Noble Woods Dialysis Clinic

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 47148 Based on interview and review of documentation, it was determined that the facility failed to ensure all staff were offered a Hepatitis B vaccination or signed a declination upon hire. Findings: Review of the document titled, “ESRD Core Survey Facility Worksheet: Personnel File” completed by the FA, revealed 5 staff members (Staff #’s 19-23) failed to have documentation of either receiving the Hepatitis B vaccination or had signed a declaration. * Staff #19, with a hire date of 04/24/2017, failed to have any documentation written in the column titled, “Hep B Results”. * Staff #20, with a hire date of 07/10/2023, failed to have any documentation written in the column titled, “Hep B Results”. * Staff #21, with a hire date of 08/15/2022, failed to have any documentation written in the column titled, “Hep B Results”. * Staff #22, with a hire date of 05/08/2006, failed to have any documentation written in the column titled, “Hep B Results”. * Staff #23, with a hire date of 11/07/2016, failed to have any documentation written in the column titled, “Hep B Results”. Review of the facility’s policy, “Employee Requirements for Testing and Vaccination for Hepatitis B” dated as “04/05/2021” stipulated, “The Hepatitis B vaccine shall be offered to all employees upon hire or rehire ... Hepatitis B vaccination status shall be documented in the employee’s vaccination record including ... signed consent or declination forms”. During an interview with the FA and DO on 06/05/2025 at 1600, the above findings were confirmed.”

“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: 37237 Based on interview, review of patient medical records and review of documentation, it was determined that the facility failed to ensure that patients received appropriate and timely hemodialysis monitoring or that the dialysis prescription was followed for 7 of 8 patients (Patients #s 1-5, 7 and 8). Findings: Patient #1 Review of Patient #1’s treatment sheets between 05/05/2025 and 06/02/2025 (13 treatments) revealed the following: - Review of Patient#1’s “Current Orders” revealed in the section titled, “Hemodialysis” that “BFR 350, DFR Autoflow 1.5.” An Autoflow DFR rate of 1.5 would be equal to 1.5 times the BFR, which would be 525 mL/min. * On 05/05/2025, the DFR was set at 600 mL/min and remained at that rate throughout the treatment. There was no documentation as to why the physician orders were not followed. * Similar findings were identified for the following treatment dates: 05/07/2025, 05/09/2025, 05/12/2025, 05/14/2025, 05/19/2025, 05/23/2025, 05/26/2025, 05/28/2025 and 06/02/2025. On 05/07/2025 and 05/09/2025, Patient #1 was documented as having elevated blood pressure readings with systolic blood pressures measuring as high as 213 and diastolic blood pressure readings measuring as high as 140. There was no documentation to indicate the blood pressure was rechecked and/or the licensed nurse was notified. Patient #2 Review of Patient #2’s treatment sheets between 05/08/2025 and 06/03/2025 (13 treatments) revealed the following: - Physician orders for treatment medication included a prescription for “Heparin Sodium (Porcine) 1,000 Units/mL Systemic Admin Method: infusion (Pump) 500 units IVP per hour. [sic] turn pump off 60 minutes prior to end of treatment, Every Treatment ...” * On 05/20/2025, treatment sheet documentation revealed that the heparin infusion was initialed at 1020 and terminated at 1425. A PCT documented treatment ended at 1425. Staff failed to turn the heparin pump off 60 minutes prior to end of treatment which allowed 2000 ml of heparin to be infused over 4 hours instead of the ordered 1500 ml. There was no documentation as to why the heparin order was not followed. * Similar findings were identified on treatment sheets dated: 05/27/2025 and 05/31/2025. Patient #3 Review of Patient #3’s treatment sheets between 05/05/2025 and 12/05/2024 (11 treatments) revealed the following: - VS monitoring and access checks were late for 2 of 11 treatments. * On 02/22/2025, a PCT documented a VS and access check at 0659. The next VS and access check was documented 65 minutes later at 0804. * On 04/16/2025, a PCT documented a VS and access check at 1600. The next VS and access check was documented 49 minutes later at 1649. At 1700, a PCT documented a VS and access check at 1700. The next VS and access check was documented 57 minutes later at 1757. - Physician orders for treatment medication included a prescription for “Heparin Sodium (Porcine) 1,000 Units/mL Systemic Admin Method: infusion (Pump) 500 units IVP per hour. [sic] turn pump off 0 minutes prior to end of treatment, Every Treatment ...” * On 02/22/2025, treatment sheet documentation revealed that the heparin infusion was initialed at 0655 and terminated at 1055. Only 1300 ml of heparin was infused over 4 hours instead of 2000 ml. There was no documentation as to why the medication amount administered was decreased. * Review of the treatment sheet dated 04/16/2025 revealed a lack of documentation regarding administration of any prescribed medications. Patient #4 Review of Patient #4’s Treatment Sheets between 05/05/2025 and 06/02/2025 (13 treatments) revealed the following: - Review of Patient #4’s “Current Orders” revealed in the section titled, “Hemodialysis” that “BFR 400, DFR Autoflow 1.5.” An Autoflow DFR rate of 1.5 would be equal to 1.5 times the BFR, which would be 600 mL/min. * On 05/05/2025, the BFR was set at 350 mL/min and remained at that rate throughout the treatment. There was no documentation as to why the physician orders were not followed. * Similar findings were identified for the following treatment dates: 05/07/2025, 05/09/2025, 05/12/2025, 05/14/2025, 05/16/2025, 05/19/2025, 05/21/2025, 05/23/2025, 05/26/2025, 05/28/2025, 05/60/2025 and 06/2/2025. - VS monitoring and access checks were late for 2 of 13 treatments. * On 05/30/2025, a PCT documented a VS and access check at 1234. The next VS and access check was documented 49 minutes later at 1323. * On 05/28/2025, a PCT documented a VS and access check at 1034. The next VS and access check was documented 57 minutes later at 1131. Patient #5 Review of Patient #5’s Treatment Sheet between 05/05/2025 and 05/30/2025 (12 hemodialysis treatments revealed the following: - Review of Patient #5’s “Current Orders” revealed in the section titled, “Hemodialysis” that “BFR 450, DFR Autoflow 2.0 ...” An Autoflow DFR rate of 2 would be equal to 2 times the BFR, which would be 900 mL/min. * On 05/05/2025, the average BFR ran at 460 mL/min and the DFR ran at 790 mL/min. There was no documentation as to why the physician orders were not followed. * On 05/07/2025, the average BFR ran at 460 mL/min and the DFR ran at 800 mL/min. There was no documentation as to why the physician orders were not followed. * On 05/09/2025, the average BFR ran at 350 mL/min and the average DFR ran at 680 mL/min. There was no documentation as to why the physician orders were not followed. * On 05/30/2025, the average BFR ran at 400 mL/min and the average DFR ran at 790 mL/min. There was no documentation as to why the physician orders were not followed. * Similar findings were identified on treatment sheets dated: 05/12/2025, 05/12/2025, 05/14/2025, 05/16/2025, 05/19/2025, 05/21/2025, 05/23/2025, 05/26/2025 and 05/28/2025. - VS monitoring and access checks were late for 3 of 12 treatments. * On 05/05/2025, a PCT documented a VS and access check at 1733. The next VS and access check was documented 61 minutes later at 1834. * On 05/07/2025, a PCT documented a VS and access check at 1505. The next VS and access check was documented 119 minutes later at 1704. * Similar findings were identified on the treatment sheet dated 05/28/2025. Patient #7 Review of Patient #7’s treatment sheets between 05/03/2025 and 05/31/2025 (13 treatments) revealed the following: - Review of Patient#7’s “Current Orders” revealed in the section titled, “Hemodialysis” that “BFR 400.” * On 05/08/2025, an RN documented treatment was initiated at 1146 with the BFR at 400 mL/min. At 1239, a PCT documented the BFR at 415 mL/min where it remained at that rate throughout the treatment. There was no documentation as to why the physician orders were not followed. * Similar findings were identified on treatment sheets dated: 05/20/2025, 05/22/2025 and 05/27/2025. - Review of Patient #7’s “Current Orders” revealed physician orders for treatment medication included a prescription for “Heparin Sodium (Porcine) 1,000 Units/mL Systemic Admin Method: infusion (Pump) 500 units IVP per hour. [sic] turn pump off 60 minutes prior to end of treatment, Every Treatment ...” * On 05/03/2025, a PCT documented treatment ended at 1555. The treatment sheet revealed the heparin pump was started at 1425 and ended at 1555. Staff failed to turn the heparin pump off 60 minutes prior to end of treatment. * Similar findings were identified on treatment sheets dated: 5/06/2025, 05/10/2025, 05/13/2025, 05/15/2025, 05/24/2025, and 05/31/2025. Patient #8 Review of Patient #8’s treatment sheets between 05/05/2025 and 06/02/2025 (13 treatments) revealed the following: * On 05/16/2025, a PCT documented treatment was initiated at 1035. Blood pressure, pulse and access checks were documented by staff; however the treatment sheet failed to have treatment data documentation by the dialysis machine at regular intervals. BFR/DFR, AP/VP, UFR/fluid removed and fluid given fields were blank. Review of facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/2023, stipulated: * “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” * “Document machine parameters and safety checks every 30 [min] or more often as needed but not to exceed 45 minutes or per state regulations.” * “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow.” * “Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” * “If heparin pump is used, ensure heparin is infusing at prescribed rate.” * “Recheck blood pressures after a drop that requires interventions such as administering normal saline.” * “Report to the nurse: Systolic blood pressures greater than 180 mm/Hg ... Diastolic blood pressure greater than 100 mm/Hg” During interview with the CN on 06/05/2025 at 1500, the above findings were confirmed.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 47148 Based on interview and facility documentation, it was determined the facility failed to implement facility policy that ensured pneumococcal vaccines were offered to qualifying patients for 6 of 70 patients reviewed (Patient #s 1, 3, 7 and 9-11). Findings: 1. Review of the Pneumonia Vaccination Report dated 06/03/2025 revealed the following: * Patient #1 had an order for a pneumococcal vaccine, but the vaccine was not administered in a timely manner. The last pneumococcal vaccination given was PCV13 on 07/20/2015 and was ordered “Admin PCV20 as ordered on or after 07/20/2020” but the vaccine was not administered as of the 06/05/2025 report. * Patient #3 had an order for a pneumococcal vaccine, but the vaccine was not administered in a timely manner. The last pneumococcal vaccination given was PCV13 on 10/10/2019 and was ordered “Admin PCV20 as ordered on or after 10/10/2024” but the vaccine was not administered as of the 06/05/2025 report. * Patient #7 had an order for a pneumococcal vaccine, but the vaccine was not administered in a timely manner. The last pneumococcal vaccination given was PPSV23 on 05/12/2020 and was ordered “Admin PCV20 as ordered on or after 05/12/2025” but the vaccine was not administered as of the 06/05/2025 report. * Patient #9 had an order for a pneumococcal vaccine, but the vaccine was not administered in a timely manner. The last pneumococcal vaccination given was PCV13 on 09/07/2016 and was ordered “Admin PCV20 as ordered on or after 09/07/2021” but the vaccine was not administered as of the 06/05/2025 report. * Patient #10 had an order for a pneumococcal vaccine, but the vaccine was not administered in a timely manner. The last pneumococcal vaccination given was PCV13 on 02/26/2020 and was ordered “Admin PCV20 as ordered on or after 02/26/2025” but the vaccine was not administered as of the 06/05/2025 report. * Patient #11 had an order for a pneumococcal vaccine, but the vaccine was not administered in a timely manner. The last pneumococcal vaccination given was PPSV23 on 01/19/2018 and was ordered “Admin PCV20 as ordered on or after 01/19/2023” but the vaccine was not administered as of the 06/05/2025 report. Review of the facility policy titled, “Pneumococcal Vaccine for Adult Patients,” dated as last revised “October 2023,” stipulated: * “Patients of any age who have only received PPSV23 required “PCV20 at least one year after most recent PPSV23” to complete the vaccination series.” * “Patients who received PPSV23 before age 65 and also received PCV13 required “PCV20 at least 5 years after most recent pneumococcal dose” to complete the vaccination series.” During an interview with the FA and DO on 06/05/2025 at 1600, the above findings were confirmed.”