Center for Dialysis Care, Cleveland East

“CFC-WATER & DIALYSATE QUALITY CFR(s): 494.40 This Condition is not met as evidenced by: 29732 Based on observations, policy review and staff interviews, the facility failed to ensure all surfaces were disinfected, including the dialysis machine, chair and shelf behind the chair between patients. The facility failed to ensure the dialysis station was completely vacated by the previous patient before cleaning, disinfection and set up of the dialysis machine for the next patient. (V225) The facility failed to ensure the pH was checked prior to the start of each treatment and failed to ensure the pH was not falsely documented. (V250) The cumulative effect of these systemic practices resulted in the facility’s inability to ensure the health and safety of the patients and staff.”

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 29732 Based on record and policy review and staff interview, the facility failed to ensure the patient care technician (PCT) notified the registered nurse (RN) of symptoms of altered fluid status, including high blood pressures (BP) and not meeting the targeted goal weight after treatment. The RN also failed to notify the physician when medication was administered to lower patient’s blood pressure. (V543) The cumulative effect of these systemic practices resulted in the facility’s inability to ensure the health and safety of the patients and staff.”

“MIXING SYSTEMS-SAFE ENVIRONMENT/PPE CFR(s): 494.40(a) 5.4.4.1 Mixing systems: safe environment/PPE Protective measures should be used to ensure a safe work environment. Operators should at all times use appropriate personal protective equipment, such as face shields, masks, gloves, gowns, and shoe protectors, as recommended by the manufacturer. This Standard is not met as evidenced by: 29732 Based on observations, policy review and staff interviews, the facility failed to ensure all surfaces were disinfected, including the dialysis machine, chair and shelf behind the chair between patients. The facility failed to ensure the dialysis station was completely vacated by the previous patient before cleaning, disinfection and set up of the dialysis machine for the next patient. This could potentially affect all patients at this facility. The census was 240. Findings include: 1. Observations on 11/19/24 at 9:12 AM of Station 11 revealed Staff F set up the dialysis machine, strung it with tubing, and started to circulate the normal saline before the previous patient left Station 11. 2. Observations on 11/19/24 at 9:44 AM in Unit 3 revealed Patient Care Technician (PCT) Staff E was observed to clean the chair in Station 27. Staff E did not clean the kick plate on the chair. 3. Observations on 11/19/24 at 9:29 AM in Unit 1 revealed PCT Staff F was observed to clean the dialysis machine in Station 12. Staff F did not clean the right side of the machine or the prime bucket. 4 . Observations on 11/19/24 at 9:35 AM in Unit 1 revealed PCT Staff H was observed to clean Station 6. Staff F did not clean the counter behind the chair. 5. Observations on 11/19/24 at 10:02 AM in Unit 4 PCT revealed Staff G was observed to clean the chair in Station 38. Staff G did not clean the kick plate of the chair or the back counter. Staff G was observed to empty the prime bucket and put it back on the dialysis machine without disinfecting it inside and out. Interview on 11/19/24 at 10:25 PM the Facility Manager confirmed this finding stating they also observed Staff G not disinfecting the prime bucket before replacing it on the machine. 6. Observations on 11/19/24 at 10:12 AM in Unit 4 revealed PCT Staff B to clean the chair in Station 42. Staff B did not clean the left side of the chair, the kick plate on the chair or the back counter. At 10:17 AM PCT Staff B was observed to clean the dialysis machine in Station 42. Staff B did not clean either sides of the machine, the front and bottom front shelf or the prime bucket. 7. Observations on 11/19/24 at 10:24AM in Unit 4 revealed PCT Staff B was observed to clean the dialysis machine in Station 43. Staff B did not clean both sides and front of the machine, or the bottom shelf. Then Staff B put supplies for the next patient on top of the machine. 8. Observations on 11/19/24 at 11:20 AM in Unit 4 revealed PCT Staff B was observed to clean the chair in Station 42. Staff B did not clean the kick plate on the chair or the counter behind the chair. 9. Observations on 11/20/24 at 9:25 AM revealed Staff J to clean Station 8. Staff J did not clean the kick plate on the chair or the counter behind the chair. 10. Observations on 11/20/24 at 9:45 AM, Staff J was observed in Station 6. Staff J did not clean the kick plate on the chair or the counter behind the chair. 11. Observations on 11/20/24 at 10:48 AM revealed Staff H was observed to clean Station 48. Staff H did not clean the inside of the chair on the left side, the kick plate on the chair or the counter behind the chair. Review of the facility’s policy titled “Cleaning and Disinfection of Exterior Surfaces and Movable Equipment,” effective 12/30/2013, revealed cleaning and disinfection of environmental surfaces, (including patient chair, dialysis equipment, adjacent tables and work areas) must be performed between patient treatments to prevent cross contamination. Disinfection of the chair the staff will wipe all surfaces vigorously. The staff will wipe the chase/shelf behind the chair. The Dialysis station will be completely vacated by the previous patient before cleaning, disinfection and set up is done for the next patient. Interview on 11/21/24 at 12:50 PM Staff L was made aware of these findings.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 29732 Based on observations, policy review and staff interviews, the facility failed to ensure the pH was checked prior to the start of each treatment and failed to ensure the pH was not falsely documented. This could potentially affect all patients at this facility. The census was 240. Findings include: 1. On 11/19/24 at 10:42 AM in Unit 4, Station 47, Patient Care Technician (PCT) Staff B was not observed to perform the pH check prior to the next patient’s treatment, Patient #6, which was started at 10:44 AM. Review of the medical record for Patient #6 and the treatment sheet dated 11/19/24, revealed Staff B documented the pH was 7.4. A number was needed to move forward with the treatment on the computer, thereby Staff B falsely documented a pH reading since th pH was not tested prior to the next treatment. 2. On 11/20/24 at 10:18 AM in Unit 2, Station 51, PCT Staff H was not observed to perform the pH check prior to the next patient’s treatment, Patient #4, which was started at 10:40 AM. Review of the medical record for Patient #4 and the treatment sheet dated 11/20/24, revealed Staff H documented the pH was 7.2. A number was needed to move forward with the treatment on the computer, thereby Staff H falsely documented a pH reading since th pH was not tested prior to the next treatment. 3. On 11/20/24 at 11:00 AM in Unit 2, Station 50, PCT Staff H was not observed to perform the pH check prior to the next patient’s treatment, Patient #5, which was started at 11:24 AM. Review of the medical record for Patient #5 and the treatment sheet dated 11/20/24, revealed Staff H documented the pH was 7.2. A number was needed to move forward with the treatment on the computer, thereby Staff H falsely documented a pH reading since th pH was not tested prior to the next treatment. Interview on 11/20/24 at 11:13 AM Registered Nurse Staff I confirmed while doing the safety check prior to the start of the treatment, they did not see the pH strip PCT Staff H would have used to check the pH level. Staff I rechecked the machine looking for the test strip and asked PCT Staff H if they did the pH. Staff I confirmed the pH was not done. Review of the facility’s policy titled “Dialysis Machine Set-up BBRAUN,” effective 04/07/22, revealed prior to treatment initiation complete pH testing and document conductivity prior to patient hook-up. The Facility Manager (FM) was made aware of this at 11:00 AM on 11/19/24.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 29732 Based on observations, policy review and staff interviews, the facility failed to ensure the access sites remained uncovered during treatments. This could potentially affect all patients at this facility. The census was 240. Findings include: Observations were made on 11/19/24 from 9:14 AM to 12:00 PM. 1. In Unit 4 from 10:30 AM to 11:30 AM the patient at Station 45 had a continuously covered access site. Interview on 11/19/24 at 11:32 AM with Staff A confirmed this finding. 2. In Unit 2 the patients in Stations 51, 53, 54 and 57 were observed to be asleep with covered access sites. Interview on 11/19/24 at 11:50 AM Staff C confirmed these findings. Staff C stated “Do you want me to go uncover them?” 3. On 11/19/24 at 11:52 AM in Unit 1 the patient in Station 6 was observed to be asleep with a covered access site. Interview on 11/19/24 at 11:52 AM with Registered Nurse (RN) Staff D confirmed this finding. Staff D was observed at 11:53 AM to re-adjust the blood pressure cuff on the patient’s right arm and walked away with the access site in the left arm covered. Staff D did not uncover or address the covered site with the patient. 4. On 11/20/24 at 8:54 AM, in Unit 4 at Station 46, the patient was observed to be asleep with the access site covered with a blanket. Patient Care Technician (PCT) Staff K was observed to look at the patient and machine then walked away leaving the access site covered. Staff K did not uncover or address the covered site with the patient. Review of the facility’s policy titled “Routine Intradialytic Monitoring,” effective 07/09/24, revealed during treatment the patient care technician will monitor to ensure the access site is uncovered and secure. Interview on 11/20/24 at 1:50 PM Staff A was made aware of these findings.”

“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: 29732 Based on record and policy review and staff interview, the facility failed to ensure the patient care technician (PCT) notified the registered nurse (RN) of symptoms of altered fluid status, including high blood pressures (BP) and not meeting the targeted goal weight after treatment. The RN also failed to notify the physician when medication was administered to lower patient’s blood pressure. This affected four (Patient #1, # 3, 7 and #8) out of six patients reviewed. The census was 240. Findings include: 1. On 11/19/24 at 11:50 AM the blood pressure (BP) on Patient #1’s dialysis machine was visible. The patient’s BP was 151/125 at 10:58 AM, 190/123 at 9:49 AM, and 178/111 at 11:28 AM. Interview on 11/19/24 at 11:52 AM, RN Staff D stated the PCT did not make the RN aware of these BPs. Review of the medical record for Patient #1 and treatment sheet dated 11/19/24 revealed at 12:17 PM the RN gave Patient #1 clonidine 0.1 milligram (mg) for a blood pressure of 184/161. After clonidine was given at 12:17 PM to lower the BP, the patient’s BP remained high. At 12:58 PM the BP was 167/141, at 1:28 PM the BP was 184/140, at 1:53 PM the BP was189/122. At the end of the treatment at 1:58 PM the BP was 202/120. There was no documented evidence the PCT notified the RN. There was no documented evidence that the physician had been notified per policy of the need to administer the clonidine. 2. Review of the medical record for Patient #3 and treatment dated 10/07/24 revealed at 9:13 AM the RN gave Patient #3 clonidine 0.2 mg for a BP of 223/148. There was no documented evidence the physician had been notified per policy. The medical record for Patient #3 and the treatment sheet dated 10/07/24 revealed the dry weight was 51 kilograms (kg) and the goal weight for this treatment was 62.7 kg. The post dialysis weight was 63.2 kg which is 11.7 kg over the dry weight. There was no documented evidence the PCT notified the RN. Review of the medical record for Patient #3 and treatment sheet dated 10/09/24 revealed Patient #3 started the treatment at 6:03 AM with a BP of 218/156. There were 10 consecutive BPs greater than 200/100. The treatment ended at 9:37 AM with a BP of 244/167. There was no documented evidence throughout the treatment the RN was notified. 3. Review of the medical record for Patient #7 and treatment sheet dated 11/16/24 revealed the target weight was 105 kg. The Post Dialysis Weight was 106.5 kg. Patient #7 left at 1.5 kg over the target/goal weight. There was no documented evidence the PCT had notified the RN per policy. 4. Review of the medical record for Patient #8 and treatment sheet dated 10/01/24 revealed Patient #8 started the treatment at 10:54 AM with a BP of 191/129. There were four consecutive instances of systolic BP >180 and two consecutive instances of a diastolic BP >100. There was no documented evidence throughout the treatment the RN was notified. Review of the medical record for Patient #8 and treatment sheet dated 10/01/24 revealed the target/dry weight was 87 kg. The Post Dialysis Weight was 89.7 kg. Patient #8 left at 2.7 kg over the target/goal weight. There was no documented evidence the PCT had notified the RN per policy. Review of the facility policy titled “Severe Hypertension,” effective 03/18/21, revealed the patient care technician (PCT) will notify the registered nurse (RN) of severe hypertension, regardless of symptoms. The PCT will notify the RN when there are two consecutive instances of systolic BP >180 or two consecutive instances of a diastolic BP >100. The registered nurse should notify the physician after giving clonidine for persistent high blood pressure systolic >200 or diastolic >110. Review of the facilty policy titled “Patient Post Assessment and Check-Out,” effective 03/01/14, revealed after the treatment obtain the patient’s post-treatment weight. The PCT must notify the RN if the patient is > 1 kg over or under the goal weight after the treatment. Interview on 11/21/24 at 10:56 AM, Staff L confirmed the RN was not notified of the consecutive BPs over 180/100 per policy. Interview on 11/21/24 at 11:23 PM Staff L confirmed the RN was not notified of the post dialysis weight being over the targeted goal and the physician was not notified of the use of clonidine for eleveated blood pressures. Interview on 11/21/24 at 11:26 AM the Facility Manager and the Director of Clinical Operations both confirmed 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: 29732 Based on observation, interview and policy review, the facility failed to ensure cleaning and disinfection of environmental surfaces and portable equipment between patients. This could potentially affect all patients and staff. The census was 217. 1. During an observation on 08/15/24 at 9:28 AM, Patient Care Technician (PCT) Staff E cleaned the chair in station 58 and did not recline the chair or open the sides. Staff E did not clean the back counter behind the chair. During interview on 08/15/24 t 9:30 AM, Staff E confirmed this finding. 2. During an observation on 08/15/24 at 9:45 AM, Staff F cleaned station 53 and did not clean the back counter behind the chair. During an interview on 08/15/24 at 9:46 AM, Staff F confirmed this finding. 3. During an observation on 08/15/24 at 9:50 AM, Staff G was observed to clean the dialysis machine in station 6 and did not clean the sides or the back of the machine. Staff G did not recline the chair or open the sides or clean the back counter. During an interview on 08/15/24 at 9:53 AM, Staff G confirmed this finding. 4. During an observation on 08/15/24 at 10:12 AM, Staff H was observed to clean station 17 and did not clean the oxygen concentrator in the station, did not clean the back counter behind the chair and did not open the sides of the chair. During an interview at the time of the observation, Staff H confirmed this finding. Review of the facility’s policy titled “Cleaning and Disinfection of Exterior Surfaces and Movable Equipment”, effective 12/30/13, revealed disinfection of the dialysis machine includes wiping all surfaces of the machine. Disinfection of the chair must be reclined and wipe the creases between the back of the chair and seat and the space between each arm of the chair and wipe the shelf behind the chair. Use low-level disinfectant cloth for each piece of equipment being removed from the station (oxygen concentrator).”

“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: 29732 Based on observation, policy review and staff interview, the facility failed to ensure staff wore disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station and that staff removed gloves and washed hands between each patient or station for two staff observed on the treatment floor (Staff D and K). This could affect all patients receiving services from the facility. The census was 218. Findings include: Review of the facility policy titled, “Personal Protective Equipment,” effective 12/13/13, revealed staff were to change gloves after touching one patient or their machine and before arriving to care for another patient or touch another patient’s machine. Wear gloves whenever there is potential for contacting blood, dialysate, or other potentially infectious substances. Hand Hygiene must be performed after every glove removal. On 11/06/23 at 6:04 AM, on Unit 3, Staff D was observed working on dialysis machine in Station 19 without gloves on. Interview on 11/06/23 at 6:08 AM with Staff D confirmed this finding. On 11/06/23 at 10:20 AM, on Unit 3, Staff K was observed to touch the machine at station 25, remove gloves, and then put on new gloves without performing hand hygiene. This deficiency represents non-compliance investigated under Substantial Allegation OH00147038.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 29732 Based on observation and staff interview, the facility failed to ensure staff wore face shields to protect themselves for one staff observed on the treatment floor (Staff M). This could affect all patients receiving services from the facility. The census was 218. Findings include: On 11/06/23 at 11:00 AM, on Unit 2, Staff M was observed without a face shield talking with the patient in station 49. After they introduced themselves to the surveyor, she stated, “I was just called in, I’ll be right back”. She returned, and at 11:12 AM was observed talking with the patient in station 49 with the face shield on top of her head. When Staff M saw the surveyor she stated, “Oh, I guess I need to put this on” and placed the face shield on correctly. This deficiency represents non-compliance investigated under Substantial Allegation OH00147038.”

“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: 29732 Based on observation, policy review, and staff interview, the facility failed to demonstrate that it follows standard infection control precautions by implementing and maintaining procedures for the cleaning and disinfection of medical devices and equipment for five staff observed on the treatment floor (Staff E, H, L, J, and C). This could affect all patients receiving services in the facility. The census was 218. Findings include: Review of the facility policy titled, “Cleaning and Disinfection of Exterior Surfaces and Movable Equipment,” effective 12/30/13, revealed cleaning and disinfection of environmental surfaces, (including patient chair, dialysis equipment and work areas) as well as any portable equipment (thermometers and stethoscopes) must be performed between patients to prevent cross contamination. On 11/06/23 at 10:25 AM, on Unit 3, Staff E was observed to use the thermometer on the patient in station 9 and then place it back in the clean area without disinfecting it first. Interview on 11/06/23 at 10:26 AM with Staff E confirmed this finding. On 11/06/23 at 10:28 AM, on Unit 4, Staff H was observed to use a stethoscope on the patient in station 43 and at 10:33 AM use the same stethoscope on the patient at station 44. Staff H did not disinfect the stethoscope between patients. On 11/06/23 at 10:40 AM, on Unit 1, Staff L was observed to use the Hoyer Lift for a patient and then return it to Unit 2 without disinfecting it first. On 11/06/23 at 10:55 AM, on Unit 1, Staff J was observed to use the Hoyer Lift for a patient and then return it to Unit 2 without disinfecting it first. On 11/06/23 at 11:05 AM, on Unit 2, Staff C was observed to use the Hoyer Lift fn a patient and then return it without disinfecting it first. Interview on 11/06/23 at 11:08 AM with Staff C confirmed this finding. This deficiency represents non-compliance investigated under Substantial Allegation OH00147038.”

“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: 29732 Based on observation, policy review, and staff interview, the facility failed to ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials for one staff observed drawing up medication (Staff J). This could affect all patients receiving services from the facility. The census was 218. Findings include: Review of the facility policy titled, “Medication Preparation and Administration,” effective 01/22/14, revealed all medications must have a clean needle for each time entered in multiple dose vials. On 11/07/23 at 9:32 AM Staff J was observed to draw up Heparin into a syringe and then used the same needle and syringe to draw up more Heparin from a second vial. Interview on 11/07/23 at 9:40 AM with Staff J confirmed the same needle was used in both multiple dose vials of Heparin.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 29732 Based on observation, policy review, record review and staff and patient interview, the facility failed to ensure patients must be in view of staff during hemodialysis treatment to ensure patient safety for two patients observed receiving treatment (Patient #15 and #10). Findings include: Review of the facility policy titled, “AV Access Cannulation (Non-Constant Site Cannulation),” effective 11/13/12, revealed staff were to always keep the access uncovered. Check the access site every half hour and document findings. When monitoring a patient that refuses to uncover their access, educate the patient on the risks of a covered access at least once during the dialysis treatment and document the education and notify the Registered Nurse (RN). Document the patient’s refusal to uncover the access at least every 30 minutes. 1. Observations were made on 11/06/23 on Unit 1. At 10:45 AM Patient #15 was observed to have his access site covered by a blanket. Interview on 11/06/23 at 10:46 AM with Patient #15 revealed his access was in the thigh and he did not want it exposed so he kept it covered. Interview on 11/06/23 at 10:52 AM with Staff I confirmed Patient #15’s access site was covered by a blanket and stated the access site was in the patient’s leg and he wanted to keep it covered. Review of the medical record for Patient #15 and treatment sheet dated 11/06/23 revealed at 10:37 AM Staff G documented the access was visible and at 11:07 AM Staff G documented the access was visible. There was no documentation of the patient’s refusal to uncover his access every 30 minutes. 2. Observations were made on 11/07/23 on Unit 1. From 7:50 AM to 8:12 AM Patient #10 was observed to have his access site covered by a blanket. Interview on 11/07/23 at 7:51 AM with Patient #10 revealed his access was in his thigh and he did not want it exposed and it was cold. He stated he always kept it covered. Review of the Patient #15’s treatment sheet revealed it was documented at 8:09 AM that his access site was visible.”

“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: 29732 Based on observation, policy review and staff interview, the medical director must ensure that all policies and procedures relative to patient care are adhered to by all individuals who treat patients in the facility. This could affect all patients receiving services from the facility. The census was 218. Findings include: Review of the facility policy titled, “Medication Preparation and Administration,” effective 01/22/14, revealed all medications must be labeled with date, time and initials on multi-use vials when opened. Observations were conducted on 11/06/23 on Units 1-4, from 6:04 AM to 7:29 AM. 1. At 6:25 AM on Unit 3 a syringe was observed to be filled with a clear liquid but was not labeled with the date, time and initials when it was drawn up. At 6:25 AM on Unit 3 a multi-use Heparin bottle was observed to be opened but not labeled with date, time and initials when it was opened. Interview on 11/06/23 at 6:30 AM with Staff D confirmed these findings. At 6:27 AM on Unit 3 two multi-use Zemplar (used for secondary hyperthyroidism) vials were observed to be open but not labeled with date, time and initials. Interview on 11/06/23 at 6:29 AM with Staff E confirmed this finding. 2. At 6:34 AM on Unit 4 a multi-use Heparin bottle was observed to be open but not labeled with date, time and initials. Interview on 11/06/23 at 6:37 AM with Staff F confirmed this finding. At 7:00 AM on Unit 4 a multi-use Heparin bottle was observed to be open but not labeled with date, time and initials. Interview on 11/06/23 at 7:01 AM with Staff G confirmed this finding.”