Davita West Shore Dialysis

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 39671 Based on review of policies/procedures, treatment records and interviews with the facility administrator and staff, it was determined that the facility failed to provide oversight for ensuring staff followed policy for monitoring vital signs, reporting and/or documenting abnormal findings during hemodialysis treatments; and failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician This CONDITION is not met as evidenced under the following standards: Findings Include: Cross Reference: 42 CFR 494.90(a)(1) POC-Manager Volume Status (TAG 0543): Facility faciled to follow its policy for monitoring vital signs, reporting and/or documenting abnormal findings during hemodialysis treatments 42 CFR 494.90(a)(1) POC-Achieve Adequate Clearance (TAG 0544): Facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician The cumulative effect of these systematic problems resulted in the ESRD’s inability to ensure the provision of target goals being achieved and sustained.”

“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: 39671 Based on review of facility policies, treatment area observations, and an interview with the facility Administrator, the facility failed to ensure the staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves, for three (3) of eighteen (18) observations. (Treatment Area Observation #1, Treatment Area Treatment #2 and Treatment Area Observation # 3). Findings: A review was conducted of facility policy on May 13, 2024 at approximately 1:00 p.m. Policy 1-04-02B ‘Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure’ ‘Procedure’ states, “...7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove...8. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds, apply to the CVC exit site in a “back and forth” pattern...’ A review was conducted of facility policy on May 13, 2024 at approximately 1:00 p.m. Policy 1-04-02B ‘Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure’ ‘Upon Completion of Dialysis’ states, “...29. Remove gloves and discard, perform hand hygiene per procedure and re-glove...30. Clamp arterial catheter limb and blood line. Aseptically disconnect arterial blood line for arterial CVC limb...Attach arterial blood line to saline infusion line and conclude dialysis and rinse back per procedure...31. Clamp venous catheter limb....” A review was conducted of facility policy on May 13, 2024 at approximately 1:10 p.m. Policy 1-04-01B ‘Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles’ ‘Procedure’ states, “1. Perform hand hygiene. Put on PPE (Personal Protective Equipment). 2. Conclude dialysis and rinse back per termination procedure specific to dialysis delivery system and blood line used in facility. 3. Verify both venous and arterial needles are clamped. 4. Un-tape safety device and move close to needle hub. 5. Remove tape from one needle insertion site. Observe needle site for changes during treatment. Place gauze gently but firmly over needle insertion site. 6. Slightly remove needle and slide safety device in place. 7. Remove needle at same or similar angle of insertion following the manufacturer’s instructions. Slide safety device over needle tip and apply pressure to insertion site. 8. With safety device engaged, dispose of safety fistula needle in the sharps container. 9. The patient will be encouraged to hold their own sites if their condition permits...10. The amount of pressure applied should be sufficient enough to stop leakage...” Treatment area observations conducted on May 13, 2024, between approximately 9:55 a.m. and 1:35 p.m. revealed the following: Treatment Area Observation #1: During observation #2 of ‘Central Venous Catheter Exit Site Care’ on 5/13/2024 at approximately 1:30 p.m. of patient #9, station #9; Employee (Emp) #2 failed to remove gloves, perform hand hygiene and don clean gloves after removing and discarding the old dressing and prior to cleansing the area around CVC exit site with antiseptic. Treatment Area Observation #2: During observation #2 of ‘Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft’ on 5/13/2024 at approximately 9:55 a.m. of patient #13, station #12; Emp #5 failed to remove gloves, perform hand hygiene and don clean gloves after reinfusing extracorporeal circuit, disconnecting bloodlines aseptically and prior to removing needles aseptically and discarding needles in the Sharps container. Treatment Area Observation #3: During observation #1 of ‘Discontinuation of Dialysis with Central Venous Catheter’ on 5/13/2024 at approximately 12:45 p.m. of patient #17, station Isolation Room; Emp #5 failed to remove gloves, perform hand hygiene and don clean gloves after reinfusing extracorporeal circuit and prior to closing CVC clamps and disinfecting CVC connections with an appropriate antiseptic. An interview with the facility administrator on May 15, 2024 at approximately 3:30 p.m. confirmed the above findings. Based on review of facility policies, treatment area observations, and an interview with the facility Administrator, the facility failed to ensure staff washed skin over access with soap and water or antibacterial scrub prior to accessing AV Fistula or Graft for one (1) of eighteen (18) observations. (Treatment Area Observation #4) Findings: A review was conducted of facility policy on May 13, 2024 at approximately 1:15 p.m. Policy 1-04-01E ‘AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose’ ‘Procedure’ states, “1. Have patient was access site with appropriate antibacterial soap, if able. If patient unable to wash access site, patient care teammate will clean access extremity with skin cleansing agent and pat dry...4. Prior to auscultating a bruit with a stethoscope, clean the diaphragm of the stethoscope first with an alcohol prep pad. 5. Perform inspection, auscultation and palpation on entire length of access. Determine presence of bruit and thrill....8. Locate and palpate the needle cannulation sites prior to skin preparation. 9. Cannulation sites are to allow at least one and one-half (1.5) inches between needle tips. 10. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry....’ Treatment area observations conducted on May 13, 2024, between approximately 9:55 a.m. and 1:35 p.m. revealed the following: Treatment Area Observation #4: During observation #2 of ‘Access of AV Fistula or Graft for Initiation of Dialysis’ on 5/13/2024 at approximately 11:04 a.m. of patient #11, station #1; Employee (Emp) #4 failed wash skin over access with soap and water or antibacterial scrub and failed to evaluate access; locate/palpate cannulation sites during procedure. An interview with the facility administrator on May 15, 2024 at approximately 3:30 p.m. confirmed the above 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: 39671 Based on review of facility policies, treatment area observations, and an interview with the facility Administrator, the facility failed to ensure staff followed standard infection control precautions by emptying the prime waste receptacle prior to disinfecting the dialysis station for one for two (2) of eighteen (18) observations. (Treatment Area Observation #5 and Treatment Area Observation #6) and facility failed to ensure staff followed standard infection control when cleaning up visible blood for one (1) of eighteen (18) observations. (Treatment Area Observation #7) Findings: A review was conducted of facility policy on May 13, 2024 at approximately 2:15 p.m. Policy 1-05-01 ‘Infection Control for Dialysis Facilities’ ‘Disinfection’ states, “12ii. After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time...” A review was conducted of facility policy on May 13, 2024 at approximately 2:15 p.m. Policy 1-05-01 ‘Infection Control for Dialysis Facilities’ ‘Disinfection’ states, “13-ii. Priming containers are to be emptied prior to disinfection. Drain line and water supply line should not be placed with ends in prime containers or in a position where they can drip into or contaminate the prime bucket...” Treatment area observations conducted on May 13, 2024, between approximately 9:55 a.m. and 1:35 p.m. revealed the following: Treatment Area Observation #5: During observation #1 of ’’Cleaning and Disinfection of the Dialysis Station’ on 5/13/2024 at approximately 10:08 a.m. station #1; Employee (Emp) #7 failed to empty prime waste receptacle after removing all bloodlines and disposable equipment and prior to disinfecting the dialysis station. Treatment Area Observation #6: During observation #2 of ’’Cleaning and Disinfection of the Dialysis Station’ on 5/13/2024 at approximately 10:38 a.m. station #12; Emp #4 failed to empty prime waste receptacle after removing all bloodlines and disposable equipment and prior to disinfecting the dialysis station. Treatment Area Observation #7: On 5/13/2024 at approximately 1:30 p.m. near station #9; Emp #2 cleaned up drops of blood on the floor that came from a 10 cc syringe filled with blood that fell with the 1:10 (one to ten) bleach solution. Emp #2 failed to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time. An interview with the facility administrator on May 15, 2024 at approximately 3:30 p.m. confirmed the above 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: 39671 Based on review of facility policies, treatment area observations, and an interview with the facility Administrator, the facility failed to ensure proper medication preparation and handling was performed for 1 (one) of 18 (eighteen) observations. Treatment Area Observation #8) Findings: A review was conducted of facility policy on May 13, 2024 at approximately 2:20 p.m. Policy 1-06-01 ‘Medication Policy’ ‘Policy’ states, “...20...If the medication is not immediately administered or is to be adminstered by another teammate, the medication must be labels with the patient name, name of medication, date, time prepared, dose and initials of teammate preparing the medication...” Treatment area observations conducted on May 13, 2024, between approximately 9:55 a.m. and 1:35 p.m. revealed the following: Treatment Area Observation #8: On 3/13/2024 at approximately 9:55 a.m. surveyor observed five (5) prefilled syringes with preprinted labels affixed. Staff failed to ensure preprinted labels affixed to the syringes included the time the medication was prepared. An interview with the facility administrator on May 15, 2024 at approximately 3:30 p.m. confirmed the above findings.”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 39671 Based on review of facility policy, water room observations, and an interview with the facility Administrator, facility failed to ensure brine tank was filled at least least way up with salt pellets for two (2) of two (2) water room observations. (Water Room Observation #1 and Water Room Observation #2). Findings: A review was conducted of facility policy on May 13, 2024 at approximately 10:00 a.m. Policy 1-17-02 ‘Daily Water Treatment System Monitoring’ ‘Policy’ section #7 states, “A licensed nurse reviews the Daily Water Treatment Log for completeness and verifies that all parameters are within specified limits. Upon satisfactory completion of this review, the licensed nurse initials and signs the log form where indicated.” Review of ‘Daily Water Treatment Log’ section titled, ‘Salt/Brine Tank # Bags Added...Tank at least half full, above the water...’ Observations conducted in the water room on May 13, 2024, at approximately 9:30 a.m. and on May 14, 2024 at approximately 9:45 a.m. revealed the following: Water Room Observation #1: On May 13, 2024 at approximately 9:30 a.m. the surveyor observed the brine tank filled 1/4 of the way up of salt pellets inside the brine tank. Water Room Observation #2: On May 14, 2024 at approximately 9:45 a.m. the surveyor observed the brine tank filled 1/4 of the way up of salt pellets inside the brine tank. An interview with the facility administrator on May 15, 2024 at approximately 3:30 p.m. confirmed the above 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: 39671 Based on review of facility policies, medical records (MR), hemodialysis (HD) treatment records and an interview with the facility Administrator, the facility failed to follow its policy for monitoring vital signs, reporting and/or documenting abnormal findings during hemodialysis treatment for five (5) of 7 (seven) MRs reviewed. (MR #1, MR# 2, MR #3, MR #4 and MR #5) Findings: A review was conducted of facility policy on May 14, 2024 at approximately 9:10 a.m. Policy 1-03-08 ‘Pre-Intra-Intra-Post treatment Date Collection, Monitoring and Nursing Assessment’ ‘Policy’ states, “Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes ... measurement of BP (blood pressure), Heart or pulse rate;” “The nursing assessment will be performed and documented by a licensed nurse. The assessment includes the following components: review of patient reports, data collection, response to treatment.” ‘Intradialytic Data Collection/Assessment’ states, “...11. Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary...12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status...13. All findings, interventions and patient response will be documented in the patient’s medical record....” ‘Abnormal Findings’ states, “.... Blood Pressure Pre-Dialysis: Systolic greater than 180 mm Hg or less than 90 mm Hg; Diastolic greater than or equal to 100 mmHg; Blood Pressure - Intradialytic: Difference of 20 mmHg increase or decrease from patient ’ s last intradialytic treatment BP reading; Blood Pressure Post Treatment: Standing systolic BP greater than 140 mmHg or less than 90 mmHg; Standing diastolic BP greater than 90 mmHg or less than 50 mmHg; Sitting BP for patient ’ s that cannot stand: Sitting systolic BP greater than 140 mmHg or less than 90 mmHg; Sitting diastolic BP greater than 90 mmHg or less than 50 mmHg; Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minutes or greater than 100 beats per minutes and/or an irregular heart beat.” Medical record reviews conducted on May 14, 2024, between approximately 10:00 a.m. and 3:00 p.m. and on May 15, 2024 between approximately 9:00 a.m. to 2:45 p.m. revealed the following: Medical Record # 1: Review of treatment flowsheets between the date range of 4/1/2024 and 5/10/2024 revelaed the following: - Treatment Flowsheet date: 4/1/2024: At 8:02 a.m. Patient Care Technician Employee (PCT Emp) #5 recorded the blood pressure (BP) as 174/107. PCT Emp #5 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 9:32 a.m. PCT Emp #7 records the BP as 160/108. PCT Emp #7 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/3/2024: At 8:32 a.m. Registered Nurse (RN) Emp# 13 recorded BP as 171/104. RN Emp # 13 failed to document any assessments, interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. At 9:02 a.m. RN Emp# 13 recorded BP as 190/110. RN Emp # 13 failed to document any assessments, interventions and findings relating to the abnormal finding of the Systolic BP being greater than 180 mm Hg and of the diastolic BP being greater than 90 mm Hg, per facility policy. - Treatment Flowsheet date: 4/5/2024: At 6:32 a.m. PCT Emp #7 recorded BP as 178/113. PCT Emp #7 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 8:02 a.m. PCT Emp #7 recorded BP as 167/102. PCT Emp #7 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/10/2024: At 5:41 a. m. RN Emp #2 recorded BP as 166/105. RN Emp #2 failed to document any assessments, interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. At 6:02 a.m. PCT Emp #8 recorded BP as 179/102. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:03 a.m. PCT Emp #6 recorded BP as 211/136. PCT Emp #6 failed to report the abnormal finding of the Systolic being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:06 a.m. PCT Emp #8 recorded BP as 216/128. PCT Emp #8 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:33 a.m. PCT Emp #6 recorded BP as 185/111. PCT Emp #6 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 8:02 a.m. PCT Emp #6 recorded BP as 180/100. PCT Emp #6 failed to report the abnormal finding of the Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 8:11 a.m. PCT Emp #8 recorded BP as 168/101. PCT Emp #8 failed to report the abnormal finding of the Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 9:32 a.m. RN Emp #13 recorded BP as 179/112. RN Emp #13 failed to document interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. At 9:36 a.m. RN Emp #13 recorded BP as 177/108. RN Emp #13 failed to document any assessments, interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. - Treatment Flowsheet date: 4/12/2024: At 5:51 a.m. PCT Emp #5 recorded the BP as 164/107. PCT Emp #5 failed to report the abnormal finding of the diastolic BP being greater than 90 mmHg, per facility policy, to the licensed nurse immediately. At 6:05 a.m. RN Emp #2 recorded BP as 157/104. RN Emp #2 failed to document any assessments, interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. At 7:02 a.m. PCT Emp #5 recorded the BP as 175/102. PCT Emp #5 failed to report the abnormal finding of the diastolic BP being greater than 90 mmHg, per facility policy, to the licensed nurse immediately. At 8:33 a.m. PCT Emp #5 recorded the BP as 199/109. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 9:03 a.m. PCT Emp #6 recorded the BP as 193/98. PCT Emp #6 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg, per facility policy, to the licensed nurse immediately. At 9:33 a.m. PCT Emp #6 recorded the BP as 159/104. PCT Emp #6 failed to report the abnormal finding of the diastolic BP being greater than 90 mmHg, per facility policy, to the licensed nurse immediately. At 9:53 a.m. PCT Emp #6 recorded the BP as 191/114. PCT Emp #6 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet 4/15/2024: At 6:03 a.m. RN Emp #13 recorded BP as 188/108. RN Emp #2 failed to document any assessments, interventions and findings relating to the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy. At 6:33 a.m. PCT Emp #5 recorded the BP as 182/109. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:03 a.m. PCT Emp #5 recorded the BP as 205/125. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:33 a.m. RN Emp #2 recorded BP as 179/114. RN Emp #2 failed to document any interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. At 8:33 a.m. PCT Emp #5 recorded the BP as 199/118. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 9:07 a.m. RN Emp #13 recorded BP as 202/122. RN Emp #2 failed to document any , interventions and findings relating to the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy. At 9:10 a.m. RN Emp #13 recorded BP as 189/94. RN Emp #2 failed to document any interventions and findings relating to the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy. At 9:33 a.m. RN Emp #13 recorded BP as 187/92. RN Emp #2 failed to document any interventions and findings relating to the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy. At 9:53 a.m. PCT Emp #7 recorded the BP as 198/91. PCT Emp #7 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet Date: 4/19/2024: At 6:33 a.m. PCT Emp #8 recorded the BP as 152/109. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 8:03 a.m. PCT Emp #5 recorded the BP as 181/113. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 9:33 a.m. RN Emp #13 recorded BP as 176/104. RN Emp #13 failed to document any interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. - Treatment Flowsheet Date: 5/1/2024: At 6:04 a.m. PCT Emp #8 recorded the BP as 148/101. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 6:34 a.m. PCT Emp #8 recorded the BP as 169/107. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:04 a.m. PCT Emp #8 recorded the BP as 179/117. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:34 a.m. PCT Emp #5 recorded the BP as 165/109. PCT Emp #5 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 8:04 a.m. PCT Emp #8 recorded the BP as 172/116. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 8:43 a.m. PCT Emp #5 recorded the BP as 172/111. PCT Emp #5 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. Patient was not assessed or provided any interventions by a registered nurse for his high blood pressure during entire treatment time. - Treatment Flowsheet Date: 5/6/2024: At 5:40 a.m. PCT Emp #7 recorded the BP as 195/110. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 6:03 a.m. PCT Emp #4 recorded the BP as 187/107. PCT Emp #4 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 6:33 a.m. PCT Emp #4 recorded the BP as 186/105. PCT Emp #4 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:33 a.m. PCT Emp #4 recorded the BP as 182/106. PCT Emp #4 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 8:34 a.m. PCT Emp #4 recorded the BP as 150/101. PCT Emp #4 failed to report the abnormal finding of the Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 9:04 a.m. PCT Emp #4 recorded the BP as 202/107. PCT Emp #4 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 9:36 a.m. RN Emp #2 recorded BP as 158/102. RN Emp #2 failed to document any assessments, interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. - Treatment Flowsheet Date: 5/8/2024: At 7:37 a.m. PCT Emp #5 recorded the BP as 184/104. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 9:33 a.m. PCT Emp #6 recorded the BP as 171/101. PCT Emp #6 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet Date: 5/10/2024: At 6:04 a.m. PCT Emp #5 recorded the BP as 170/115. PCT Emp #5 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 6:34 a.m. PCT Emp #5 recorded the BP as 153/102. PCT Emp #5 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:08 a.m. PCT Emp #5 recorded the BP as 184/117. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 7:26 a.m. RN Emp #3 recorded the BP as 166/109. RN Emp #3 failed to document any assessments, interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. At 7:36 a.m. PCT Emp #8 recorded the BP as 169/111. PCT Emp #8 failed to report the abnormal finding of the Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 8:04 a.m. PCT Emp #8 recorded the BP as 174/103. PCT Emp #8 failed to report the abnormal finding of the Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 8:34 a.m. PCT Emp #5 recorded the BP as 179/105. PCT Emp #5 failed to report the abnormal finding of the Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 9:04 a.m. PCT Emp #5 recorded the BP as 176/106. PCT Emp #5 failed to report the abnormal finding of the Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 10:02 a.m. PCT Emp #8 recorded the BP as 172/113. PCT Emp #8 failed to report the abnormal finding of the Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. Medical Record # 2: Review of treatment flowsheets between the date range of 4/2/2024 and 4/27/2024 revelaed the following: - Treatment Flowsheet date: 4/4/2024: At 12:33 p.m. PCT Emp #4 recorded the heart rate (HR) as 41. PCT Emp# 4 failed to report the abnormal finding of the HR being less than 60 beats per minute, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/9/2024: At 11:32 a.m. PCT Emp #8 recorded the BP as 106/49. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being less than 50 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/11/2024: At 12:33 p.m. PCT Emp #7 recorded the HR as 51. PCT Emp #7 failed to report the abnormal finding of the HR being less than 60 beats per minutes, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/13/2024: At 10:03 a.m. PCT Emp #5 recorded the HR as 59. PCT Emp# 4 failed to report the abnormal finding of the HR being less than 60 beats per minute, per facility policy, to the licensed nurse immediately. At 10:33 a.m. PCT Emp #7 recorded the BP as 77/38 and HR as 47. PCT Emp #7 failed to report the abnormal findings of the Systolic bring less than 90 mm Hg, Diastolic being less than 50 mm Hg and HR being less than 60 beats per minute, per facility policy, to the licensed nurse immediately. At 10:35 a.m. PCT Emp #7 recorded the BP as 98/42 and HR as 53. PCT Emp #7 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg and HR being less than 60 beats per minute, per facility policy, to the licensed nurse immediately. At 12:03 p.m. PCT Emp #5 recorded the BP as 109/49 and HR as 53. PCT Emp #5 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg and HR being less than 60 beats per minute, per facility policy, to the licensed nurse immediately. At 1:07 p.m. PCT Emp #5 recorded the BP as 94/49. PCT Emp# 4 failed to report the abnormal findings of the Systolic bring less than 90 mm Hg and Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/27/2024: At 11:34 a.m. PCT Emp #5 recorded the BP as 94/41. PCT Emp #5 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. At 1:07 a.m. PCT Emp #7 recorded the BP as 85/55. PCT Emp #7 failed to report the abnormal findings of the Systolic being less than 90 mm Hg per facility policy, to the licensed nurse immediately. Medical Record # 3: Review of treatment flowsheets between the date range of 4/10/2024 and 5/10/2024 revelaed the following: - Treatment Flowsheet date: 4/10/2024: At 5:42 a.m. PCT Emp #7 recorded the BP as 107/48. PCT Emp #7 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. At 7:32 a.m. PCT Emp #6 recorded the BP as 101/46. PCT Emp #6 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. At 8:32 a.m. PCT Emp #8 recorded the BP as 109/27. PCT Emp #8 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/12/2024: At 3:02 p.m. PCT Emp #5 recorded the BP as 120/44. PCT Emp #5 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/15/2024: At 2:02 p.m. RN Emp# 13 recorded the BP as 102/37. RN Emp #13 failed to document any assessments, interventions and findings relating to the abnormal finding of the Diastolic being less than 50 mm Hg per facility policy. At 3:02 p.m. PCT Emp# 5 recorded the BP as 110/42. PCT Emp #5 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. At 5:02 p.m. RN Emp# 2 recorded the BP as 133/38. RN Emp #2 failed to document any assessments, interventions and findings relating to the abnormal finding of the Diastolic being less than 50 mm Hg per facility policy. - Treatment Flowsheet date: 4/17/2024: At 6:01 a.m. PCT Emp #8 recorded the HR as 59. PCT Emp# 8 failed to report the abnormal finding of the HR being less than 60 beats per minutes, per facility policy, to the licensed nurse immediately. At 7:33 a.m. RN Emp #3 recorded the BP as 99/49. RN Emp #3 failed to document any interventions and findings relating abnormal findings of the Systolic bring less than 90 mm Hg and Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. At 8:01 a.m. PCT Emp #5 recorded the BP as 120/47. PCT Emp #5 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. At 8:34 a.m. PCT Emp #5 recorded the BP as 92/48. PCT Emp #5 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. At 9:01 a.m. PCT Emp #5 recorded the BP as 101/40. PCT Emp #5 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/19/2024: At 4:02 p.m. PCT Emp #7 recorded the BP as 158/49. PCT Emp #7 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/24/2024: At 9:32 a.m. RN Emp# 3 recorded the BP as 120/35. RN Emp #3 failed to document any assessments, interventions and findings relating to the abnormal finding of the Diastolic being less than 50 mm Hg per facility policy. - Treatment Flowsheet date: 5/1/2024: At 6:32 a.m. PCT Emp #8 recorded the BP as 111/49. PCT Emp #8 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 5/10/2024: At 3:02 p.m. PCT Emp #8 recorded the BP as 94/33. PCT Emp #8 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. At 3:32 p.m. PCT Emp #4 recorded the HR as 59. PCT Emp# 4 failed to report the abnormal finding of the HR being less than 60 beats per minutes, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 5/8/2024: At 5:35 a.m. PCT Emp #5 recorded the HR as 59. PCT Emp #5 failed to report the abnormal finding of the HR being less than 60 beats per minutes, per facility policy, to the licensed nurse immediately. At 7:31 a.m. PCT Emp #8 recorded the BP as 119/47. PCT Emp #8 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. At 8:02 a.m. RN Emp# 2 recorded the BP as 104/46. RN Emp 2 failed to document any interventions and findings relating to the abnormal finding of the Diastolic being less than 50 mm Hg per facility policy. At 9:09 a.m. PCT Emp #5 recorded the BP as 135/49. PCT Emp #5 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. Medical Record # 4: Review of treatment flowsheets between the date range of 4/1/2024 and 5/10/2024 revelaed the following: - Treatment Flowsheet date: 4/1/2024: At 9:45 a.m. PCT Emp #5 recorded the BP as 205/92. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/5/2024: At 1:04 p.m. RN Emp #3 recorded the BP as 100/45. RN Emp #3 failed to document any interventions and findings relating to the abnormal finding of the Diastolic being less than 50 mm Hg per facility policy. At 1:30 p.m. RN Emp #3 recorded BP as 143/128. RN Emp #2 failed to document any assessments, interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. - Treatment Flowsheet date: 4/8/2024: At 10:01 a.m. PCT Emp #7 recorded the BP as 92/40. PCT Emp #7 failed to report the abnormal finding of the diastolic BP being less than 50 mm Hg, per facility policy, to the licensed nurse immediately. At 12:32 p.m. PCT Emp #7 recorded the BP as 107/49. PCT Emp #7 failed to report the abnormal finding of the diastolic BP being less than 50 mm Hg, per facility policy, to the licensed nurse immediately. At 1:21 p.m. PCT Emp #7 recorded the BP as 93/44. PCT Emp #7 failed to report the abnormal finding of the diastolic BP being less than 50 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/12/2024: At 12:45 p.m. PCT Emp #5 recorded the BP as 90/35. PCT Emp #7 failed to report the abnormal finding of the diastolic BP being less than 50 mm Hg, per facility policy, to the licensed nurse immediately. At 12:49 p.m. PCT Emp #5 recorded the HR as 103. PCT Emp #5 failed to report the abnormal finding of the HR being greater than 100 beats per minute, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/15/2024: At 12:35 p.m. RN Emp #13 recorded BP as 249/174. RN Emp #13 failed to document any interventions and findings relating to the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy. At 12:36 p.m. RN Emp #13 recorded BP as 182/138. RN Emp #13 failed to document any interventions and findings relating to the abnormal finding of the Systolic BP being greater than 180 mm Hg and Diastolic BP being greater than 90 mm Hg, per facility policy. At 1:07 p.m. RN Emp #13 recorded the HR as 104. RN Emp #13 failed to document any assessments, interventions and findings relating to the abnormal finding of the HR being greater than 100 beats per minute, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/19/2024: At 11:31 a.m. PCT Emp #8 recorded the BP as 171/142. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 11:32 PCT Emp # 8 notified RN regarding the BP reading 164/101. Registered nurse failed to document assessments, interventions and findings relating to the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy. At 12:01 p.m. PCT Emp #8 recorded the BP as 159/105. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 12:32 p.m. PCT Emp #8 recorded the BP as 162/108. PCT Emp #8 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 1:01 p.m. PCT Emp #4 recorded the BP as 168/106. PCT Emp #4 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 4/22/2024: At 10:20 a.m. PCT Emp #7 recorded the HR as 105. PCT Emp #7 failed to report the abnormal finding of the HR being greater than 60 beats per minute, per facility policy, to the licensed nurse immediately. At 1:03 p.m. RN Emp #13 recorded the BP as 64/50. RN Emp #13 failed to document any interventions and findings relating to the Systolic BP less than 90 mm Hg per facility policy. - Treatment Flowsheet date: 4/29/2024: At 10:07 a.m. PCT Emp #4 recorded the HR as 118. PCT Emp# 4 failed to report the abnormal finding of the HR being greater than 100 beats per minute, per facility policy, to the licensed nurse immediately. At 11:02 a.m. PCT Emp #7 recorded the HR as 110. PCT Emp #7 failed to report the abnormal finding of the HR being greater than 100 beats per minute, per facility policy, to the licensed nurse immediately. At 11:31 a.m. RN Emp #3 recorded the HR as 116. RN Emp #3 failed to document any interventions and findings relating to the abnormal finding of the HR being greater than 100 beats per minute, per facility policy. At 1:32 p.m. RN Emp #3 recorded the BP as 174/112 and HR as 106. RN Emp #3 failed to document any interventions and findings relating to the abnormal finding of the Diastolic BP being greater than 90 mm Hg and of HR being greater than 100 beats per minute, per facility policy. - Treatment Flowsheet date: 5/3/2024: At 10:33 a.m. PCT Emp #7 recorded the BP as 117/39. PCT Emp #7 failed to report the abnormal findings of the Diastolic being less than 50 mm Hg per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 5/6/2024: At 9:25 a.m. RN Emp #2 recorded the BP as 97/49. RN Emp #2 failed to document any interventions and findings relating to the abnormal finding of the Diastolic being less than 50 mm Hg per facility policy. At 11:06 a.m. RN Emp #2 recorded the BP as 181/92. RN Emp #2 failed to document any interventions and findings relating to the abnormal finding of the Systolic BP being greater than 180 mm Hg per facility policy. At 11:33 a.m. PCT Emp #4 recorded the BP as 207/68. PCT Emp #4 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg, per facility policy, to the licensed nurse immediately. - Treatment Flowsheet date: 5/10/2024: At 11:31 a.m. PCT Emp #4 recorded the BP as 161/104. PCT Emp #4 failed to report the abnormal finding of the diastolic BP being greater than 90 mm Hg, per facility policy, to the licensed nurse immediately. At 12:32 p.m. PCT Emp #5 recorded the BP as 184/86. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg, per facility policy, to the licensed nurse immediately. Medical Record # 5: Review of treatment flowsheets between the date range of 4/2/2024 and 5/11/2024 revelaed the following: - Treatment Flowsheet date: 5/2/2024: At 6:04 a.m. RN Emp #3 recorded the BP as 194/88. RN Emp #2 failed to document any assessments, interventions and findings relating to the abnormal finding of the Systolic BP being greater than 180 mm Hg per facility policy. At 6:34 a.m. PCT Emp #5 recorded the BP as 186/97. PCT Emp #5 failed to report the abnormal finding of the Systolic BP being greater than 180 mm Hg, per facility policy, to the licensed nurse immediately. Interview with employee # 2 was conducted on May 15, 2024 at approximately 10:00 a.m. Surveyor asked employee # 2 regarding the out of range vial signs and the lack of interviention documentation. Employee # 2 replied, “We are made aware of that vital signs and we do implement interventions, we just didn’t document them I guess. [MR# 1] has always had issues with his vital signs and we keep track of them and make sure he is okay before he leaves every treatment. They move up and down but this is chronic with him.” An interview with the facility administrator on May 15, 2024 at approximately 3:30 p.m. confirmed the above findings.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 39671 Based on review of facility policies, medical records (MR), hemodialysis (HD) treatment records and an interview with the facility Administrator, the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for two (2) of seven (7) MRs reviewed (MR# 3 and MR# 5). Findings: A review was conducted of facility policy on May 14, 2024 at approximately 9:10 a.m. Policy 1-03-08 ‘Pre-Intra-Intra-Post treatment Date Collection, Monitoring and Nursing Assessment’ ‘Purpose’ states, “To obtain and document baseline and ongoing information about the patient before, during and after dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge...3. Patient identity, prescription and machine settings re verified by teammate prior to initiation of treatment with exception of blood flow rate which is verified and documented when the order is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with nursing assessment...INTRADIALYTIC DATA COLLECTION ASSESSMENT...9. Intradialytic monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. vital signs and treatment monitoring...b. At a minimum, obtain and document the following:..iii. Blood and dialysate flows, arterial and venous pressures...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtained prescribed blood flow rate) the reason will be documented and the licensed nurse informed...12. The licensed nurse notifies the physician as needed of changes in patient status. 13. All findings, interventions and patient response will be documented int the patient’s medical record.” Medical record reviews conducted on May 14, 2024, between approximately 10:00 a.m. and 3:00 p.m. and on May 15, 2024 between approximately 9:00 a.m. to 2:45 p.m. revealed the following: Medical Record # 3: Admission Date: 12/11/2023. Treatment flowsheets reviewed between dates of 4/10/2024-5/10/2024. - Physican Order on 4/19/2024 was BFR: 400. Treatment flowsheet date 4/19/2024 showed a treatment start time of 1:31 p.m. and treatment termination at 4:28 p.m. BFR was set to 250 from 1:31 p.m. to 4:28 p.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 4/22/2024 was BFR: 400. Treatment flowsheet date 4/22/2024 showed a treatment start time of 1:41 p.m. and treatment termination at 4:32 p.m. BFR was set to 250 from 1:41 p.m. to 4:32 p.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 4/24/2024 was BFR: 400. Treatment flowsheet date 4/24/2024 showed a treatment start time of 6:08 a.m. and treatment termination at 9:32 a.m. BFR was set to 250 from 6:08 a.m. to 9:32 a.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 4/29/2024 was DFR: 800. Treatment flowsheet date 4/29/2024 showed a treatment start time of 1:49 p.m. and treatment termination at 5:02 p.m. DFR was set to 600 from 2:31 p.m. to 5:02 p.m. Medical record did not contain documentation regarding the changes in the DFR. - Physican Order on 5/6/2024 was BFR: 350. Treatment flowsheet date 5/6/2024 showed a treatment start time of 1:54 p.m. and treatment termination at 4:45 p.m. BFR was set to 305 from 1:54 p.m. to 4:31 p.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 5/10/2024 was DFR: 800. Treatment flowsheet date 5/10/2024 showed a treatment start time of 5:35 a.m. and treatment termination at 9:09 am. DFR was set to 600 from 7:01 a.m. to 9:09 a.m. Medical record did not contain documentation regarding the changes in the DFR. Medical Record # 5: Admission Date: 8/31/2023. Treatment flowsheets reviewed between dates of 4/2/2024-5/11/2024. - Physican Order on 4/9/2024 was BFR: 450. Treatment flowsheet date 4/9/2024 showed a treatment start time of 6:07 a.m. and treatment termination at 9:13 a.m. BFR was set to 400 from 7:32 a.m. to 9:02 a.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 4/16/2024 was BFR: 450. Treatment flowsheet date 4/16/2024 showed a treatment start time of 6:05 a.m. and treatment termination at 9:07 a.m. BFR was set to 400 from 8:02 a.m. to 9:07 a.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 4/27/2024 was BFR: 450. Treatment flowsheet date 4/27/2024 showed a treatment start time of 6:09 a.m. and treatment termination at 9:11 a.m. BFR was set to 400 from 8:02 a.m. to 9:32 a.m. and BFR was set to 300 from 9:02 a.m. to 9:11 a.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 4/30/2024 was BFR: 450. Treatment flowsheet date 4/30/2024 showed a treatment start time of 6:00 a.m. and treatment termination at 8:57 a.m. BFR was set to 400 at 8:02 a.m. and BFR was set to 350 from 8:32 a.m. to 8:57 a.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 5/2/2024 was BFR: 450. Treatment flowsheet date 5/2/2024 showed a treatment start time of 6:04 a.m. and treatment termination at 9:10 a.m. BFR was set to 440 at 7:30 a.m. and BFR was set to 400 from 7:33 a.m. to 9:10 a.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 5/7/2024 was BFR: 450. Treatment flowsheet date 5/7/2024 showed a treatment start time of 6:05 a.m. and treatment termination at 9:13 a.m. BFR was set to 400 at 7:33 a.m. and BFR was set to 350 from 8:03 a.m. to 8:33 a.m. and then BFR was set to 300 at 9:03 a.m. Medical record did not contain documentation regarding the changes in the BFR. - Physican Order on 5/11/2024 was BFR: 450. Treatment flowsheet date 5/11/2024 showed a treatment start time of 6:09 a.m. and treatment termination at 9:15 a.m. BFR was set to 350 from 8:03 a.m. to 9:03 a.m. Medical record did not contain documentation regarding the changes in the BFR. An interview with the facility administrator on May 15, 2024 at approximately 3:30 p.m. confirmed the above findings.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 39671 Based on review of facility policies, medical records (MR), Peritoneal Dialysis (PD) treatment records and an interview with the facility Administrator, the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for one (1) of seven (7) MRs reviewed (MR# 7). Findings: A review was conducted of facility policy on May 15, 2024 at approximately 10:10 a.m. Policy 5-01-29 ‘Daily Home Treatment Record (Flowsheet)’ ‘Policy’ states, “...4. All Daily Home Treatment Records will be reviewed, attested to, and maintained as a part of the patient’s medical record. In the absence of Daily Home Treatment Records and the patient’s responsibility to provide them and issue new paper flowsheets and provide instruction as applicable for electronic documentation. All of the above will be documented and attested to by the licensed nurse in the medical record. In addition, the patient’s plan of care should address any problems with adherence to this requirement...” Medical record reviews conducted on May 14, 2024, between approximately 10:00 a.m. and 3:00 p.m. and on May 15, 2024 between approximately 9:00 a.m. to 2:45 p.m. revealed the following: Medical Record # 7: Admission Date: 3/24/2023. Treatment flowsheets reviewed between dates of 1/11/2024-5/7/2024. Treatment flowsheet records missing for the following dates: 3/1/2024-3/7/2024, 4/9/2024-4/20/2024, 4/28/2024 and 4/30/2024. No documentation provided of the license nurse identifying the missing treatment flowsheets and no documentation provide of the license nurse discussing/educating the patient on the importance of keeping and bringing in all treatment flowsheets. An interview with the facility administrator on May 15, 2024 at approximately 3:30 p.m. confirmed the above findings.”

“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: 39671 Based on review of facility policies, medical records (MR), treatment records and an interview with the facility Administrator, the facility failed to ensure patients had a minimal evaluation completed by a registered nurse (RN), prior to initiating treatment for immediate needs which contained the minimal elements of nursing standards of care for four (4) of seven (7) MRs reviewed. (MR #2, MR# 3, MR# 4 and MR# 5) Findings: A review was conducted of facility policy on May 15, 2024 at approximately 10:30 a.m. Policy 1-03-07 ‘Initial Patient Nursing Assessment for New Patients’ ‘Policy’ states, “A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility” Medical record reviews conducted on May 14, 2024, between approximately 10:00 a.m. and 3:00 p.m. and on May 15, 2024 between approximately 9:00 a.m. to 2:45 p.m. revealed the following: Medical Record # 2: Admission Date: 10/5/2023. Initial dialysis treatment was on 10/2/2023 at 10:23 a.m. Initial RN assessment was completed on 10/5/2023 and time stamped 10:38 a.m. Medical Record # 3: Admission Date: 12/11/2023. Initial dialysis treatment was on 12/11/2023 at 1:28 p.m. Initial RN assessment was completed on 12/11/2023 and time stamped 2:16 p.m. Medical Record # 4: Admission Date: 2/13/2023. Initial dialysis treatment was on 2/13/2023 at 2:53 p.m. Initial RN assessment was completed on 2/13/2023 and time stamped 3:09 p.m. Medical Record # 5: Admission Date: 8/31/2023. Initial dialysis treatment was on 8/31/2023 at 9:52 a.m. No initial RN assessment provided by facililty. An interview with the facility administrator on May 15, 2024 at approximately 3:30 p.m. confirmed the above findings.”