Atlantis Caguas

“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: 47632 Based on observational tour of the patient treatment area on 06/25/2024 thought 06/26/2024 from 9:00 AM through 4:00 PM, it was determined that the facility failed to ensure provide and monitor a sanitary environment to minimize the transmission of infectious agent. Findings include: 1. During the observations made in the medicine room with the Supervisor (employee #4), the following was found: a. On 06/25/2024 at 9:47 AM a bottle of Clonidine Hydrochloride 0.1mg of 100 tablets was observed opened without a date and signature of the nursing staff. b. On 06/25/2024 at 9:48 AM a bottle of Sensipar 30mg tablets was observed opened without a date and signature of the nursing staff. c. On 06/25/2024 at 10:10 AM a vial of Epogen Epoetin Alfa 20.000 units/2ml were observed opened without date and signature by the nursing staff. d. On 06/25/2024 at 10:18 AM a vial of Humulin R 100 units/10ml observed opened without date and signature by the nursing staff. Manufacturer’s directions: discard all opened vials after 28 days, even if there is still insulin in the vial. e. On 06/25/2024 at 10:21 AM a syringe of Aranesp 100 mcg/ 0.5ml was observed to have expired on 8/2023. f. On 06/25/2024 at 10:25 AM five Hemodialysis Fistula Needle Set #16 were observed to have expired on 03/31/2024. g. On 06/25/2024 at 10:27 AM fifteen Hemodialysis Fistula Needle Set #15 were observed to have expired on 04/2021and 04/05/2024. h. On 06/25/2024 at 10:32 AM a box of catheter inline type #18 was observed, 45 out of 50 expired on 06/15/2024. i. On 06/25/2024 at 10:37 AM a 0.9% Sodium Chloride Injection USP 250 ml was observed to have expired on 04/2023. j. On 06/25/2024 at 10:42 AM two boxes of Triple Antibiotic Ointment 0.5g of 144 packets were observed expired on 4/2024. k. On 06/25/2024 at 10:33 AM the drawers where medical surgical equipment was in the medicine room were observed to be dusty. l. On 06/25/2024 at 11:00 AM the surfaces of the two refrigerators in the medicine room were observed with dust. 2. During observations made in the sample Room with de Supervisor (employee #4) on 06/25/2024 at11:00 AM, the following was found: a. On 06/25/2024 at 11:14 AM the surface of the refrigerator in the sample room was observed with dust. 3. During observations made in the treatment area on 06/25/2024 at 9:30 AM to 1:30 PM, the following was found: a. On 06/25/2024 at 12:00 PM Clorox disinfectant wipes and an osmometer were observed near the patient at station #15. b. On 06/25/2024 at 12:05 PM the registered nurse (employee # 8) was cleaning the catheter of the patient at station #15. The pad where the medical surgical equipment was located was touching the wall and a drop of blood was observed on the wall. c. On 06/25/2024 at 1:03 PM the physician entered the treatment unit without washing his hands, without putting on his mask and without putting on his gown. 15884 4. The dialysis facility failed to promote and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit accordingly with the following findings identified on 06/26/2024 at 9:55 AM: On 06/25/2024 at 9:15 AM clinical manager (employee #5) inform that she has been informed that one of the patients of the third shift of Tuesday, Thursday and Saturday tested positive for Covid. She explains that patient’s physician evaluates the patient and orders to dialyze the patient at the unit taking the required infection control precautions. 5. On 06/26/2024 at 8:39 AM it was informed that this patient receives hemodialysis on 06/25/2024 (the day before) on the third shift and that he was located in the isolation room. 6. Information related patient assessment when received to receive treatment on 06/25/2024 was requested to the facility clinical manager (employee #5) on 06/26/2024 at 9:19 AM. Accordingly with information provided by facility clinical manager (employee #5) on 06/26/2024 at 10:00 AM patient’s assessment was performed by nurse in charge of the patient and was documented as part of the hemodialysis flowsheet. 7. No information was found documented on the hemodialysis flowsheet in relation with nursing assessment of common signs and symptoms of a respiratory infection (such as chills, nasal congestion, muscle pain, headache, sore throat, loss of taste or smell, and gastrointestinal symptoms) if any presented by this patient. 8. Facility nursing supervisor (employee #4) was asked on 06/26/2024 at 10:45 AM in relation to the supply of n95 mask and other personnel protective equipment. Nursing supervisor (employee #4) showed the surveyor the area where facility store n95 respirator and personnel protective equipment that must be used when personnel provide services to patients who tested positive to Covid. In the area designated to store these personnel protective equipment it was found a closed box of 10 pieces of particulate mask with the code SAT-T-Fit Plus P100-N-1125. Nursing supervisor (employee #4) also showed a box of n95 respirators. 9. The surveyor asked the facility clinical manager (employee #5) on 06/26/2024 at 10:55 AM if this particulate mask with the code SAT-T-Fit Plus P100-N-1125 is approved for the use with patients who tested positive to Covid as personnel protective equipment. She explains that this mask should not be used because had an exhalation valve that is a feature that n95 or other similar respirators should not have. She explains that this type of mask was brought when the Covid pandemic started and that she thought that had been removed from all hemodialysis units because they are not allowed to be used. 10. Facility clinical manager (employee #5) was asked by the surveyor on 06/26/2024 at 11:15 AM if the employees who are required to wear a respirator n95 had an updated n95 annual fit test. Facility clinical manager (employee #5) stated that the n95 annual fit test must be performed on the month of July 31, 2023, but that this n95 annual fit test was not done. 17959 11. During the observations made in the Hemodialysis treatment area it was observed dust around the borders table materials. Clips, pieces of paper and dust were observed in the interior of drawers. 12. During the observations in the Isolation Room at 8:40 AM with the nurse supervisor (employee #4), the following was found: a. On 06/25/2024 at 8:35 AM yellow spots, dust, the control of TV, disinfectant pot, a gallon of Acetic Acid 5%, tray with Chlorox with date of 03/21/2024 at 5:00 AM. b. Screen and the entire dialysis machine with white spots. c. A syringe of 10 ml. with transparent liquid content does not indicate what it is. d. Biohazard trash can with content filters, lines and gloves. e. Sharp container with date of 06/10/2024 syringes with blood content, dust and dried blood on the outside of the sharp container was observed. f. Lock of the entrance door to the isolation room was observed with white spots. g. Hemodialysis treatment chair is missing ‘Emergency Kit “ on the left side. h. During the observation in the station’s areas at 8:55 AM on patients’ stations #11, #16 and #20 sheets touching the floor. i. At 9:00 AM material cart located in front of stations from one (1) to nine (9) and from ten (10) to twenty (20), it was observed with dust on the outside and inside of the drawers. j. At 9:10 AM during the disconnection of right-side catheter process it was observed in station #20 patient lump on the right side of the treatment chair. k. At 9:10AM it was observed that patient ended the hemodialysis treatment on station #17 and he leaves accompanied by a nurse employee #2 however, only wet hands and dry. l. At 9:15 AM it was observed that patient ended the hemodialysis treatment on station #27 and he left accompanied by a nurse however he did not wash his hands. m. At 10:05 AM during the disconnection on station #4 of left forearm it was observed that the nurse employee #3 went to station #16 and turned off the alarm later then removed and discarded her gloves she put her right hand in the glove box she took two gloves and put them on, she did not dry wash or wash with soap and water, she went to station number four and continue the disconnection process of patient from the left forearm. n. At 10:18 AM during the disconnection on station #20 of catheter of right side it was observed that the nurse employee #7 patient lump on the right side of the treatment chair on the left side them placed the sterile materials kit on the table on the right side, did not disinfect the arm rest. Did not put protective screen in front of the patient to maintain the privacy because in front of this patient, a male patient remains. o. On 06/25/2024 at 10:30 AM during the disconnection process, a housekeeping employee was observed collecting regular garbage and biohazard garbage in station #20. p. On 06/25/2024 at 11:10 AM it was observed a cleaning employee used a broom in the unit during patients receiving the hemodialysis treatment. q. On 06/25/2024 at 10:35 AM during the disconnection process in station #24 patient with catheter left femoral a housekeeping employee was observed collecting regular garbage and biohazard garbage. r. On 06/25/2024 at 11:30 AM during the second shift, at station #14 ambulance employee after cleaning the stretcher at station #14 removed gloves and then put hands in the glove box he took two gloves and placed them in his hands he did not wash his hands. s. The dialysis facility failed to promote and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit accordingly with the following findings identified on 06/25/2024.”

“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: 15884 Based on observations made of the treatment area, during the second shift of 06/25/2024 from 12:00 PM through 1:35 PM, it was determined that the facility failed to ensure that the nursing staff perform infection control prevention measures according to agency’s policies and procedures for 1 out of 4 observations at patient stations (PT) (PT#22). Findings include: 1. Facility personnel failed to promote measures to prevent cross contamination during patient care treatment on the hemodialysis unit accordingly with the following findings identified during survey procedures. a. On 06/25/2024 at 10:15 AM it was observed registered nurse (RN) (employee #1) while providing care and services to patients located on stations #19 and #22 and #24. She took gloves from the glove box without performing hand hygiene first when accessing hemodialysis circuit of patient located on station #22.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 15884 Based on observations made of the treatment area, during the second shift of 06/25/2024 from 12:00 PM through 1:35 PM, it was determined that the facility failed to ensure that patients follows instructions related with the hazards of eating while on dialysis for 5 out of 20 observations at patient stations #5, #8,#11,#13 and #25. Findings include: A document title: Patients Responsibilities at the Hemodialysis Unit is reviewed on 06/25/2024 at 2:50 PM. This document stated on item #4 that is prohibited ingest food inside the unit not even before or after having received the treatment. 1. During observations performed on 06/25/2024 from 12:00 PM through 1:35 PM at the hemodialysis treatment area, it was identified the following: a. Patient located on station #5 was drinking apple juice and eating vanilla cookies after personnel connected him to the hemodialysis circuit. b. Patient located on station #8 was eating sugar frosted flakes after personnel connected him to the hemodialysis circuit. c. Patient located on station #11 was sucking a lollipop and eating starburst chewy candy after personnel connected him to the hemodialysis circuit. It was observed that this patient had a Ziplock bag full of sweet and salty snacks on his left table of the hemodialysis chair. d. Patient located on station #13 was observed eating corn flakes after personnel connected him to the hemodialysis circuit. e. Patient located on station #25 was observed drinking grape juice and eating crackers and cheese after personnel connected him to the hemodialysis circuit. 2. No staff were observed informing patient located on station #12 risk associated with the ingestion of food right before the process of connection him to the hemodialysis circuit. 3. Facility failed to discourage the consumption of food before and while on hemodialysis treatment to comply with infection standards and facility policies and procedures.”

“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 water treatment area, during the first and second shift of 06/25/2024, it was determined that the facility failed to perform as required the chlorine, chloramine, or total chlorine test. Findings include: At the time of the visual review of the chlorine test with Regional Bio Tech (employee #9) ,it was noticed that the nursing staff was uncertain of the swish time (60 seconds) required for the testing strip.”

“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 nursing supervisor (employee #4), and review of policies/procedures, it was determined that the facility failed to ensure that 3 out of 11 nursing personnel (RN#3, RN #9 and RN #10) 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 06/26/2024 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 06/25/2024 from 11:35 AM till 1:30 PM and on 06/26/2024 from 11:25 AM till 1:00 PM: a. The register nurse (RN#3) is observed, performing the pH and conductivity test at the hemodialysis machine located at station #5 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. b. The register nurse (RN#9) is observed, performing the pH and conductivity test at the hemodialysis machine located at station #1, #17, #19 and #22. To perform the pH test on this machine, RN#9 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. c. The register nurse (RN#10) is observed, performing the pH and conductivity test at the hemodialysis machine located at station #18. To perform the pH test on this machine, RN#10 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. 2. Facility nursing supervisor (employee #4), stated in an interview on 06/26/2024 at 1:08 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: 47384 Based on the observational tour of the facility treatment area on 06/25/2024 through 06/26/2024 from 8:30 AM to 4:00 PM, it was determined that the facility failed to maintain the building in which dialysis services are furnished to ensure the safety of the patients, the staff and the public. Findings include: 1. Six television stations which had 2 televisions each. These had cable TV boxes and both the televisions and the boxes were connected to multi-plugs that did not meet the safety requirements (Hospital Grade). 2. Patient in station #23 was observed using a thermal blanquet. 3. Facility failed to maintain emergency disconnection kit on every chair where a patient is receiving treatment or orientation. One kit was missing on chairs #7, #9, #12, #18. 47632 4. During the observations made in the Medicine Room with the Supervisor (employee #4), the following was found: a. On 06/25/2024 at 10:42 AM one of the emergency lights was dim.”

“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 observation made of the outside of the facility on 06/25/2024 through 06/26/2024 at 8:00 AM to 4:00 PM, it was determined that the facility failed to asure that 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. Findings include: 1. During the visual observation of the parking area, 4 handicapped parking spaces were observed in front of the unit. This 4 parkings had the acces aisles but did not have ramp acces to the entrance of the unit. Patients would have to go through traffic area of the parking lot in orther to enter the unit. 2. Plinth between station #4 and #5, behind station #17, and between stations #22 and #27 were observed unattached and stained. 47632 3. During the observations made in the Medicine Room with the Supervisor (employee #4), the following was found: a. On 06/25/2024 at 10:33 AM the drawers where medical surgical equipment was in the medicine room were observed to be dusty. b. On 06/25/2024 at 11:14 AM the surface of the refrigerator in the sample room was observed with dust. 4. During the observations made in the Sample Room with the Supervisor (employee #4), the following was found: a. On 06/25/2024 at 11:14 AM the surface of the refrigerator in the sample room was observed with dust.”

“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, interview with the Regional Biomedical Tech (employee #9), and review of policies/procedures and Preventive Maintenance (PM) documentation it was determined that the facility failed to implement and maintain a program to ensure that all equipment are maintained and operated in accordance with the manufacturer’s recommendations. Findings include: 1. A empty class E oxygen tank was found on the emergency cart inside the unit. 2. After reviewing five (5) dialysis machine preventive maintenance it was notices that two (2) out of five (5) did not follow operation hors sequence. Missing or incomplete hours were also observed. 3. Two (2) #18 catheters on the emergency suitcase were found expired with expiration date of 06/16/2024. 4. After review of the electrical outlet inspection documentation it was noticed that information provided does not match what was found at the facility. The report stated that 4 outlets were inspected on the waiting area and when counted there were 8 outlets.”

“PE-PT CARE ENVIRONMENT-SUFFICIENT SPACE CFR(s): 494.60(c)(1) The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. This Standard is not met as evidenced by: 47384 Based on the observational tour of the facility treatment area on 06/25/2024 through 06/26/2024 from 8:30 AM to 4:00 PM, it was determined that the facility failed to provide sufficient space needed to prevent cross-contamination, and to accommodate medical emergency equipment and staff, for 4 out of 31 stations (ST). (ST #2, #5 , #8 and # 27) Findings include: It was observed that the stations #2, #5, #8 #27 do not contemplate the minimum of 3 feet on both sides of the treatment chairs as established by The Facility Guidelines Institute. This could make difficult to attend any patient in need of emergency medical atention.”

“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 #4), 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 06/25/2024 from 8:35 AM thru 1:35 PM at patient’s stations #8, #11 #13, #15, #17 and #19. This deficient practice affects 6 out of 31 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 06/25/2024 at 3:00 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 06/25/2024 from 8:35 AM thru 1:35 PM the following was observed: a. Patient located on station #8 was observed face and line connections located on left chest catheter covered with blankets while receiving treatment. b. Patient located on station #11 was observed with his left arm vascular access and line connections covered with a blanket while receiving treatment. c. Patient located on station #13 was observed face and line connections located on right chest catheter covered with blankets while receiving treatment. d. Patient located on station #15 was observed face and line connections located on right chest catheter covered with blankets while receiving treatment. e. Patient located on station #17 was observed with his left arm vascular access and line connections covered with a blanket while receiving treatment. f. Patient located on station #19 was observed with his left arm vascular access and line connections covered with a blanket while receiving treatment. 2. Facility nursing supervisor (employee #4), stated on interview on 06/25/2024 at 1:17 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 in 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 on observations made of the treatment area and waiting area, during the first and second shift of 06/25/2024 and 06/26/2024, it was determined that the facility failed to maintain measures to ensure patients, visitors and staff safety from fire. Findings include: 1.Approximately at 11:45 AM in the waiting room, exit was observed obstructed by patient stretchers waiting to enter the unit as well as a patient in a wheelchair obstructing fire extinguishers and pull stations. 2. Fire extinguishers were observed obstructed by trash containers next to station #11. 3. Medical screens were observed obstructing fire exit.”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 47632 Based on ESRD Core survey, an observation tour in the patient treatment area on 06/25/2024 through 06/26/2024 from 8:00 AM to 1:30 PM, it was determined that the facility failed to ensure privacy on expose private body part during the connection from the hemodialysis machine in the dialysis facility. Finding includes: 1. During the round provided in the treatment area on 06/25/2024 at 10:00 AM to 1:30 PM, the following was observed: a. On 06/25/2024 at 1:00 PM, registered nurse (employee #7) is observed cleaning the catheter without the screen in place. The facility failed to ensure privacy with the screen at the time of connection and cleaning of the patient’s catheter during dialysis treatment. 17959 b. At 10:18 AM during the disconnection on station #20 of catheter of right side it was observed that the nurse employee #7 patient lump on the right side of the treatment chair on the left side them placed the sterile materials kit on the table on the right side did not disinfect the arm rest. Did not put protective screen in front of the patient to maintain the privacy because in front of this patient, a male patient remains.”

“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 interview, policies, and procedure reviewed, and twelve records reviewed (RR), it was determined that the facility failed to monitor and document the patients’ blood pressure (B/P) and document nurse action when patient present hypotension and/or hypertension during dialysis treatment for 2 of 12 record review (R.R. #6 and #7). Findings include: 1. R.R #6 is an 86-year-old female patient admitted to the facility on 10/17/2023 with a diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 06/06/2024 at 1:20 PM, it was found that this patient had hemodialysis order dated 05/09/2024 to receive hemodialysis treatment three times a week for 4 hours by CV Catheter -Tunneled with a BFR of 300 and DFR of 700, Dialyzer Optiflux 160 NRe. Patient Dry weight (EDW) 44.5 kilogram (Kg). During review of the most 6 recent treatment sheets on 06/06/2024 at 1:20 PM, it was identified that: a. On 06/04/2024 at 16:01 AM, the hemodialysis machine did not register the blood pressure at 30 minutes according to the policy and procedure. 2. R.R #7 is a 42-year-old male patient admitted to the facility on 02/10/2024 per transient and decided stay for admission. Diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 06/06/2024 at 11:250 AM, it was found that this patient had hemodialysis order dated 04/10/2024 to receive hemodialysis treatment three times a week for 4 hours by CV Catheter -Tunneled with a BFR of 400 and DFR of 800, Dialyzer Optiflux 180 NRe. Patient Dry weight (EDW) 102 kilogram (Kg). During review of the most 6 recent treatment sheets on 06/06/2024 at 1:20 PM, it was identified that: a. On 05/27/2024 the patient only received three hours and 30 minutes of treatment, however no evidence from the nurse documented the reason to shorten treatment. b. On 05/29/2024 patient BFR was maintained at 500 per eight times not according with the physician orders of 400. c. On 05/31/2024 the patient DFR did not register on the hemodialysis machine when the patient initiated the hemodialysis treatment at 5:28 PM.”