Fresenius Medical Care of Batesburg Leesville

“CFC-WATER & DIALYSATE QUALITY CFR(s): 494.40 This Condition is not met as evidenced by: 28883 Based on observation, interview, review of Fresenius machines operator manual and manufacturer guidelines, the dialysis facility failed to ensure staff check the independent conductivity of the dialysate as per the machine operator’s manual, were knowledgeable of the correct way to check the independent conductivity, and/or ensure the facility policy included information on how the independent conductivity check was to be completed with changes to the acid concentrate and/or bicarbonate changes. The findings include: Cross Reference V-0250: Registered Nurse (RN) #1 and Patient Care Technician (PCT) #1 failed to perform the independent check of conductivity of dialysate as per the machine operator’s manual instructions after one of one random patients observed had a change in acid concentrate during treatment, were not knowledgeable of how to check the independent conductivity per the manufacturer, and the facility policy and the Biomedical Services Bulletin did not include information to on when to check the independent conductivity if there was a change in acid concentrates or if the bicarbonate source was changed from a bibag to liquid bicarbonate and/or include information on how the independent conductivity checks were to be completed by dialysis staff in these instances.”

“CFC-PERSONNEL QUALIFICATIONS CFR(s): 494.140 This Condition is not met as evidenced by: 28883 Based on observation and interview, the dialysis facility failed to ensure Registered Nurse (RN) #1 correctly identified a patient prior to initiation of hemodialysis treatment and RN #1 failed to notify/document notification of the physician/advanced practice provider related to an elevated Potassium level for a patient. The findings include: Cross reference V 0681: Failed to verify the identity and initiate the correct dialysis treatment for 1 of 3 patients observed for prescription treatments and staff failed to ensure that high blood potassium levels were properly addressed and documented for 1 of 2 patient charts reviewed (Patient #3).”

“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: 28883 Based on observations, interviews, and review of facility policy “Hand Hygiene”, two of four Patient Care Technicians observed for dialysis care, PCT’s #1 and #2, failed to ensure the facility scale button and treatment room door was not disinfected post usage by patients holding their access sites with gloves and did not perform hand hygiene post glove removal. The findings include: Observation on 7/22/24 at 11:05 AM of the patient treatment floor revealed Patient Care Technician (PCT) #1 taping up the needle sites for a patient at machine #24, station #21. The patient with a glove donned to the right hand, held their access sites to stop the bleeding after the dialysis treatment. The patient stood up for a blood pressure check and removed the glove on the right hand and placed it in the trash. PCT #1 removed his/her glove and performed hand hygiene and walked with the patient to the scale. Without performing hand hygiene, the patient used his/her right hand to touch the scale button to obtain a weight, potentially contaminating the scale button without disinfection post usage, and left the treatment room without performing hand hygiene. PCT #1 did not ask the patient to perform hand hygiene prior to exiting. During an interview on 7/22/24 at 11:09 AM, PCT #1 verified the observation. Observation on 7/22/24 at 11:18 AM of the patient treatment floor revealed PCT #2 taping up the needle sites for a patient at machine #23, station #19. The patient held pressure to his/her access sites using a gloved hand to stop the bleeding after the dialysis treatment. The patient removed the glove and stood for a blood pressure check. PCT #2 accompanied the patient to the scale without performing hand hygiene and the patient touched the scale button with his/her left hand (used to hold the needle sites) with no disinfection of the scale button post usage. The patient left the treatment room without performing hand hygiene. PCT #2 did not ask the patient to perform hand hygiene prior to exiting the treatment room floor. During an interview on 7/22/24 at 11:22 AM, PCT #2 verified the observation. Review on 7/25/24 at 1:52 PM of the facility policy, “Hand Hygiene” revealed hands will be decontaminated using alcohol-based hand rub or by washing hands when entering and leaving the treatment area, immediately after removing gloves; and after contact with body fluids, non-intact skin, and wound dressings if hands are not visibly soiled.”

“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: 28883 Based on observation, interview, and review of facility policy “Hand Hygiene”, Registered Nurse (RN) #2, one of two nurses observed performing dialysis care, failed to perform hand hygiene at opportune times to prevent cross contamination. The findings include: Observation on 7/22/24 at 11:44 AM of the patient treatment floor revealed Registered Nurse (RN) #2 adjusted a trash bag in the trash can next to the medication storage counter with gloves donned. RN #2 removed her/his gloves, but did not perform hand hygiene before opening a medication drawer and removed two syringes containing medication. RN #2 donned gloves without performing hand hygiene first, went to a patient at station #4, machine #12 and attached one medication syringe to the Heparin pump, the other syringe to the venous needle and administered Heparin intravenously. RN #2, with the same gloved hands, went to the clean supply cart and removed a blue clamp and clamped the dialysis lines to the patient’s clothes. During an interview on 7/22/24 at 12:04 PM, the surveyor reviewed the observation with RN #2 who verified the finding. Review on 7/25/24 at 1:52 PM of the facility policy entitled, “Hand Hygiene” revealed information that hands will be decontaminated using alcohol based hand rub or by washing hands before performing any invasive procedure such as administration of parenteral medications, immediately after removing gloves, or after contact with inanimate objects near the patient.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 28883 Based on observation, interview, and review of the policy “Personal Protective Equipment”, Patient Care Technician (PCT) #2, one of four PCT’s observed providing dialysis care, failed to wear eye protection when placing dialysis needles into a vascular access. The findings include: Observation on 7/22/24 at 11:10 AM of the treatment room floor revealed Patient Care Technician (PCT) #2 at dialysis station #20, machine #2 insert a dialysis needle into a patient’s access and adjusting it without wearing a face shield and/or goggles for eye protection. After cleaning the 2nd needle site, PCT #2 inserted the 2nd needle in without a face shield and/or goggles for eye protection. PCT #2 then attached the dialysis lines to the needles without eye protection and started the patient’s treatment. During an interview on 7/22/24 at 11:22 AM, PCT #2 verified the observation. Review on 7/25/24 at 1:52 PM of the facility policy “Personal Protective Equipment” (PPE) revealed that PPE including a full-face shield or mask and protective eyewear with full side shield must be worn to protect employees from blood or other potentially infectious materials when performing procedures during which spurting or spattering of blood might occur such as during initiation and termination of dialysis.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 22313 Based on observation, interview and review of facility policy, the dialysis facility staff failed to change a transducer protector timely for 1 of 3 patients observed for wet transducers. (Patient Care Technician (PCT) #1). The findings include: Observation on 07/22/24 at 9:55 AM of the treatment room floor revealed a patient on hemodialysis machine #16 with a wet transducer. Patient Care Technician (PCT) #1 came and adjusted the hemodialysis machine at 10:02 AM and 10:05 AM with no change to the transducer. At 10:18 AM, PCT#1 walked by the machine and glanced at it with no change to the transducer. PCT#1 returned to the hemodialysis machine to check and adjust the tubing at 10:35 AM and 11:05 AM with no changes to the transducer. At 11:35 AM, PCT #2 took over for PCT #1 and immediately recognized the wet transducer and proceeded to change it out. PCT #2 did check the backside of the transducer protector before disposing of it. In an interview with PCT #2 on 07/22/24 at 11:45 AM, PCT #2 stated, “wet transducer protectors must be changed out immediately according to our policy.” Facility policy entitled, “Maintenance of Transducer Protectors” reads, “The transducer protector must be changed immediately when contaminated with saline or blood. If the back of the transducer protector is contaminated with blood, the internal transducer must be checked by biomedical staff prior to use of the machine for another patient for contamination and changed or disinfected as necessary.””

“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: 22313 Based on observation, interviews, review of the Fresenius 2008T Machine Operator’s Manual, the facility policy “Checking Conductivity and pH of Final Dialysate”, and review of the service bulletin for Biomedical Services, Registered Nurse (RN) #1 and Patient Care Technician (PCT) #1 failed to perform the independent check of conductivity of dialysate as per the machine operator’s manual instructions after one of one random patients observed had a change in acid concentrate during treatment, were not knowledgeable of how to check the independent conductivity per the manufacturer, and the facility policy and the Biomedical Services Bulletin did not include information to on when to check the independent conductivity if there was a change in acid concentrates or if the bicarbonate source was changed from a bibag to liquid bicarbonate and/or include information on how the independent conductivity checks were to be completed by dialysis staff in these instances. The findings include: Observations on 7/22/24 between 9:15 am and 12:30 PM of the treatment room floor revealed the facility hemodialysis machines used bibags and performed an independent check of the pH and conductivity during the machine alarm/pressure tests before each patient treatment. Observation on 07/22/24 at 3:12 PM of the treatment room floor revealed RN #1 began a patient treatment on the patient at hemodialysis machine #21. After the treatment began running, RN #1 was asked to verify the orders with the treatment being provided. Noticing the error of the dialysate being used, RN #1 abruptly pulled the tubing from the jug labeled 3251 (3 K (potassium) 2.5 Ca (calcium)) to the jug labeled 2251 (2 K 2.5 Ca). RN #1 then left the patient without checking the pH or conductivity on the new 2251 dialysate. RN#1 was asked if s/he had checked the pH and conductivity levels on the 2251 dialysate and said that s/he had asked the Patient Care Technicians (PCT) to do the pH and conductivity checks. In an interview with PCT #1 on 07/22/24 at 3:30 PM and PCT #2 at 3:35 PM it was confirmed that neither PCT #1 nor PCT #2 had heard the order to check the pH and conductivity. In an interview with RN #1 and PCT #1, on 7/22/24 at 3:45 PM, both were unaware the pH and conductivity should be changed with a change in bath, stating “the machine does the pH and conductivity for you”. On 07/22/24 At 3:52 PM, RN #1 admitted that there had been several errors. S/he had the wrong patient in the wrong hemodialysis station, s/he had not looked at the identity picture of the patient(s) on the hemodialysis screen, which was African American, but the patient in the station was Caucasian due to a mix up in chair assignments. RN #1 also was unfamiliar with the operation of the hemodialysis machine, stating “the machine does the pH and conductivity for you”. In an interview with biomedical staff on 07/23/24 at 10:00 AM and review of the directions for use for the hemodialysis machine, it was confirmed that when dialysate is changed, an independent pH and conductivity reading must be confirmed by pH strips and a conductivity meter. Review on 7/23/24 at 8:15 AM of the facility policy entitled, “Checking Conductivity and pH of Final Dialysate”, dated 5/6/24, revealed when replacing the (acid) concentrate to a new formula or when using a bicarbonate source other than a bibag, a pH must be checked”. Review of the Fresenius 2008T Machine Operator’s Manual about performing an independent check of the conductivity if the acid concentrate was changed or bicarbonate source was changed from the bibag to liquid bicarbonate did not include information regarding these changes. During an interview on 7/23/24 at 12:42 PM, the Area Technical Manager (ATM) #1 provided the surveyor with a page from a Fresenius 2008T Machine Operator’s Manual. It documented “...Warning! Always verify the conductivity and approximate pH of the dialysate through independent means before beginning treatment. Independent means could be by using an external conductivity meter, pH meter, pH paper or by using the machine’s independent conductivity test. Verify also when changing concentrates during treatment and when switching from the bibag system to liquid bicarbonate. The wrong conductivity or pH may cause serious injury or death...”. When the surveyor expressed concern that the nursing staff had not performed an independent conductivity check using the dialysis machine’s independent conductivity test or with an external conductivity meter after the acid concentrate had been changed; ATM #1 stated the 2nd verification (the independent conductivity check) was in the hemodialysis machine and that dialysis staff did not need to use a meter or the machine’s independent conductivity test function. ATM #1 stated that there was a conductivity cell that read/verified the independent conductivity, that this cell would fluctuate and show the independent conductivity of the dialysate during the patient’s treatment. ATM #1 reviewed the Fresenius 2008T Machine Operator’s Manual and stated that the “Pre Tx (pre treatment) Conductivity” block on the dialysate screen was the one that showed the independent conductivity and would fluctuate during treatment. Staff would just need to look at this reading when switching concentrates and it would tell them the independent conductivity. The surveyor stated s/he had been under the impression that this “Pre Tx Conductivity” was the result of the independent conductivity machine test completed before patient treatment, and did not fluctuate. ATM #1 stated this was not a pre treatment conductivity from the machine’s independent conductivity test, but was showing the conductivity of the dialysate before the dialyzer. The surveyor stated that since the manufacturer’s operator’s instructions for use for the Fresenius 2008T hemodialysis machine stated the test could only be completed using the machine’s independent conductivity test or with an external meter; that ATM #1 would need to show the surveyor that there were alternate instructions from the manufacturer on how to do the independent conductivity check. On 7/24/24 at 8:00 AM, paperwork entitled “Biomedical Support Services, Regulatory Guidance for Using the 2008T Independent Conductivity and pH”, dated 2/1/23, was noted on the conference room table. Review of the guidance revealed that CMS (Centers for Medicare and Medicaid Services) regulation and interpretive guidance stated it was 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. It included if the dialysis machine manufacturer required testing of conductivity, this must also be tested using an independent testing device prior to each treatment and before using a different composition of acid concentrate during the same treatment. ( The paper went on to state that there have been advances in the Fresenius 2008T Technology in relation to Independent Conductivity and pH Verification. It stated that the Bluestar functional software incorporated a method for the machine to independently verify conductivity and pH when used in accordance with machine instructions for use and using the bibag disposable, which stated: “Note: If the Service Mode “Independent Cond (conductivity) Test” option is enabled, the Independent Conductivity self-test will be listed among the self tests. Running this test will independently verify the conductivity of the dialysate. If the bibag disposable is the bicarbonate source for the treatment, the Independent Conductivity/pH self test will be listed and the machine will independently verify both the conductivity and pH of the dialysate.”) The last page of the Guidance for Biomedical Support Services included a table which outlined the required concentrate verifications when changing concentrates during treatment. The table showed that if you replaced a bibag disposable with liquid, carton mixed, or central delivered bicarbonate; or replaced the current acid concentrate with a different catalog number (example 2K 2.5 CA to 3K 2.5 Ca), that a pH check was required. It did not include information that an independent check of the conductivity was required also. This information was contrary to information included in the Fresenius 2008T machine operator’s manual which documented that an independent conductivity check was required with these type of changes. During an interview on 7/24/24 at 12:57 PM, the Area Technical Manager #1 reviewed information in the Fresenius 2008T Machine Operator’s Manual and verified that staff must do an independent check of the conductivity when changing acid concentrates and when using a bicarbonate source other than the bibag. ATM #1 stated that the staff check the independent conductivity by looking at the conductivity cell reading labeled Pre Tx. ATM #1 explained how the cell worked to verify the machine conductivity. Review of the Fresenius 2008T Machine Operator’s Manual Revision A/B with ATM #1 revealed on page 84, that the Pre Tx Conductivity reading is frozen after the self tests and will not change in the course of the treatment. The reading will not change until the start of self test for the next treatment. Review of information under “Dialysate Screen” revealed that you can view the independent conductivity reading when the dialysate lines are on the shunt (not during patient treatment). ATM #1 verified the Fresenius 2008T Machine Operator’s Manual did not include information that reading the Pre Tx Conductivity was a way to check the independent conductivity after the patient’s treatment had started and concentrates changed. ATM #1 reviewed the Biomedical Support Services Bulletin entitled “Regulatory Guidance for Using the 2008 Independent Conductivity and pH” and verified the table did not agree with what the Fresenius 2008T Machine Operator’s Manual stated regarding checking the independent conductivity with a change in the acid concentrate or if the bibag was replaced with a bicarbonate source that was not a bibag. 28883 Review on 7/25/24 at 1:55 PM of the facility policy, “Pre-Treatment Safety Checks Procedure” revealed that after the patient is seated, “...The clinician initiating treatment must verify the prescribed set up matches the patient: Patient’s identity per policy...”.”

“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: 22313 Based on observation, interview and review of facility policy “Total Chlorine Test Strips”, the dialysis facility failed to ensure expired supplies, open and/or undated supplies were removed from the patient treatment area. The findings include: Observation on 07/22/24 at 9:20 AM of the water room revealed one bottle of expired Hach Total Chlorine Test strips with an expiration date of 03/24. The Biomedical staff immediately confirmed the expired strips and removed them. Observation on 07/22/24 at 9:40 AM of the treatment room floor revealed one open bottle of Residual Chlorine test strips with no open date on the listed on the bottle a treatment cart. In an interview with PCT #6 on 07/22/24 at 9:45 AM, the strips were confirmed open but undated. Facility policy entitled, “Total Chlorine Test Strips,” reads “Verify test strips are not expired and bottle labeled with date opened.” Facility policy entitled, “Storage of Supplies” reads, “Appropriately dispose of items that have reached the expiration date.””

“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: 22313 Based on record review, interview, and facility policy, the dialysis facility failed to ensure one of six patient charts reviewed for dry weights was achieved and out of normal range blood pressures during treatment were reported to nursing staff. (Patient #1). Findings include: Record review on 07/22/24 at 1:00 PM of Patient #1’s treatment records revealed Patient #1 was admited to the dialysis facility on 03/26/24, designated as an unstable patient. Physician orders dated 3/26/24 revealed an estimated dry weight (EDW) for 48.5 kilograms (kg). For the week of 06/29/24 a post-dialysis weight of 51.9 kg was recorded (3.5 kg over EDW), on 07/02/24 a post-dialysis weight of 52.50 kg was recorded (4.0 kg over EDW), on 07/04/24 a post-dialysis weight of 51.00 kg was recorded (2.5 kg over EDW), on 07/06/24 a post-dialysis weight of 50.80 kg was recorded (2.3 kg over EDW), on 07/09/24 a post-dialysis weight of 50.90 kg was recorded (2.4 kg over EDW), on 07/11/24 a post-dialysis weight of 52.70 kg was recorded (4.2 kg over EDW), on 07/13/24 a post-dialysis weight of 50.10 kg was recorded (1.6 kg over EDW), on 07/16/24 a post-dialysis weight of 50.48 kg was recorded (1.98 kg over EDW) This demonstrates a pattern of not meeting the dry weight goal. Record review on 07/13/24 at 2:31 PM of Patient #1 revealed Patient #1 with a blood pressure (BP) of 201/100 milliliters of mercury (mm/Hg) which was not reported by PCT #4 to the nurse. On 7/16/24 at 1:12 PM, Patient #1 had a blood pressure of 226/101 mm/Hg which was not reported by PCT #4 to the nurse. On 07/16/24 at 3:05 PM, Patient #1 had a blood pressure of 223/98 which was not reported by PCT #4 to the nurse. In an interview on 07/24/24 at 2:00 PM, the Administrator reviewed the records and confirmed the findings. Facility policy entitled, “Patient Assessment and Monitoring” reads, “Report to the nurse systolic blood pressures greater than 180 mm/Hg, Diastolic blood pressure greater than 100 mm/Hg.””

“QAPI-QAPI-IMMEDIATELY CORRECT ANY IJ ISSUES CFR(s): 494.110(c) The facility must immediately correct any identified problems that threaten the health and safety of patients. This Standard is not met as evidenced by: 28883 Based on record review and interviews, the dialysis facility administrative staff did not review an adverse event timely to ensure interventions to prevent reoccurrence could be implemented if needed. The findings include: Review on 7/24/24 at 11:07 AM of a treatment sheet for Patient #7 revealed a needle had dislodged during treatment with blood loss greater than 100 milliliters. The nursing staff had documented timely monitoring of the patient at least every 30 minutes. Review on 7/24/24 at 12:26 PM of an adverse event report for Patient #7 revealed a blood loss event due to needle dislodgement on 7/2/24, where the Patient Care Technician noticed blood under the chair. The access was visible but blood was running down through the side of the chair to the floor. Information included in the report revealed that it had been created by Registered Nurse (RN) #3 on 7/2/24 at 8:15 AM and had last been updated by the nurse on 7/2/24 at 8:18 AM. The event status was listed as incomplete and did not include any action taken by administrative staff to investigate what might have happened so that possible interventions (if needed) were put into place to prevent reoccurrence. During an interview on 7/25/24 at 9:30 AM, RN #3 stated s/he had come back from break and there was a big puddle of blood on the floor greater than 100 milliliters. S/he stated the best s/he could tell the dialysis needle was partially out with blood running down the chair. There was also prolonged bleeding which s/he thought happened because the needle dislodgement made the hole bigger than normal. RN #3 stated it could have been bad. “They tell us in orientation that patients can lose all their blood (exsanguination). Review of QAPI (Quality Assessment/Performance Improvement) data on 7/25/24 at 10:15 AM revealed nothing had been documented about the adverse event. During an interview on 7/25/24 at 10:40 AM, the Facility Administrator stated that s/he had spoken with the Clinic Manager (CM) and none of the staff had informed the CM of the adverse event on 7/2/24 and they should have. The CM stated s/he pulls the adverse event reports before the QAPI meetings to review them. The QAPI meeting had not yet been completed to review the July data.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 22313 Based on observation, record reviews, interviews and review of facility policy, the dialysis facility staff members observed, Registered Nurse (RN #1) and Patient Care Technician (PCT) #1, failed to verify the identity and initiate the correct dialysis treatment for 1 of 3 patients observed for prescription treatments and staff failed to ensure that high blood potassium levels were properly addressed and documented for 1 of 2 patient charts reviewed (Patient #3). Findings include: Observation on 07/22/24 at 3:12 PM of the treatment room floor revealed RN #1 began a patient treatment on the patient at hemodialysis machine #21. After the treatment began running, RN #1 was asked to verify the orders with the treatment being provided. Noticing the error of the dialysate being used, RN #1 abruptly pulled the tubing from the jug labeled 3251 (3 K (potassium) 2.5 Ca (calcium)) to the jug labeled 2251 (2 K 2.5 Ca). RN #1 then left the patient without checking the pH or conductivity on the new 2251 dialysate. RN#1 was asked if s/he had checked the pH and conductivity levels on the 2251 dialysate and said that s/he had asked the Patient Care Technicians (PCT) to do the pH and conductivity checks. In an interview with PCT #1 on 07/22/24 at 3:30 PM and PCT #2 at 3:35 PM it was confirmed that neither PCT #1 nor PCT #2 had heard the order to check the pH and conductivity. On 07/22/24 At 3:52 PM, RN#1 admitted that there had been several errors. S/he had the wrong patient in the wrong hemodialysis station, s/he had not looked at the identity picture of the patient(s) on the hemodialysis screen, which was African American, but the patient in the station was Caucasian due to a mix up in chair assignments. RN#1 also was unfamiliar with the operation of the hemodialysis machine, stating “the machine does the pH and conductivity for you”. In an interview with biomedical staff on 07/23/24 at 10:00 AM and review of the directions for use for the hemodialysis machine, it was confirmed that when dialysate is changed, an independent pH and conductivity reading must be confirmed by pH strips and a conductivity meter. Review on 7/25/24 at 1:55 PM of the facility policy, “Pre-Treatment Safety Checks Procedure” revealed that after the patient is seated, “...The clinician initiating treatment must verify the prescribed set up matches the patient: Patient’s identity per policy...”. Review of the patient record on 07/24/24 at 10:45 AM for Patient #3 revealed Patient #3 on 5/13/2024, with a blood potassium (K) level of 7.9 milligrams per deciliter (mg/dl) with normal level of 3.5 mg/dl - 5.2 mg/dl). On 05/17/2024, blood potassium level was drawn and results returned a potassium level of 7.1 mg/dl. Review of nursing documentation on 5/20/24 revealed no interventions, and/or documentation of notification to the provider. Review of provider chairside notes on 5/22/24 revealed no notification of the elevated potassium and/or orders related to the elevated level. On 05/23/24, the Nurse Practitioner’s notes read “Medications and labs reviewed” with no documentation and/or acknowledgement of the elevated potassium from 05/13/24 and 05/17/24 with education on compliance with orders documented. Patient #3 was admitted to the hospital on 06/02/24 with an elevated blood potassium level of 10.0 mg/dl with emergency hemodialysis due to abnormal heart rhythms per the hospital report. Record review further revealed the Registered Dietician (RD) educated the patient on 05/22/2024 to “avoid high potassium foods” and provided the patient a list of foods to avoid. In an interview with RN #1 on 7/25/2024 at 2:45 PM, s/he said that “the physician was called when the potassium level came back at alert value. I told him/her that s/he said that s/he was eating a lot of bananas. The doctor told me to tell the patient to stop eating bananas. This conversation was not documented in the patient record. 28883”