Fmc Hilltop Dialysis

“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: 37237 Based on observation and interview, it was determined that the facility failed to maintain a safe, functional, and comfortable environment for the patients, staff and public. Findings: Observations of the facility on 08/05/2025 beginning at 0935 revealed the following: - The AED pads ready for use inside the AED expired 06/24/2025. - The fire extinguisher by the lab area lacked the monthly check for July. All other fire extinguishers in the facility were signed off for the month of July. - Two of the privacy screens had pieces of bubble wrap taped around a section of the metal frame. The frame could not be cleaned effectively for infection control purposes. - The door to the staff lounge was propped open. The sign “Fire Door Keep Closed” was posted on the door. - Approximately 1/3 package of red-topped lab tubes that expired on 02/28/2025 was available for use. Review of QAPI meeting minutes from 06/26/2025 revealed the line item, “Crash Cart AED Pads expire soon, 6/24/2025.” The above findings were confirmed with the FA and DO on 08/06/2025 at 1615.”

“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 medical records, and review of documentation, it was determined that the facility failed to ensure that patients received hemodialysis treatments as prescribed and that VS monitoring was completed according to facility policy for 3 of 4 in-center hemodialysis patients reviewed (Patient #s 1, 2 and 4.) Findings: Patient #1 Review of Patient #1’s treatment sheets dated 07/08/2025 through 08/05/2025 (12 hemodialysis treatments) revealed the following: Review of the “Orders Summary Report” stipulated in the section “Special Attentions” that “Patient to take 5mg midodrine if SBP is less than 110. Every treatment” and “Self administer Midodrine 5 mg prior to start of tx, Every Treatment.” - On 07/08/2025: * At 0904, a PCT documented “Treatment interrupted due to clotting in the venous chamber, unable to resolve, 200 ml blood loss, rn aware.” There was no follow-up documentation found in the treatment sheet from the RN about the patient’s blood loss. In the post-treatment evaluation, the RN documented at 1330 “Late Entry: Pt left at 111.4kg, +2.4kg over EDW. BP 141/78. Pt denies any complaints after treatment. Pt left clinic normative to baseline.” * At 1000 the BFR/DFR was documented as 350/800 (as prescribed by the MD), at 1035, the BFR/DFR was documented as 350/0 and at 1113 it was documented as 350/500. There was no documentation found in the treatment sheet notes to explain the changes in DFR. - On 07/10/2025, the patient’s BP was recorded as 104/58 at 0912 and a PCT documented “pt denies c/o[,] uf resume at min[,] will check bp in 10[,] rn notified ...” The next BP check was 20 minutes later at 0932 and 22 minutes later at 0954. - On 07/12/2025, the patient’s BP was documented as 92/56 at 0817. At that time, a PCT documented “...low bp, uf off, rn aware ...” At 0913, the RN documented that 5.0 mg Midodrine was administered. There was no documentation that the patient self-administrated Midodrine prior to start of treatment. * The patient’s BFR was documented as 350 (as prescribed by the MD) at 1002. At 1033, the BFR was documented as 400; at 1100 the BFR was 350 and at 1119, the BFR was documented as 400. Treatment was terminated at 1121. There was no documentation as to why the BFR was changed. - On 07/15/2025, the patient’s BP was documented as 106/55 at 0833. At that time, a PCT documented “ ...low bp o2 given will check in 15 ...” The next BP was taken at 29 minutes later at 0904. There was no documentation that the patient self-administrated Midodrine prior to start of treatment or was advised to administer Midodrine when their SBP fell below 110. Patient #2 Review of Patient #1’s treatment sheets dated 07/08/2025 through 08/05/2025 (5 hemodialysis treatments) revealed the following: - On 07/15/2025, VS and patient assessment checks were documented at 1031. The next access check and face visualization was documented 65 minutes later at 1136. - Similar findings were identified for 07/17/2025. Patient #4 Review of Patient #4’s treatment sheets dated 06/09/2025 through 08/01/2025 (13 hemodialysis treatments) revealed the following: Review of the “Orders Summary Report” stipulated in the section “Hemodialysis” orders of “BFR 400, DFR Autoflow 2.0.” Autoflow 2.0 means that the DFR is two times the BFR which would be 800. - On 07/25/2025, at 0857, the patient’s BFR/DFR was documented as 200/800. At 0905, the BFR/DFR was documented as 200/400; at 0935, the BFR/DFR was documented as 250/700; at 1032, the BFR/DFR was documented as 200/400. There was no documentation found in the treatment sheet notes to explain the changes in the BFR/DFR. - On 07/30/2025, treatment was initiated at 0932 with the BFR at 425 and remained throughout treatment which ended at 1301. There was no documentation found in the treatment sheet notes to explain why the BFR was not set at prescribed. 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.” During interview with the FA on 08/06/2025 at 1500, the above findings were confirmed.”