/24 at 1:25 PM revealed the temperature at the clean handwash sinks across from Station #10 and Station #17 exceeded 110 degrees Fahrenheit. The temperature of the clean sink across from Station #10 was 121.5 degrees Fahrenheit and the temperature at the clean sink across from Station #17 was 120.5 degrees Fahrenheit. Hot water temperature at fixtures utilized by patients use must not exceed 110 degrees Fahrenheit. Interview on 06/14/24 at 2:00 PM with Staff (S), Area Tech Operations Manager, verified this finding. Staff (S) stated that the blending valves required replacement.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 34528 Based on policy review, document review, and interview, the facility did not document four of four required fire drills per facility policy. Findings Include Review on 06/13/24 of policy, “Fire Drill”, last reviewed 08/02/17, revealed quarterly all Fresenius Kidney Care facilities shall perform a fire drill. Review on 06/13/24 at 11:32 AM of the fire drill log revealed there were no documented fire drills for 2023. Interview on 06/13//24 at 02:30 PM with Staff (A), RN Nurse Manager, verified these findings.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 34528 Based on policy review, observation and interview, the facility does not prominently display a copy of Patients’ Rights that contains all the rights required by Center for Medicare and Medicaid Services, including the contact information for the State Agency and the ESRD Network. Lack of posting may delay or inhibit a patients ability to make a complaint. Findings Include: Review on 06/12/24 of policy, “Patient Rights and Responsibilities”, last reviewed 04/04/12, revealed dialysis facilities must prominently display a copy of the patients’s rights in a visible and accessible area in the facility and must include contact information for the State survey agency and ESRD network. Observation on 06/12/24 at 09:00 AM, in the patient waiting room and treatment unit revealed no evidence that the Patient’s Rights that was posted included the addresses and phone numbers for the State agency and the ESRD Network. Interview on 06/13/24 at 02:30 PM with Staff (A), Registered Nurse Manager, verified these findings and that there is no policy pertaining to the posting of Patients’ Rights.”

“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 medical record review, policy review, and interview, the facility does not ensure that blood flow rates are maintained, per physician order, for two of five patients (Patient #7 and Patient #16). Failure to maintain the ordered blood flow rate has the potential for an inadequate hemodialysis treatment and/or a delay in identifying an issue with the access. Findings Include: Review on 06/14/24 of the treatment flow sheets for Patient #7 from 05/22/24 to 06/12/24 revealed a prescribed blood flow rate of 450 milliliters (ml)/minute (min) was not maintained on 05/31/24, 06/03/24, 06/07/24, 06/10/24, and 06/12/24. There was no documentation in the medical record to indicate why the blood flow rate was not maintained. Review on 06/14/24 of the treatment flow sheets for Patient #16 from 05/22/24 to 06/12/24 revealed a prescribed blood flow rate of 450 ml/min was not maintained on 05/27/24, 05/31/24, 06/03/24, 06/05/24, 06/07/24, 06/10/24, and 06/12/24. There was no documentation in the medical record to indicate why the blood flow rate was not maintained. Review on 06/14/24 of policy, “Patient Assessment and Monitoring”, dated 05/01/23, revealed to monitor the patient and machine parameters during treatment. Check prescribed blood flow rate is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. Interview on 06/14/24 at 10:00 AM with Staff (B), Nurse Manager confirmed these findings.”