Atlantis Toa Baja

“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 observational tour of the patient treatment area during the first shift, on 06/20/2024 thought 06/21/2024 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. The isolation room mop was observed inside the cube and not hanging as required. 2. Patient belongings were observed on the floor next to their chairs or hanging from the chairs. 3. The drainage area of station #20 was observed and it was found that the drainage tube and the drainage platform were filled with particulate matter. 4. Biohazard container used for the disposal of isolation gowns was observed overflowing and with the lid open 5. Regular garbage and biohazard garbage containers were observed very close to the sharp containers, this allows cross contamination. 6. The entry and exit of paramedic personnel was observed and it was observed that they did not comply with the infection control standards (hand washing) and the use of personal protective equipment. 47632 7. During observations made in the treatment area on 06/20/2024 at 8:30 AM to 1:30 PM, the following was found: a. On 06/20/2024 at 9:50 AM the nurse (employee #8) was observed after using the screen with the patient at station #25, there was no disinfection of the screen and then he used it with the patient at station #24. b. On 063/20/2024 at 8:53 AM sheets were observed touching the floor in stations #13, stations, #18, and station #20. 8. During the observations made in the medicine room with de Supervisor (employee #2), the following was found: a. On 06/20/2024 at 10:44 AM a box of catheter inline type #18 was observed, 37 out of 50 expired on 06/15/2024. b. 06/20/2024 at 10:48 AM 2 vials of heparin 30.000 units/30ml were observed without date and signature by the nursing staff. 17959 8. During observations made in the Hemodialysis Treatment Unit on 06/20/2024 at 9:10 AM through 1:00 PM, the following was found: a. On 06/20/2024 at 9:10 AM on stations #30 and #31 a Biohazard container used for the disposal of gowns, hemodialysis lines with blood residual was observed exposed overflowing and with the lid was maintain open. b. Patient belongings were observed on the floor next to their chairs or hanging from the chairs left and right side of the patient treatment chair stations: #5, #7, #11, #12, #13, #16, #18, #20, #22, #25, #26, #27, #28 and #29. c. Patient treatment chair station #26 was observed near the wall patient belonging was observed directly on the right side of the wall and directly on the floor. d. A large Biohazard container used for the disposal of gowns was observed overflowing and with the lid open, three boxes of gowns ’’ small, medium and large ’’ were observed in the rack at small distance of the biohazardous container this allows cross contamination. e. At 9:25 AM the Laboratory was visited and provided evidence that the refrigerator used for blood samples revealed that the facility failed to take daily temperature no evidence of temperature on 06/17/18/19/ and 20,2024. f. At 9:25 AM the Isolation Room was visited and a ‘privacy screen ‘was observed in the interior of the bathroom.’ g. At 9:35 AM the toilet of the patient bathroom was observed with urine residual. h. At 10:50 AM and during patient’s ended the hemodialysis treatment was observed that the housekeeping employee (#10) used the duster when removed the garbage of the floor and shake the garbage all the time then goes to the main entrance of the personal puts the garbage, the duster and the broom near the patient hemodialysis station #31 directly on the floor per long time. A large Biohazard container was maintained at the right side of the entrance and used gowns were observed outside and exposed of the Biohazard container and lid was observed open. This Biohazard container was observed near the surgical supply material. i. At 11:28 AM a transparent plastic bag with ’’ 71 ’’ Seventy-One Suture Removal Kit (Disposable Device) Fluid Path Sterile with expiration date was February /18/2024 Lot #30085b. ’’ were identified in the daily supply cart. j. At 11:35 AM 16 Units of Hemodialysis Fistula Needle Set Lot #210327F3 with Expiration Date was 03/31/2024 was identified in the daily used materials. Dust, pieces of paper, tourniquets and other materials were observed on the interior of the daily supply cart.”

“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 06/20/2024 from 12:30 PM through 1:30 PM , it was determined that the facility failed to ensure that patients follows instructions related with the hazards of eating while on dialysis for 1 out of 4 observations at patient stations #12. Findings include: A document title: Patients Responsibilities at the Hemodialysis Unit is reviewed on 06/20/2024 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 06/20/2024 from 1:20 PM at the hemodialysis treatment area, it was observed that patient located on station #12 was eating white rice of a plastic container before personnel connect 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.”

“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 observational tour of the patient treatment area during the first shift on 06/20/2024 review of facility policies and interview with facility vice president (employee #5) it was determined that the facility failed to follow standard infection control precautions. This deficient practice had the potential to affect 31 out of 31 patients receiving treatment on the first shift. Findings include: 1. A mechanism to ensure that facility clean and disinfect contaminated surfaces with blood spills accordingly with Center for Disease Control recommendations and accepted facility established policies and procedures was not performed accordingly with these findings identified during survey procedures on 06/20/2024 on the first shift of treatment from 8:35 AM thru 11:55 AM: a.On 06/20/2024 at 11:35 AM behind the hemodialysis station #21 it was observed blood spill on the water treatment cabinet and near the biohazard waste container. b. The blood spill located on the water treatment cabinet and near the biohazard waste container were not clean and the area were not disinfected until 12:50 PM when was informed to the facility vice president (employee #5). c. During interview on 06/20/2024 at 3:50 PM facility vice president (employee #5) stated that accordingly with facility policy # 15.50 Cleaning and Disinfection the blood spill must be clean immediately at the time of the spill with a bleach solution preparation of 1:10 dilution. d. Facility failed to follow policies and procedures to clean blood spills as soon as they occur with a bleach solution 1:10 dilution accordingly with facility policies and procedures. This practice constitutes a risk for cross contamination.”

“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 06/20/2024, it was determined that the facility failed to perform as required the chlorine, chloramine, or total chlorine test. Findings include: 1. At the time of the visual review of the chlorine test, the nursing staff was observed touching the edges of the sample container with the strip and when comparing the color of the strip with the comparison table, they touched the cardboard, which could alter and give an incorrect measurement. 2. The nursing staff performing the chlorine test were asked about the accepted parameters, they showed doubt about the parameters and the actions to take if a parameter outside the accepted parameters is noticed.”

“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 home training room area, on 06/20/2024 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 ceiling tiles that cover ceiling area of the home dialysis training room. Findings include: 1. On 06/20/2024 at 10:00AM during the observational tour at the home dialysis training room were observed with brown spots. 47384 Observation of the home training room area, on 06/20/2024 through 06/21/2024 it was found: 2. White spots were observed on most chairs in the seat area and footrest joint. 3. The scale was observed to be out of date. 4. The use of sinks was observed to disinfect hands when entering and leaving the unit. The surveyor noticed that the size of the sinks is very small and does not contain water which allows water to fall to the floor and this represents a fall risk for both patients and staff. 5. Uneven flooring was observed throughout the unit, this represents a fall risk for patients using walkers.”

“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 observational tour of the treatment area during the first shift, on 06/20/2024 thought 06/21/2024 from 9:00 AM through 4:00 PM, it was determined that the facility failed to ensure that all equipment including emergency equipment are maintained and operated in accordance with the manufacturer’s recommendations. Findings include: 1. Two (2) #18 catheter were found expired with expiration date of 06/16/2024. 47632 2. During observations made in the chart cart with the Supervisor (employee #2) on 06/20/2024 at 11:00 AM, the following was found: a. On 06/20/2024 at 11:01 AM, 7 catheter inline type #18 were observed expired on 06/16/2024.”

“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 review of policies and procedures, and interview with facility manager (employee #6), 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 06/20/2024 from 8:35 AM thru 1:30 PM at patient’s stations #1, #2, #6, #10, #11, #18, #20, #21, #24 and #29.This deficient practice affects 10 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 06/20/2024 at 3:30 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 06/20/2024 from 8:35 AM thru 1:30 PM the following was observed: a. Patient located on station #10 was observed with his left arm vascular access and line connections covered with a blanket while receiving treatment. b. Patient located on station #29 was observed with her left arm vascular access and line connections covered with a blanket while receiving treatment. 2. Facility manager (employee #6), stated on interview on 06/20/2024 at 3:17 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. 47632 4. During the observation made in treatment area on 02/13/2024 at 8:00 AM through 12:00 PM the following was found: a. On 06/20/2024 at 8:45 AM the patient located in station #1, it was observed the vascular access covered with sheet. b. On 06/20/2024 at 8:46 AM the patient located in station #2, it was observed the vascular access covered with sheet. c. On 06/20/2024 at 8:47 AM the patient located in station #6, it was observed the vascular access covered with sheet. d. On 06/20/2024 at 8:50 AM the patient located in station #11, was observed the vascular access covered with sheet. e. On 06/20/2024 at 8:52 AM the patient located in station #18, was observed the vascular access covered with sheet. f. On 06/20/2024 at 8:53 AM the patient located in station #20, was observed the vascular access covered with sheet. g. On 06/20/2024 at 8:55 AM the patient located in station #21, was observed the vascular access covered with sheet. h. On 06/20/2024 at 8:57 AM the patient located in station #24, was observed the vascular access covered with sheet. The facility failed to ensure vascular access site should be seen by a staff member during all dialysis treatment. Allowing patients to cover access provides an opportunity for accidents of needle dislodgement or line disconnection and could result in bleeding or death.”

“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 06/20/2024 and 06/21/2024, 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, both exits were 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. On 06/21/2024 around 1:45 PM an open electrical panel in the patient bathroom of the Home Hemodialysis area was observed. This represents a high electric shock risk to patients and visitors. 3. on 06/20/2024 around 8:30 AM, the patient at station #31 was observed using an electrical extension cord. The extension was connected to the receptacle where the dialysis machine was located. When asked by the surveyor, the Biomedic stated that it was not authorized.”

“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: 47632 Based on nineteen records reviewed (RR) and review of Policy and Procedure (P&P), it was determinate that the facility failed to monitor and document the patient high blood pressure (BP) dialysis treatment for 4 out of 19 records reviewed (RR #5, #6, #7 and #8). Findings include: 1. RR# 5 is a 54-year-old female patient admitted on 08/17/2021 with End Stage Renal Disease. During the record review performed on 06/20/2024 at 3:00 PM, hemodialysis treatment three a week for three hours and fifteen minutes, Dialyzer NR160 ELEC-BEAM, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 600 and Patient Dry Weight (EDW) 62. kilogram (kg). a. On 05/30/2024 at 6:20 AM it was revealed that the BP was 198/108mg/Hg, at 6:25 AM it was revealed that the BP was 200/108/Hg, at 6:35 AM, it was revealed that the BP was 193/106mg/Hg, at 7:05 AM, it was revealed that the BP was 201/104mg/Hg, at 7:35 AM, it was revealed that the BP was 181/99mg/Hg, at 9:05 AM, and it was revealed that the BP was 187/71mg/Hg. No evidence was found of the nursing intervention or the documentation for hypertension. 17959 2. RR# 6 is a 64-year-old male patient admitted on 06/15/2021 with End Stage Renal Disease. During the record review performed on 06/20/2024 at 2:00 PM, hemodialysis treatment three a week for three hours, Dialyzer NR160, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 500 and Patient Dry Weight (EDW) 67.00 kilogram (kg). a. On 06/06/2024 it was revealed that the dialysis machine summary reveled eight Blood Pressures Alerts ’’, on 06/08/2024 two ’’ Alerts of Blood Pressure,’’ on 06/15/2024 was revealed that the hemodialysis machine reveled eight ’’ Alert’s ’’ of Blood Pressure, on 06/18/2024 it was revealed one ’’ Alert of Blood Pressure and on 06/20/2024 reveled three ’’Alerts of Blood Pressure however, the documents for ’’ Alerts Blood Pressure was maintain in blank and no evidence of the nursing intervention or the documentation. 3. RR# 7 is a 77-year-old male patient admitted on 03/13/2018 with End Stage Renal Disease. During the record review performed on 06/21/2024 at 9:35 AM, hemodialysis treatment three a week for three hours and thirty minutes, Dialyzer NR160, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) 68.20 kilogram (kg). a. On 06/07/2024 it was revealed that the dialysis machine summary reveled ’’ Nine Blood Pressures Alerts ’’, on 06/10/2024 two ’’ Alerts of Blood Pressure,’’ on 06/12/2024 was revealed that the hemodialysis machine reveled one ’’ Alert’s ’’ of Blood Pressure, on 06/14/2024 it was revealed one ’’ Alert of Blood Pressure, on 06/17/2024 reveled three ’’Alerts of Blood Pressure and on 06/19/2024 four ’’Alerts of Blood Pressure ’’ all the Alert’s provide evidence of Hypotension, however, the documents for ’’ Alerts Blood Pressure was maintain in blank and no evidence of the nursing intervention or the documentation. 4. RR# 8 is a 69-year-old male patient admitted on 06/20/2019 with End Stage Renal Disease. During the record review performed on 06/21/2024 at 10:20 AM, hemodialysis treatment three a week for three hours, Dialyzer NR180, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 500 and Patient Dry Weight (EDW) 75.50 kilogram (kg). a. On 06/06/2024 it was revealed that the dialysis machine summary reveled ’’ Four Blood Pressures Alerts ’’, on 06/08/2024 five ’’ Alerts of Blood Pressure,’’ on 06/11/2024 was revealed that the hemodialysis machine reveled four ’’ Alert’s ’’ of Blood Pressure and two alerts of ’’ Weight Cnhange Management ’’, on 06/13/2024 it was revealed two ’’ Alerts of Blood Pressure and two ’’Alerts of Weight Change,’’ on 06/15/2024 reveled five ’’Alerts of Blood Pressure and one ’’Alert Weigh Change ’’ and on 06/18/2024 one ’’Alert of Weight Change Management ’’ all the Alert’s provide evidence of Hypotension, however, the documents for ’’ Alerts Blood Pressure was maintain in blank and no evidence of the nursing intervention or the documentation.”

“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 06/21/2024 at 10:00 AM it was identified that the facility failed to follow physicians’ orders in the Bood flow rate (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 17 records reviewed (RR), (RR#1, #5, #8, and #9). Findings include: 1. RR# 1 is a 34-year-old female patient admitted to the facility on 04/16/2024 with a diagnosis of End Stage Renal Disease and Hypertension. This patient’s hemodialysis treatment order dated 04/19/2024 establishes that this patient must receive treatment by a Catheter located on right side of chest with a, a BFR 350 and DFR 500. Review of hemodialysis flowsheet dated 06/12/2024 with the agency Clinical Manager (employee #6) on 06/21/2024 at 10:50 AM evidenced that treatment was given on 06/12/2024 with a BFR of 325 from 6:34 PM through at 8:34 PM. The facility Manager (employee #6), stated in an interview on 06/22/2024 at 11:45 AM that after reviewing the medical record did not find a rationale documented for the change of the BFR on this case. 2. 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. 47632 3. RR# 5 is a 54-year-old female patient admitted on 08/17/2021 with End Stage Renal Disease. During the record review performed on 06/20/2024 at 3:00 PM, hemodialysis treatment three a week for three hours and fifteen minutes, Dialyzer NR160 ELEC-BEAM, Blood Flow Rate (BFR) of 350, Dialysis Flow Rate (DFR) of 600 and Patient Dry Weight (EDW) 62. kilogram (kg). a. On 06/04/2024 at 7:02 AM, 7:05 AM, 7:34 AM, 8:04 AM, 8:34 AM, 9:05 AM, and 9:30 AM the DFR was increased to 700. No evidence was found of the justification on the nurse note or authorized decrease from the physician. 4. RR# 9 is an 83-year-old male patient admitted on 01/01/2019 with End Stage Renal Disease. During the record review performed on 06/21/2024 at 8:03 AM, hemodialysis treatment three a week for three hours and thirty minutes, Dialyzer NR180 ELEC-BEAM, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) 77. kilogram (kg). a. On 06/11/2024 at11:30 AM, 11:35AM, 11:40 AM, 12:00 PM, 12:31 PM, 1:00 PM, 1:31 PM, and 1:34 PM the DFR was decreased to 500. No evidence was found of the justification on the nurse note or authorized decrease from the physician. 17959 5. RR# 8 is a 69-year-old male patient admitted to the facility on 06/20/2019 with a diagnosis of End Stage Renal Disease. This patient’s hemodialysis treatment order dated 05/23/2024 establishes that this patient must receive treatment by a AV Fistula Right Forearm with BFR 350 and DFR 500. Review of hemodialysis flowsheet dated 06/08/2024 with the agency Clinical Manager (employee #6) on 06/21/2024 at 10:20 AM evidenced that treatment was given on 06/08/2024 at 7:32 AM however, the machine failed to registered the BFR it was maintain in ’’ Blank .’’”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 15884 Based on review of policies and procedures, and interview with facility vice president (employee #5), it was determined that the facility failed to ensure that treatment flowsheets include accurate and pertinent documentation related with patient’s status and potential complications. This deficiency was identified in 1 out of 19 records reviewed (RR), (RR#17). Findings include: Facility policy # 5.02 Prescription Safety & Verification Checks last update 10/30/2023 was review on 06/21/2024 at 10:30 AM. Policy clearly stated that during dialysis personnel in charge of patients must notify the physician on those occasions when patient’s refuse medications ordered to be administered during hemodialysis treatment. 1. RR#17 is a 39-year-old female patient admitted to the facility on 07/27/2015 with a diagnosis of End Stage Renal Disease. Review of hemodialysis flowsheet dated 06/17/2024 with the agency Vice president (employee #5) on 06/21/2024 at 11:00 AM evidenced that personnel did not document that the patient refuse Clonidine 01. mg 1 oral tablet ordered by the physician due to high blood pressure 168/98 presented while receiving hemodialysis treatment this day at 6:05 PM and did not notify to the physician that patient refuse to take this medication. According to information documented by the nurse in charge of the patient on 06/17/2024, the patient refused Clonidine 01. mg 1 oral tablet at 6:05 PM. 2. When discussing the case with the agency Vice President on 06/21/2024 at 11:20 AM it was identified evidenced that personnel did not document that he/she inform the patient the risk and complications that may occur as result of her decision of no taking the medication accordingly with physician orders. There is no evidence that nurse in charge of the patient notifies the physician that patient refuse Clonidine 01. mg 1 oral tablet at 6:05 PM. The facility Vice President, stated on interview on 06/21/2024 at 11:30 AM that nurses in charge of patients who refuse to follow specific orders for medications; must notify the physician and educate those patients regarding the consequences and risks to refuse medications. She also stated that the education provided to patients must be documented in the medical record. 3. The facility failed to ensure that the medical record includes complete and pertinent information related to the patient’s individual treatment and refusal of medications ordered by the physician.”