Atlantis Ponce

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 51629 Based on interviews, observations and documents reviewed, it was determined that the facility failed to provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any other adjacent hospital or other public areas. Findings include: 1. During observation and inspection of the crash cart on 05/06/2025 at 9:25 AM, a. It showed dead ants at the corners of the superior surface. Document review of the facility crash cart inspection log showed that the cleaning process was performed on the day of the inspection (05/06/2025). b. Two vials of sterile water were found with expiration dates of May 1, 2025, and April 1, 2025, respectively. 2. During observation and inspection of the medication room on 05/06/2025 at 1:50 PM, an open, labeled multidose vial of Doxecarciferol 4 mcg. / 2 ml. was found. The label specified that the vial was opened on 05/06/2025 and was to be discarded on 06/03/2025. a. Upon interview with the nurse supervisor (employee # 10) on 05/06/2025 at 1:50 PM, it was informed that multidose vials must be discarded 28 days after initial opening. b. After inspecting manufacturers’ recommendations in the product box, the literature states that the vial must be discarded 3 days after opening. c. The facility failed to comply with the manufacturer’s recommendations in order to ensure safety and infection control in medication management. 17959 3. During observation and inspection on the Home Peritoneal Dyalisis and Home Hemodialys on 05/06/2025 at 9:00 AM, the following was observed: a. Room #2 two sets of sutures with expiration date 01/28/2025 b. Room #5 One vial of Heparin 30,000 units the label specified that the vial was opened on 07/12/2024 at 8:00 PM. 4. During observation and inspection on the Hemodialys Treatment Unit on 05/06/2025 at 10:00 AM, it was observed on patient station #5 and #10 that the personnel blanket touching the floor.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 47384 Based on observations made of the treatment area, during the first and second shift on 05/06/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to maintain procedures, in accordance with accepted public health procedures, for the handling, storage and disposal of potentially infectious waste. Findings include: 1. Approximately at 8:45 AM, mantainance personnel was observed transfering biomedical waste from inside the unit to the outside shed passing next to a tratment station where a patient was recieving tratment. 2. Biomedical waste shed on the outside premises was observed unlocked and side window was observed opened, this practice could permit acces to the inside of waste area to un authorised persons, rodents or animals.”

“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: 51629 Based on observations, it was determined that the facility failed to provide proper cleaning and disinfection of contaminated surfaces, medical devices, and equipment. Findings include: 1. During observation of two patient disconnections on 05/06/2025 at 10:40 AM in station # 13 and at 10:50 AM on station # 14, it was observed that the Registered nurse (employee # 11) did not clean the privacy screens after removing it from correspondent patient treatment cubicles. Both were placed at one end of the unit. 47384 2. Approximately at 9:00 AM dead flying insects were observed on a counter near station #31. 3. Excessive dust was observed on top of counters behind treatment stations.”

“ENVIRONMENT- ALARMS IN TREATMENT AREA CFR(s): 494.40(a) 8 Environment: alarms in treatment area Critical alarms, such as those associated with deionizer exhaustion or low water levels in a storage tank, should be configured to sound in the patient treatment area, as well as in the water treatment room. This Standard is not met as evidenced by: 47384 Based on observations made of the treatment area, document review and interview during the first and second shift on 05/06/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to have critical alarms, to be configured to sound in the patient treatment area, as well as in the water treatment room. Findings include: No notification system was identified regarding RO conditions or time of testing for chlorine and chloramine in the treatment area.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 47384 Based on observations made of the treatment area, document review and interview during the first and second shift on 05/06/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to test for free chlorine, chloramine, prior to patients initiating treatment and again prior to the beginning of each patient shift or approximately every 4 hours. Findings include: At approximately 2:30 PM, during the evaluation of the water treatment room, the nursing staff was asked to perform a test simulation. Upon requesting the log of tests performed, it was identified that the test corresponding to 1:30 PM was not performed. Test was performed at 2:40 PM after issue was identified by surveyor exceeding the four (4) hour as stablished in facility’s policy and AAMI Rationale for the Development and Provision of Recommended Practices”

“RO-MEETS AAMI/MONITORED, RECORDED ON LOG CFR(s): 494.40(a) 5.2.7 Reverse osmosis: meets AAMI/monitored/recorded on log Refer to RD62:2001, 4.3.7 Reverse osmosis: When used to prepare water for hemodialysis applications, either alone or as the last stage in a purification cascade, reverse osmosis systems shall be shown to be capable, at installation, of meeting the requirements of Table 1, when tested with the typical feed water of the user, in accordance with the methods of [AAMI] 5.2.2. 5.2.7 Reverse osmosis Users should carefully follow the manufacturer’s instructions for feed water treatment and monitoring to ensure that the RO is operated within its design parameters. 6.2.7 Reverse osmosis All results of measurements of RO performance should be recorded daily in an operating log that permits trending and historical review. This Standard is not met as evidenced by: 47384 Based on document review made of the treatment area, document review and interview during the first and second shift on 05/06/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to certify measurements of RO performance and historical review. Findings include: During the review of the monthly log “Registro de Desinfeccion de RO y Loop” it was observed that the document did not have the validation and certification countersignature for several months.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 47384 Based on observations made of the surroundings and treatment area, document review and interview during the first and second shift on 05/06/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to monitor the building in which dialysis services are furnished and maintained to ensure the safety of the patients, the staff and the public. Findings include: 1. A pothole and loose gravel were identified in the parking area prior to the patient drop-off area. 2. The asphalt before the disabled ramp was observed to be uneven and with loose gravel, which could pose a risk of falling. 3. Air conditioning grills on treatment unit were observed with dust and black mold like stains. 4. Columb with gypsum board damage in two sides, next to station #11.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 47384 Based on observations made of the surroundings and treatment area, document review and interview during the first and second shift on 05/06/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to maintain a program to ensure that all equipment are maintained and operated in accordance with the manufacturer’s recommendations. Findings include: 1. Brown stain and signs of water hardness were observed at the stations’ drainage ports. 2. Five (5) out of thirty (30) dialysis machines were observed to have damage to the platform for placing dialysate gallons. 3. UV insect light #4 found not operating.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 47384 Based on observations made of the surroundings and treatment area, document review and interview during the first and second shift on 05/06/2025 from 8:00 AM through 3:30 PM,it was determined that the facility failed to maintain Life Safety measures that complies with NFPA 101 (Life Safety Code) and NFPA 99 (Health Care Facilities Code) provisions which could affect all patients receiving treatment and staff. Findings include: 1. Fire extinguisher was observed blocked in annex. 2. Exit discharge leading to the parking lot has a elevation (.5 inches) which poses a safety risk for evacuation of patients in wheelchairs or treatment chairs. It does not comply with NFPA 101 7.2.5. 3. Corroded and rusty sprinkler heads were observed throughout the treatment unit. 4. At the moment of the survey no written evidence that fire doors in the facility had been inspected. After further observation, none of the fire doors or frame had the fire rating decal to validate fire rating. To assure that fire doors are working properly NFPA 80 (Standard for Fire Doors and Other Opening Protectives) section 5.2.1 mandates that fire doors should be inspected and tested at least once a year.”

“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: 20423 Base on twenty one records reviewed (RR), review of policies and procedures and interview with Home Dialysis Manager (employee #13) and Assistant Vice President (employee #8), it was determinate that the facility failed to follow established procedures after identify patients’ high blood pressure (BP) or low blood pressure (BP) during dialysis treatment for 4 out of 21 records reviewed (RR #7, #8, #9 and #14). Findings include: During the flowsheet review performed on 05/07/2025 from 9:00 AM to 3:30 PM the following was found: Upon review of the facility’s policy Title: Hypotension last update on 10/11/2023, on 05/07/2025 at 1:30 PM. Policy clearly stated on the procedures that during hemodialysis treatment personnel will recognized, report and immediately address diastolic blood pressures decrease than 100/50-millimeter mercury (mm/Hg). The policy stated that if diastolic blood pressure is less than 100 mm/hg; personnel must assess patient’s condition, take manual blood pressure and determine if further nursing interventions are needed including notifying the physician for additional orders/interventions. Upon review of the facility’s policy Title: Establishing Dry Weight (EDW) last update on 04/14/2023, on 05/07/2025 at 1:30 PM. Policy clearly stated on the procedures that the nurse in charge of patients must have a dry weight established during the first month of admission and be evaluated monthly by the nephrologist. The patient who do not reach the established EDW resulting in kilograms above or below the pre-established EDW should be notified to the physician for reassessment. The physician progress notes reflect the intervention when patient does not reach the EDW. The nurses’ progress note reflects the intervention performed when the patient do not reach the EDW. 1. RR #7 is a 75-year-old male patient admitted to the facility on 12/18/2020 with diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 05/07/2025 at 8:53 AM, it was found that patients have hemodialysis treatment three a week for 3 hours 30 minutes, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) 500, Dialyzer with 160 NRe Optiflux and patient EDW 75 kilogram (kg). a. On 04/25/2025 at 2:29 PM, it was revealed that the Blood Pressure (BP) was 97/49 millimeters of mercury (mm/Hg). No evidence was found of the nurse’s intervention or documentation performed by personnel of patient’s assessment when identifying low blood pressure. b. On 05/02/2025 at 2:39 PM, it was revealed that the BP was 95/41mm/Hg. No evidence was found of the nurse’s intervention or documentation performed by personnel of patient’s assessment when identifying low blood pressure. Interview with the Assistant Vice President employee #8 on 05/07/2025 at 9:49 AM refer that did not find other nurse documentation related to management of patient blood Pressure during the treatments. 2. RR #8 is a 62-year-old male patient admitted to the facility on 01/08/2023 with diagnosis of ESRD. During the record review performed on 05/07/2025 at 9:59 AM, it was found that patients have hemodialysis treatment three times a week for 4 hours 15 minutes, BFR of 400, DFR 700, Dialyzer with 180 NRe Optiflux and patient EDW 122.73 kg. a. On 04/24/2025 at 10:23 AM, it was revealed that the EDW at the end of treatment was 124.09 Kg, 1.36 kg above the established. b. On 04/29/2025 at 10:10 AM, it was revealed that the patient EDW at the end of treatment was 125.00 Kg, 2.27 kg above the established. c. On 05/01/2025 at 10:25 AM, it was revealed that the patient EDW at the end of treatment was 124.55 Kg, 1.82 kg above the established. d. On 05/03/2025 at 10:15 AM, it was revealed that the patient EDW at the end of treatment was 124.09 Kg, 1.36 kg above of established. e. On 05/06/2025 at 09:15 AM, it was revealed that the patient EDW at the end of treatment was 125.45 Kg, 2.72 kg above of established. No evidence was found of the nurse documented the notification to the physician for reassessment or the physician documentation in the progress note the reassessment of the EDW. 3. RR #9 is a 68-year-old male patient admitted to the facility on 05/02/2019 with diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 05/07/2025 at 10:40 AM, it was found that patients have hemodialysis treatment three a week for 3 hours 45 minutes, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) 500, Dialyzer with 160 NRe Optiflux and patient EDW 50.45 kilogram (kg). a. On 04/24/2025 at 10:02 AM, it was revealed that the Blood Pressure (BP) was 96/57 mm/Hg. No evidence was found of the nurse’s intervention or documentation performed by personnel of patient’s assessment when identifying low blood pressure. Interview with the Home Dialysis Manager nurse employee #13 on 05/07/2025 at 10:49 AM refer that did not find other nurse documentation related to management of patient blood Pressure during the treatments. 4. RR #14 is an 83-year-old female patient admitted to the facility on 09/10/2024 with diagnosis of ESRD. During the record review performed on 05/07/2025 at 11:57 AM, it was found that patients have hemodialysis treatment three a week for 3 hours 30 minutes, BFR of 400, DFR 500, Dialyzer with 160 NRe Optiflux and patient EDW 33.64 kg. a. On 04/26/2025 at 12:00 PM, the nurse assesses patient Blood Pressure (BP), and the next assessment was 12:59 PM. The nurse failed to follow physician standing order to assess B/P every 30 minutes. Interview with the Home Dialysis Manager nurse employee #13 on 05/07/2025 at 12:00 PM refer that did not find other nurse documentation related to assess of patient B/P every 30 minutes during the treatments.”

“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: 20423 Based on twenty one records reviewed (RR), and interview with Home Dialysis Manager (employee #13) and Assistant Vice President (employee #8), on 05/07/2025 at 9:00 AM till 3:30 PM, it was identified that the facility failed to follow physicians’ orders in the blood flow (BFR) and dialysate flow rate (DFR) during the dialysis treatment and documented their intervention in the management of the patients BFR and DFR. This deficient practice is identified in 4 out of 21 records reviewed (RR #7, #8, #9, and #17). Findings include: During the flowsheet review performed on 05/07/2025 from 9:00 AM to 3:30 PM the following was found: 1. RR #7 is a 75-year-old male patient admitted to the facility on 12/18/2020 with diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 05/07/2025 at 8:53 AM, it was found that patients have hemodialysis treatment three a week for 3 hours 30 minutes, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) 500, Dialyzer with 160 NRe Optiflux and patient EDW 75 kilogram (kg). a. On 04/25/2025 at 2:29 PM, it was revealed that the Blood Pressure (BP) was 97/49 millimeters of mercury (mm/Hg) and the BFR was 0. No evidence was found of the nurse’s documented reason for decrease the BFR or physician notification. Interview with the Assistant Vice President employee #8 on 05/07/2025 at 9:49 AM refer that did not find other nurse documentation related to management of the BFR during the treatments. 2. RR #8 is a 62-year-old male patient admitted to the facility on 01/08/2023 with diagnosis of ESRD. During the record review performed on 05/07/2025 at 9:59 AM, it was found that patients have hemodialysis treatment three times a week for 4 hours 15 minutes, BFR of 400, DFR 700, Dialyzer with 180 NRe Optiflux and patient EDW 122.73 kg. a. On 04/24/2025, the patient did not complete the 4 hours 15 minutes, according to physician order the patient takes only 4 hours 05 minutes and no evidence was found the justification for short the treatment time and that patient sign the consent for release treatment b. On 04/29/2025, the patient did not complete the 4 hours 15 minutes, according to physician orders the patient take only 4 hours 10 minutes and no evidence was found the justification for short the treatment time and that patient sign the consent for release treatment 3. RR #9 is a 68-year-old male patient admitted to the facility on 05/02/2019 with diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 05/07/2025 at 10:40 AM, it was found that patients have hemodialysis treatment three a week for 3 hours 45 minutes, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) 500, Dialyzer with 160 NRe Optiflux and patient EDW 50.45 kilogram (kg). a. On 04/24/2025 at 7:28 AM, at 7:51 AM, the BFR increased to 400. No evidence was found of the justification on the nurse note or authorized increase from the physicians Interview with the Home Dialysis Manager nurse employee #13 on 05/07/2025 at 10:49 AM refer that did not find other nurse documentation related to management of BFR during the treatments. 4. RR #17 is an 81-year-old male patient admitted to the facility on 09/12/2023 with diagnosis of ESRD. During the record review performed on 05/07/2025 at 2:57 PM, it was found that patients have hemodialysis treatment three a week for 3 hours 45 minutes, BFR of 350, DFR 600, Dialyzer with 180 NRe Optiflux and patient EDW 84.55 kg. a. On 05/01/2025 from 11:35 am to 1:02 PM the DFR was decreased to 500. No evidence was found of the justification on the nurse note or authorized increase from the physicians Interview with the Home Dialysis Manager nurse employee #13 on 05/07/2025 at 10:49 AM refer that did not find other nurse documentation related to management of BFR during the treatments.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 20423 Base on twenty one record review (R.R) and interview with the Assistant Vice President (employee #8), on 05/07/2025 at 9:00 AM till 3:30 PM, it was identified that the facility failed to provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access whether the patient is a potential candidate for arteriovenous fistula placement for 4 out of 21 record review (R.R # 8, #9, #14 and # 17). Findings include: During the flowsheet review performed on 05/07/2025 from 9:00 AM to 3:30 PM the following was found: 1. RR #8 is a 62-year-old male patient admitted to the facility on 01/08/2023 with diagnosis of ESRD. During the record review performed on 05/07/2025 at 9:59 AM, it was found that patients have hemodialysis treatment three times a week for 4 hours 15 minutes, BFR of 400, DFR 700, Dialyzer with 180 NRe Optiflux and patient EDW 122.73 kg. This patient has a Catheter double lumen in the Right internal jugular vein since 12/16/2022, 2 years 5 months ago, however no evidence was found of the monthly intervention of the vascular access coordinator that justified the time that patient has without permanent vascular access. During an interview with the vascular access coordinator employee #7 on 05/07/2025 at 11:00 AM she states that this patient has an arteriosus vascular fistula (AVF) in 2024 but was inactive due to coagulation complication and patient refuse other vascular access. 2. RR #9 is a 68-year-old male patient admitted to the facility on 05/02/2019 with diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 05/07/2025 at 10:40 AM, it was found that patients have hemodialysis treatment three a week for 3 hours 45 minutes, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) 500, Dialyzer with 160 NRe Optiflux and patient EDW 50.45 kilogram (kg). This patient has a Catheter double lumen cuffed in the Right internal jugular vein since 03/13/2024, 1 year 2 months ago, however no evidence was found of the monthly intervention of the vascular access coordinator that justified the time that patients have without permanent vascular access. During an interview with the vascular access coordinator employee #7 on 05/07/2025 at 11:00 AM she states that the family of this patient was referring to the physician for multiples time for vascular access, but patient was ankylosing, and physician refers not to have other type of vascular access. 3. RR #14 is an 83-year-old female patient admitted to the facility on 09/10/2024 with diagnosis of ESRD. During the record review performed on 05/07/2025 at 11:57 AM, it was found that patients have hemodialysis treatment three a week for 3 hours 30 minutes, BFR of 400, DFR 500, Dialyzer with 160 NRe Optiflux and patient EDW 33.64 kg. This patient has a Catheter double lumen in the Right internal jugular vein since 09/02/2024, 8 months ago, however no evidence was found of the monthly intervention of the vascular access coordinator that justified the time that patients have without permanent vascular access. During interview with the vascular access coordinator employee #7 on 05/07/2025 at 1:00 PM she states that this patient was with multiples hospitalization since admission and does not have evaluation for permanent vascular access. 4. RR #17 is an 81-year-old male patient admitted to the facility on 09/12/2023 with diagnosis of ESRD. During the record review performed on 05/07/2025 at 2:57 PM, it was found that patients have hemodialysis treatment three a week for 3 hours 45 minutes, BFR of 350, DFR 600, Dialyzer with 180 NRe Optiflux and patient EDW 84.55 kg. This patient has a Catheter double lumen cuffed in the Left internal jugular vein since 09/09/2023, 1 year 8 months ago, however no evidence was found of the monthly intervention of the vascular access coordinator that justified the time that patient have without permanent vascular access. During the interview with the vascular access coordinator employee #7 on 05/07/2025 at 3:00 PM she states that on 03/10/25 an arteriosus venous graft (AVG) was created but have still syndrome, on 03/27/2025 was performed an fistulogram. On 5/02/2025 the physician authorized used the graft, and was assigned in the nurse assignment however was not used on 5/3/2025 and 5/6/2025, not know the reason. However, the nurse does not document this 2-treatment day, the reason for not using the permanent vascular access and continues using the catheter. 5. Facility vascular access coordinator failed to document monthly progress not that explain all intervention and justification for the use of a catheter in 4 out of 21 records reviewed.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 51629 Based on twenty-one records reviewed (RR) and staff interview, it was determined that the facility failed to provide monitorization to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This deficient practice was identified in 2 out of 21 records reviewed (RR # 2 and RR # 16). Findings include: 1. RR # 2 is a 73-year-old female who was admitted on 03/26/2019 with a diagnosis of End Stage Renal Disease, Hypertension and Diabetes. Access type is a curved graft on the left upper arm. The treatment order dated 04/10/2025 states a 4-hour hemodialysis treatment duration, Blood Flow Rate (BFR) 400 mL/min. and dialysate flow rate (DFR) 500 mL/min. Expected dry weight 72.73 kg. According to the medical record review performed on 05/07/2025 at 9:00 AM, the following was found: a.The Assessment and Integrated Plan of Care (POC) document dated 03/17/2025 stated proper functioning of vascular access. b. On 04/24/2025, BFR parameter was 300 mL/min. from 7:02 through 10:02 hour. The registered nurse stated on the nurses’ notes (7:02) that vascular access was having problems of imminent collapse on multiple occasions. At 10:28 the registered nurse stated that the patient “did not comply due to vascular access problems” and that the nurse supervisor was notified. c. On 04/26/2025, BFR parameter was 300 mL/min. from 7:03 through 8:03, 350 mL/min. at 8:33, 250 mL/min. at 9:03 and 300 mL/min. from 9:32 through 10:02. At 8:00 the registered nurse stated on the nurses’ notes that vascular access was having “poor flow”. d. On 04/29/2025, BFR parameter was 350 mL/min. from 7:03 through 9:03 and 300 mL/min. at 9:33. The registered nurse stated on the nurses’ notes (10:05) that patient “completed treatment without complications”. e. On 05/03/2025, BFR parameter was 300 mL/min. from 7:15 through 10:15. At 6:50 the registered nurse stated on the nurses’ notes that BFR was increased to 350 mL/min. due to “venous collapse”. At 7:15 stated that BFR was “decreased to 300 mL/min. due to arteriovenous fistula (AVF) collapse”. At 10:50 stated that patient “does not comply with liters (lts.) and that BFR was decreased due to arteriovenous fistula (AVF) collapse”. f. On 05/01/2025, BFR parameter was 300 mL/min. from 6:25 through 10:02. The registered nurse stated on the nurses’ notes (6:25) that BFR was 300 mL/min. due to “collapse in arterial parameters”. g. On 05/06/2025, BFR parameter was 350 mL/min. at 6:25, 320 mL /min. from 7:03 through 8:03, 350 mL/ min. at 8:33, 300 ml /min. 275 mL / min., and 275 mL /min. from 9:32 through 10:02. h. No evidence of referral to the vascular access registered nurse was provided. i. The facility failed to ensure periodic monitoring, surveillance and follow-up of the vascular access with signs of impending failure. 2. RR # 16 is a 73-year-old male who was admitted on 01/14/2025 with a diagnosis of End Stage Renal Disease, Hypertension, Diabetes Mellitus, Congestive Heart Failure, Acute Systemic Heart Disease, Coronary Arteriosclerosis and Angina Pectoris. Access type is a central catheter, double lumen cuffed in right internal jugular vein. The treatment order dated 03/06/2025 states a 4-hour hemodialysis treatment duration, Blood Flow Rate (BFR) 350 mL/min. and dialysate flow rate (DFR) 500 mL/min. Expected dry weight 65.91 kg. According to the medical record review performed on 05/07/2025 at 10:00 AM, the following was found: a. The Assessment and Integrated Plan of Care (POC) document dated 10/15/2024 stated functional vascular access. b. On 04/23/2025, BFR parameter was 300 mL/min. 12:31 hour, at 250 mL/min. from 13:01 through 14:01 and at 200 mL/min. 15:02. The registered nurse stated on the nurses’ notes (3:01) that BFR was decreased due to constant vascular access collapse. At 13:30 the registered nurse stated that treatment was stopped on various occasions due to constant patient’s neck movement. c. On 04/28/2025, BFR parameter was 265 mL/min. at 14:01, and 230 mL/min. from 14:31 through 15:01. At 14:01 the registered nurse stated on the nurses’ notes that vascular access was “collapsing on various occasions”. At 15:38 stated that patient “does not comply with liters (lts.) due to catheter collapse”. d. No evidence of referral to the vascular access registered nurse was provided. e. The facility failed to ensure periodic monitoring, surveillance and follow-up of the vascular access with signs of impending failure.”