Fkc Olney

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 49513 Based on a review of facility policy, medical records (MR), and an interview with the Clincal Manager, the facility did not follow its policy for patient assessment and monitoring for one (1) of three (3) MRs reviewed, (MR # 1). Findings include: A review of facility policy titled “Hypertension” conducted on August 27, 2025 at approximately 11:00 AM states, “Follow the steps below to address hypertension: Step Action 1. Notify the nurse in charge if a patient has a systolic blood pressure greater than 180 mm/Hg and / or diastolic blood pressure greater than 100 mm/Hg. 2. The RN will assess the patient and determine if further nursing interventions are needed. 3. If hypertension is related to hypervolemia, decrease EDW: Follow CMAB Fluid Management algorithm or notify physician for possible estimated dry weight adjustment outside of algorithm parameters. 4. If hypertension is not related to hypervolemia, notify the physician for additional orders/interventions. 5. Document in patient’s treatment record....” A review of MRs was conducted on 08/26/2025 from approximately 9:30 AM -10:30 AM: MR #1, Start of Care: 05/19/2022. Review of treatments sheets for 08/12/2025 through 08/23/2025 revealed the following: 08/23/2025: PCT documented at 12:15 PM, B/P 198/108. PCT documented at 12:36 PM, B/P 196/112. PCT documented at 1:02 PM, B/P 186/104. PCT documented at 2:30PM, B/P 194/103. Note: There is no documentation of a recheck of the blood pressure and no documentation of RN notification of the high blood pressure and therefore, no RN patient assessment performed at the time of occurrences or documentation of any further interventions. An interview conducted with the Clinical Manager on August 29, 2025, at approximately 9:10 AM confirmed the above findings.”

“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: 41684 Based on review of facility policy, observation (OBS) of the treatment area, and an interview with the Facility Administrator, the facility did not follow its policy regarding teammate fingernails for four (4) observations, (OBS #2, 4, 6, and 10). Findings include: A review of facility policy on March 13, 2024, at approximately 1:00 P.M. revealed the following: Policy titled “Hand Hygiene” stated, “Caution regarding fingernails: Do not wear artificial fingernails, extenders or nail wraps when having direct contact with patients. Natural fingernail length shall be kept to 1/4 inch or less...” Observation of the treatment area was conducted on March 11, 2024, from approximately 9:00 A.M. to 11:30 A.M. revealed the following: OBS #2, at station #6, PCT# 1 was observed to have artificial nails. OBS #4, at station #4, PCT# 5 was observed to have lengthy artificial nails. OBS #6, at station #15, RN# 1 was observed to have artificial nails. OBS #10, at station #10, PCT #3 was observed to have artificial nails. An interview with the Facility Administrator on March 13, 2024, at approximately 1:30 P.M. confirmed the above 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: 41684 Based on review of Facility Phoenix Meter - All Models Log for the Months of January, 2024 and February, 2024, Facility policy, and an interview with the Facility Administrator and Facility BioMed Technician, it was determined, that the facility failed to ensure that a calibration of the meter was completed when a reading is outside the manufacturer’s specifications for nineteen (19) entries. Findings include: A review of Facility policy titled “pHoenix Meter, pHoenix XL and Tri-Station Care and Maintenance” on March 13, 2024 at approximately 10:30 am states, “Verification: Note: If the reading is outside the manufacturer’s specifications, calibration is needed...” For the Month of January, 2024, on the following dates, mS verification range is stated to be within 49 mS - 51 mS, readings were reported as “Greater than 51 mS” and no Post-Calibration Value was completed: January 2 January 3 Janaury 11 January 12 January 13 January 15 January 17 January 26 January 27 January 29 For the Month of February, 2024, on the following dates, mS verification range is stated to be within 49 mS - 51 mS, readings were reported as “Greater than 51 mS” and no Post-Calibration Value was completed: February 9 February 10 February 12 February 14 February 21 February 23 February 26 February 27 February 28 An interview conducted with the Facility Administrator and Facility BioMed Technician on March 13, 2024 at approximately 1:30 PM 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: 41684 Based on review of facility policies/procedure, medical records (MR), and an interview with the facility manager, the facility failed to ensure the blood flow rate (BFR) and/or the dialysate flow rate (DFR) was administered per physician order for five (5) of seven (7) incenter hemodialysis patient MR’s reviewed. (MR #3, 4, 5, 6, and 7). Findings include: A review of facility policy titled “Unable to Achieve Prescribed Blood Flow Rate” was conducted on March 13, 2024 at approximately 11:00 am. The policy reads in part, “Policy: staff, patient and/or care partner will recognize and report to the nurse in charge the inability to achieve prescribed blood flow rate .... Actions To Achieve Prescribed Blood Flow Rate: staff, patient and/or care partner should take the following actions to reduce the possibility of poor access blood flow: projection bloodlines in a way that keeps them from restricting flow kinking, ensure access and bloodline clamps have been appropriately opened/removed, properly cannulate access, avoid the flipping needles, administer heparin as ordered. staff should review the following: ensure needle size is appropriate for prescribed the blood flow rate, monitor KECN, perform access flow testing per physician order, ensure adequate heparin to minimize dialyzer clotting .... Notification: notify physician/extender if unable to achieve prescribed the blood flow rate. Documentation: document in patient’s treatment record what action taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physician orders...” A review of patient medical records (MR) was conducted on March 12, 2024 starting from approximately 9:00 AM through 2:30 PM. MR #3: Admission Date: 9/28/22. Total treatment records reviewed: 7, Treatment record reviewed between 1/3/2024 to 3/4/2024. Order reads in part the following: Blood Flow Rate (BFR): 500 mL/min; Dialysate Flow Rate (DFR): Autoflow 1.5. Review of Dialysis Treatment Details Reports revealed the BFR and DFR was not administered at prescribed rates on the following dates: On 1/31/2024, the entire treatment the BFR was administered at 400 mL/min. On 2/9/2024, the entire treatment the BFR was administered at 400 mL/min. On 2/12/2024, between 11:27 AM to 12:04 PM, the BFR was administered at 400 mL/min. On 2/26/2024, between 2:04 PM to 3:30 PM, the BFR was administered at 450 mL/min. On 2/21/2024, the entire treatment the BFR was administered at 400 mL/min. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates. MR #4: Admission Date: 4/21/2021. Total treatment records reviewed: 7, Treatment record reviewed between 2/19/2024 to 3/11/2024. Order reads in part the following: Blood Flow Rate (BFR): 400 mL/min; Dialysate Flow Rate (DFR): Autoflow 1.5. Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates: On 2/19/2024, between 6:02 AM to 6:30 AM, the BFR was administered at 250 mL/min, between 6:30 AM to 9:24 AM, BFR was administered at 350 mL/min. On 2/23/2024, between 5:38 AM to 6:03 AM, the BFR was administered at 300 mL/min, and between 6:03 AM to 8:45 AM, the BFR was administered at 350 mL/min. On 2/28/2024, between 5:23 AM to 6:01 AM, the BFR was administered at 300 mL/min, and between 6:01 AM to 8:08 AM, the BFR was administered at 350 mL/min. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates. MR #5, Admission Date: 2/13/2024. Total treatment records reviewed: 7, Treatment record reviewed between 2/24/2024 to 3/9/2024. Order reads in part the following: Blood Flow Rate (BFR): 400 mL/min; Dialysate Flow Rate (DFR): Autoflow 1.5. Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates: On 2/27/2024, between 8:31 AM to 10:06 AM, the BFR was administered at 350 mL/min. On 3/2/2024, between 8:34 AM to 9:33 AM, the BFR was administered at 300 mL/min. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates. MR #6, Admission Date: 1/23/14. Total treatment records reviewed: 7, Treatment record reviewed between 2/24/2024 to 3/9/2024. Order reads in part the following: Blood Flow Rate (BFR): 500 mL/min; Dialysate Flow Rate (DFR): Autoflow 1.5. Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates: On 2/24/2024, between 6:35 AM to 7:03 AM, the BFR was administered at 200 mL/min. On 3/2/2024, between 8:04 AM to 10:33 AM, the BFR was administered at 400 mL/min. On 3/9/2024, during the entire treatment, the BFR was administered at 400 mL/min. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates. MR #7, Admission Date: 12/26/2023. Total treatment records reviewed: 8, Treatment record reviewed between 2/24/2024 to 3/9/2024. Order reads in part the following: Blood Flow Rate (BFR): 400 mL/min; Dialysate Flow Rate (DFR): Autoflow 1.5. Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates: On 2/24/2024, between 6:12 AM to 6:42 AM, the BFR was administered at 200 mL/min. On 2/27/2024, between 10:01 AM to 10:34 AM, the BFR was administered at 450 mL/min. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates. An interview with the facility clinical manager was conducted on March 13, 2024, at approximately 1:30 pm confirmed the above findings.”