Atlantis Mayaguez

“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: 17959 Based on interviews, observations on the Home Hemo and Home Peritoneal Area and documents reviewed with the facility Nurse Manager (employee #1), it was determined that the facility failed to monitor the environment to ensure that it is sanitary to reduce possible transmission of infections agents related to crash cart with expiration medications available to use in the unit. Findings include: During the tour performed to the unit on 05/28/2025 at 10:30 AM reviewed the crash cart accompanied with the facility Nurse Manager, it was identified eleven vials (11) of Tobramycin 80 mgs /2ml multiple doses with expiration date in April 2025. 1. Upon interview with the Nurse Manager (employee #1) on 05/28/2025 at 10:30 AM she stated that the crash cart was reviewed and signed by the nurse weekly. 2. The facility failed to comply with the manufacture’s recommendations in order to ensure safety.”

“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 treatment area , 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: During a walk-through of the dialysis unit’s exterior, the transfer switch door in the generator area was found unlocked. A request was made by the surveyor to close the door, but the facility reported that they did not have a key for it and that the generator service provider would provide one.”

“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: 17959 Based on eighteen records reviewed (RR) and Review of Policy and Procedure (P&P), it was determinate that the facility failed to monitor and document the assessment perform to patients when a hemodialysis machine emits a blood pressure alerts according to the facility policy for 2 of 18 sample selected. (RR #10 and RR#12). Findings include: 1. RR #10 is a 78-year-old male patient admitted to the facility on 07/23/2021 with diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 05/28/2025 at 2:00 PM, it was found that patient has hemodialysis treatment three a week for 3.5 hours, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 500, Dialyzer with NR160, heparin/ anticoagulant 3,000 units and patient Dry Weight (EDW) 72.73 kilogram (kg). a. On 05/28/2025 at 2:00 PM review of the medical record revealed that on 05/19/2025 reveled that the patient received the hemodialysis treatment according with the physician orders however, according with the flowsheet treatment at 11:05 AM the nurse provide evidence that the BFR increase according with the physician order however, no evidence of BFR of 350 ordered by the physician on 5/15/2025. b. At 14:30 the nurse writes ’’ Does not comply with the liters according with the physician order, the technician is notified, however no evidence of technician intervention. c. At 14:30 PM the nurse writes ’’ The patient ended the treatment without complications total liters processed 64.8 not compatible with the physician order service technician is notified. ’’ However, the patient withdraws from the unit walking accompanied by the nurse. d. At 14:37 the flowsheet provide evidence that the patient received Heparin 18000 units intra-catheter, and the correct ones are used but at this time the patient had already left the unit. e. On 05/28/2025 at 2:00 PM review of the medical record revealed that on 05/21/2025 reveled that the patient received the hemodialysis treatment according with the physician orders however, according with the flowsheet treatment at 14:05 the nurse write ’’ It accompanies the scale weighing 161 pounds KTV 1.33. However, the patient withdraws from the unit walking accompanied by the nurse. f. At 14:05 the flowsheet provide evidence that the patient received Heparin intra-catheter and the correct ones, Aranesp 10 mcg IV and Doxercalciferol 2.0 mcg IV patient did not refer pain. However, at this time the patient withdraws from the unit walking accompanied by the nurse before administration of medicines. 2. RR #12 is a 76-year-old female patient admitted to the facility on 12/13/2024 with diagnosis of End Stage Renal Disease (ESRD. During the record review performed on 05/29/2025 at 9:25 AM, it was found that patient has hemodialysis treatment three a week for 3.5 hours, Doble Lumen Cuffed Right Internal Jugular Vein, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 700, Dialyzer with NR 160 and patient Dry Weight (EDW) 91.82 kilogram (kg). a. On 05/29/2025 at 9:25 AM review of the medical record revealed that on 05/14/2025 the BFR was maintained on 400 per seven times during the treatment not according with the physician order of 350. b. On 05/29/2025 at 9:25 AM review of the medical record reveals that on 05/21/2025 and 05/26/2025 the patient received intravenous medications after disconnection.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 47632 Based on observation made of Peritoneal and Home hemodialysis area with the Peritoneal Nurse (employee#2) on 06/11/2024 at 11:41 AM, it was determined that the facility failed to monitor that emergency drugs are on the premises at all times and immediately available for use. Findings include: 1. During the observations on the peritoneal area, the following was observed: a. On 06/11/2024 at 11:41 AM four vials of dopamine 200mg/ 5ml expired on April 1, 2024, were found in the crash cart. The facility failed to ensure that the nursing staff evaluated the expiration date of the medications on the chart cart monthly.”

“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: 47384 Based on observations made of the treatment area on 06/11/2024 through 06/12/2024 and interview with Regional Operational Manager employee # 6, it was determined that the facility failed to monitor the physical environment to ensure that it is sanitary to reduce possible transmission of infectious agents and maintain optimal conditions of facility. Findings include: During observation of the treatment area on 06/11/2024 the following was observed: 1. Dust particles were found in all counter tops behind treatment stations. 2. Exesive dust was observed on counter tops behind patients chairs. 3. Dust clogs were observed on air conditioning vent and ceiling tiles. 47632 4. During the observations in Peritoneal area on 06/11/2024 at 9:30 AM to 12:00 PM, the following was observed: a. On 06/11/2024 at 10:56 AM room PD# 1, the floor was observed in need of cleaning. b. On 06/11/2024 at 11:03 AM room PD# 1, the floor was observed in need of cleaning. 15884 5. On 06/11/2024 at 9:55 AM tiny white dust particles were observed covering all hemodialysis treatment back cabinets on hemodialysis stations #34 through hemodialysis station #41 On 06/11/2024 at 10:05 AM tiny white dust particles were observed covering hemodialysis treatment chairs and machines located on stations #34,#35,#36,#37,#38,#39,#40 and #41. Regional Operational Manager stated on interview on 06/11/2024 at 2:45 PM that hemodialysis treatment chairs and machines located on stations #34 through hemodialysis station #41 are part of an area that is not in use for patients and that may be requested if the patient census increases in the future.”

“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: 15884 Based on review of policies, interview, and observations during patient connections procedures, it was determined that the facility failed to demonstrate that follows infection control precautions to prevent transmission of infections among hemodialysis patient’s related to lack of disinfection of privacy screens after being used during connection process for 1 out 6 observations made at stations #5. Findings include: Upon review of the facility’s policy #47806 Cleaning and Disinfection of Dialysis station last reviewed in 2022 on 06/11/2024 at 3:05 PM. Policy clearly stated that dialysis station could become contaminated with blood or other body fluids during treatment. The policy also stated that all work surfaces should be cleaned and disinfected with 1:100 bleach solution before and after contact or working on them. Policy clearly stated that all supplies and non-disposable equipment used by personnel must be discarded or cleaned and disinfected with 1:100 bleach or EPA registered disinfectant when finish the procedure and before being removed from dialysis station area. 1.Hemodialysis nurse staff (employee #3) was observed on 06/11/2024 at 11:35 AM performing a connection process on station #5 to a patient who had a Right chest catheter. While she was performing the connection process, she used 1 privacy screen for the patient’s privacy. When nurse staff (employee #3) finishes the connection process she returns the 2-privacy screen to the area where personnel put them without cleaning and disinfection. 2.Facility Manager (employee #7), stated on interview on 06/11/2024 at 3:10 PM as per policy established that non disposable equipment used by personnel during the hemodialysis treatment connection and disconnection process must be discarded or cleaned and disinfected with 1:100 bleach or EPA registered disinfectant when finish the procedure and before being removed from dialysis station area. 3. The facility failed to promote and implement policies and procedures to prevent transmission of infections among hemodialysis patients’.”

“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: 15884 Based on observations, interview with the clinical manager (employee #7), and review of policies/procedures, it was determined that the facility failed to ensure that 2 out of 9 nursing personnel (RN#3, and RN #4) follow policies and procedures when checking pH of water used for dialysis, before starting the treatment on a patient. Findings include: Upon review of the facility’s policy #15.43 Dialysate pH Testing and Conductivity last update on 03/31/2017, on 02/08/2023 at 2:40 PM. Policy clearly stated on the procedures that to test pH personnel must fill the Osmometer’s “ Plunger “ with dialysate from the machine’s sleeve and dip the test strip to be tested and move back and forth for one second. That remove the strip and shake the excess liquid; and after 10 seconds compare the strip to the color chart on the bottle. 1. The following was observed while personnel were preparing hemodialysis machines for the second shift on 06/11/2024 from 8:35 AM till 1:20 PM: a. The register nurse (RN#3) is observed, performing the pH and conductivity test at the hemodialysis machine located at station #1. To perform the pH test on this machine, RN#3 pour the dialysate directly from the machine dialysate sleeve to the PH test strip. She let the pH test strip to absorb the liquid and then made the lecture of pH results. While RN#3 perform the pH test RN#4 was located at the side of hemodialysis machine on station #1, RN#4 read and countersign the pH test. 2. Facility clinical manager (employee #7), stated in an interview on 06/11/2024 at 2:48 PM that nursing personnel must perform pH test accordingly with policies and procedures to ensure that solutions correspond to physician’s prescribed dialysate.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 15884 Based on observational tour of the patient treatment area during the first shift, on 06/11/2024 it was determined that the facility failed to ensure that dialysis facility is equipped, to provide dialysis patients comfortable treatment environment and fail to promote proper maintenance of floor tiles and wooden Formica that cover nursing station unit to promote adequate cleaning and disinfection surfaces in order to prevent infections control practice who had the potential to affect 21 out of 21 patients on the first shift of 06/11/2024. Findings include: 1. The following was identified on 06/11/2024 at 10:00AM during the first shift of hemodialysis. a. Two stools with wheels used by personnel located in front of station #5 and station #3 were observed with broken vinyl and in need of repair. b. Cracked floor tiles were observed behind station #1 and in front of water treatment room. c. Floor tiles with holes and in need of repair were observed in front of station #4, #3, #5 and in front of station #18. d. Nursing station located in front of station #30 is observed with broken Formica. 47384 2. Facility failed to maintain emergency disconnection kit on every chair where a patient is receiving treatment or orientation.”

“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 treatment area, on 06/11/2024, it was determined that the facility failed to monitor the physical environment to ensure that it is maintained to ensure the safety of the patients, the staff and the public. Findings include: During observational survey performed on Hemodialysis treatment area on 06/11/2024 it was found: 1. Water damage was found between gypsum board wall and plinth next to treatment station # 5. 2. Five stations ( #3, #8, #15, #23 and #32) were observed with limited space, this limits the space staff has to attend the patient in an emergency situation. Stations are located close to the walls not contemplating the minimum 3 feet clearance. 47632 3. During the observations in peritoneal area on 06/11/2024 at 9:30 AM to 12:00 PM, the following was observed: a. On 06/11/2024 at 10:56 AM room PD#1, the stained sink drain was observed. b. On 06/11/2024 at 11:03 AM room PD# 2, the stained sink drain was observed. c. On 06/11/2024 at 11:28 AM the examination room, the sink drain was observed to be stained and rusty.”

“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 treatment area, on 06/11/2024, it was determined that the facility failed to monitor the physical environment to maintain all equipment in accordance with the manufacturer’s recommendations. Findings include: During observation of the facilities treatment chairs it was observed that nine (9) chairs on stations (#1, #2, #3, #4, #8, #9, #12, #14, #20) had rust on the wheel base conecting to the chair frame.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 15884 Based on observational tour, review of policies and procedures, and interview with facility nursing supervisor (employee #1), it was determined that the facility failed to ensure that patients receive treatment in a manner that allows staff to have full view of patient’s access sites for the first shift and second shift during on 06/11/2024 from 8:35 AM thru 1:20 PM at patient’s stations #3, #6, #10, #12 and #24. This deficient practice affects 5 out of 24 patients observed receiving treatment. Findings include: Upon review of the facility’s policy # 3.03 Patient assessment Before, During and After Dialysis last update on 06/2014, Patient assessment and Monitoring on 06/11/2024 at 2:30 PM. Policy clearly stated that during dialysis personnel in charge must monitor the function and condition of the patient’s vascular access. This policy stated that the cannulation site/catheter insertion site and the line connections must remain visible. 1. During observations of the hemodialysis treatment area on 06/11/2024 from 8:35 AM thru 1:20 PM the following was observed: a. Patient located on station #3 was observed face and line connections located on left chest catheter covered with blankets while receiving treatment. b. Patient located on station #6 was observed with his left arm vascular access and line connections covered with a blanket while receiving treatment. c. Patient located on station #10 was observed with his left arm vascular access and line connections covered a blanket while receiving treatment. d. Patient located on station #12 was observed with his left arm vascular access and line connections covered with a blanket while receiving treatment. e. Patient located on station #24 was observed with line connections located on left femoral catheter covered with blankets while receiving treatment. 2. Facility nursing supervisor (employee #1), stated on interview on 06/11/2024 at 12:17 PM as per policy established that if nursing identifies that vascular access and line connections are not visible, they must request to their patient to uncover the vascular access. She stated that policy established indicates that nursing personnel must educate and explain to the patient as a manner that the patient understand about the risks associate if not maintain the vascular access visible at all time during the treatment. 3. The facility failed to promote policies and procedures that establish that access sites are to be left uncovered to allow complete visibility by the nursing staff, during hemodialysis treatment.”

“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 observations made of the treatment area, on 06/11/2024, it was determined that the facility failed to comply with provisions of the Life Safety Code. Findings include: 1. Loaded sprinklers were observed in front of stations #32 and #30 2. Fire extinguisher were observed obstructed by trash cans in front of stations between stations #2 and #3, between #14 and #15 and between #22 and #23. 3. Trash cans were observed obstructing fire extinguisher in stations #5 and #25. 4. Unprotected penetrations were observed between the water treatment room area and the hemodialysis unit.”

“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: 15884 Based on eighteen records reviewed (RR) and Review Policy and Procedure (P&P), it was determinate that the facility failed to monitor and document the assessment perform to patients when a hemodialysis machine emits a blood pressure alerts according to the facility policy for 6 of 18 sample selected. (RR #1, RR#3, RR#4, RR#5, RR #10 and RR#13). Findings include: 1. RR #1 is a 75-year-old male patient admitted to the facility on 02/16/2024 with diagnosis of End Stage Renal Disease (ESRD) and Diabetes Mellitus (DM). During the record review performed on 06/11/2024 at 1:03 PM, it was found that patient has hemodialysis treatment three a week for four hours, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 600, Dialyzer with 160 NR ELEC-BEAM and patient Dry Weight (EDW) 77.73 kilogram (kg). a. On 06/11/2024 at 1:33 PM review of the medical record revealed that on 05/29/2024, 06/03/2024, 06/05/2024 and 06/10/2024 the hemodialysis machine emits blood pressure alerts while the patient was receiving the treatment. b. Documentation who includes an assessment performed to the patient in those intervals where the blood pressure alerts are emitted by the hemodialysis were not found. 2. RR #13 is an 81-year-old female patient admitted to the facility on 02/16/2024 with diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 06/11/2024 at 11:33 AM, it was found that patient has hemodialysis treatment three a week for three hours, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 600, Dialyzer with 180 NR ELEC-BEAM and patient Dry Weight (EDW) 80.45 kilogram (kg). a. On 06/11/2024 at 11:53 AM review of the medical record revealed that on 06/11/2024, the hemodialysis machine emits blood pressure alerts while the patient was receiving the treatment. b. Documentation who includes an assessment performed to the patient in those intervals where the blood pressure alerts is emitted by the hemodialysis were not found. 3. Facility Manager (employee #7), stated on interview on 06/11/2024 at 3:20 PM that with the purpose that nursing personnel address patient’s blood pressure changes during hemodialysis treatment, facility set the machine in such a way that when the system detect a blood pressure that suddenly present a change, the system alert the nurse so that the personnel perform a complete assessment. 4. Facility Manager (employee #7), stated in an interview on 06/11/2024 at 3:23 PM that blood pressure fluctuations are common in patients while receiving hemodialysis. She explains that those fluctuations entail changes in systolic blood pressure and diastolic blood pressure that occur before (pre-dialysis) during (intradialytic) or after (post-dialysis). She also explains that depending on what the case is nursing personnel must perform a complete assessment in order to evaluate patient status and the need of physician notification for intervention. 47632 5. RR# 4 is an 88-year-old female patient admitted on 05/02/2024 with End Stage Renal Disease and High Blood Pressure. During the record review performed on 06/12/2024 at 11:20 AM, hemodialysis treatment three a week for four hours, Dialyzer 160NRe ETHIL, Blood Flow Rate (BFR) of 300, Dialysis Flow Rate (DFR) of 500 and Patient Dry Weight (EDW) 45.45 kilogram (kg). a. On 05/28/2024 at 4:35 PM it was revealed that the BP was 161/49mg/Hg, at 5:31 PM the BP was 168/52mg/Hg, at 6:01 PM the BP was 165/50mg/Hg, at 6:32 PM the BP was 174/57mg/Hg, at 7:00 PM the BP was 166/50mg/Hg, at 7:31 PM the BP was 162/53mg/Hg and at 5:31 PM the BP was 168/54mg/Hg. No evidence was found of the nurse intervention or documentation performed. b. On 06/06/2024 at 4:32 PM it was revealed that the BP was 145/49mg/Hg, at 5:32 PM the BP was 150/46mg/Hg, and at 7:32 PM the BP was 148/49mg/Hg. No evidence was found of the nurse intervention or documentation performed. 6. RR# 10 is a 63-year-old male patient admitted on 08/28/2024 with End Stage Renal Disease and High Blood Pressure. During the record review performed on 06/11/2024 at 1:42 PM, hemodialysis treatment three a week for three hours and forty-five minutes, Dialyzer 160NRe ETHIL, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 500 and Patient Dry Weight (EDW) 78.64 kilogram (kg). a. On 06/03/2024 at 2:30 PM it was revealed that the BP was 89/46mg/Hg. No evidence was found of the nurse intervention or documentation performed. 17959 7. RR #3 is a 51-year-old male patient admitted to the facility on 08/23/2018 with diagnosis of End Stage Renal Disease (ESRD) and Diabetes Mellitus (DM). During the record review performed on 06/12/2024 at 1:40 PM, it was found that patient has hemodialysis treatment three a week for four hours, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 600, Dialyzer with F160 NRE- ETHIL (FILTER) HIGT and patient Dry Weight (EDW) 100.00 kilogram (kg). a. On 06/12/2024 at 1:40 PM review of the medical record revealed that on 05/28/2024 the patient developed twenty alerts of hypotension during received the hemodialysis treatment, on 06/06/2024 developed six alerts of hypotension during received the hemodialysis treatment, on 06/08/2024 seven alerts of hypotension and 06/11/2024 seven alerts of hypotension the hemodialysis machine emits blood pressure alerts while the patient was receiving the treatment. b. Documentation who includes an assessment performed to the patient in those intervals where the blood pressure alerts are emitted by the hemodialysis were not found. No evidence when the nurse notifies the physician. 8. RR #5 is a 53-year-old female patient admitted to the facility on 05/27/2022 with diagnosis of End Stage Renal Disease (ESRD. During the record review performed on 06/12/2024 at 11:40 AM, it was found that patient has hemodialysis treatment three a week for 3.5 hours, Catheter Double Lumen Cuffed Right Internal Jugular Vein, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 600, Dialyzer with F160 NRE- ETHIL (FILTER) HIGT and patient Dry Weight (EDW) 55.91 kilogram (kg). a. On 06/12/2024 at 11:40 AM review of the medical record revealed that on 05/31/2024 the patient developed one alert of hypotension during received the hemodialysis treatment, on 06/03/2024 develop five alerts of hypotension during received the hemodialysis treatment, on 06/05/2024 four alerts of hypotension, on 06/07/2024 two alerts of hypotension and on 06/10/2024 two alerts of hypotension the hemodialysis machine emits blood pressure alerts while the patient was receiving the treatment. b. Documentation who includes an assessment performed to the patient in those intervals where the blood pressure alerts are emitted by the hemodialysis were not found. No evidence when the nurse notifies the physician.”

“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: 15884 Based on review of the treatment flowsheets on 06/12/2024 at 10:00 AM it was identified that the facility failed to follow physicians’ orders in the BFR and DFR during the dialysis treatment and documented their intervention in the management of the patients BFR and DFR. This deficient practice is identified in 1 out of 18 records reviewed (RR #2). Findings include: 1. RR# 2 is a 77-year-old male patient admitted to the facility on 11/01/2021 with a diagnosis of End Stage Renal Disease and Hypertension. This patient’s hemodialysis treatment order dated 05/25/2024 establishes that this patient must receive treatment by Arterio Venous on Left Upper Arm with a, a BFR 350 and DFR 500. Review of hemodialysis flowsheet dated from 06/05/2024 with the agency Clinical Manager (employee #7) on 06/12/2024 at 10:50 AM evidenced that treatment was given on 06/05/2024 with a DFR of 500 at 11:25 AM and 3:25 PM. 2. Facility Manager (employee #7), stated in an interview on 06/12/2024 at 11:00 AM that after reviewing the medical record did not find a rationale documented for the change of the DFR on this case on those intervals. 3. The facility failed to ensure that the medical record includes pertinent information related to the patient’s individual dialysis treatment change on prescription and parameters administered were not according with the physician order.”