Fresenius Medical Care Church Street

“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 observations, interviews, and review of the policy “Hand Hygiene”, Patient Care Technicians (PCT’s) #1 and #3, and Registered Nurse (RN) #4 (two of four PCT’s and one of four RN’s observed) failed to prevent cross contamination by not performing hand hygiene after glove removal and at opportune times after touching “dirty” items. The findings included: Observation on 5/28/24 at 12:30 PM of the treatment room floor revealed Patient Care Technician (PCT) #1 at station 13 cleaning up a blood spill on the floor with gloved hands and a bleach cloth. PCT#1 then went to the clean counter and opened a package of “clean” cloths and removed some of them. PCT #1 took the rest of the package of cloths and placed them on the “dirty” counter, and placed the cloths taken from the package into the bleach solution container on the “dirty” counter. PCT #1 removed some of the cloths from the bleach solution. PCT #1 did not remove gloves s/he had worn to clean up the blood spill and did not perform hand hygiene before retrieving a package of clean cloths from the clean counter and placing the cloths into the bleach solution. During an interview on 5/28/24 at 12:47 PM, PCT #1 verified the observation. Observation on 5/29/24 at 12:15 PM revealed Registered Nurse (RN) #4 at machine #0593 at station 15. The nurse was discontinuing a dialysis treatment for a patient with a Central Venous Catheter (CVC). The nurse pulled the patient’s mask up over his/her nose, touching the mask with his/her gloved hands and did not change gloves and/or perform hand hygiene before clamping the dialysis lines, disconnecting the lines from the CVC catheter, scrubbing the catheter hubs with alcohol pads, flushing the ports with normal saline, administering heplock solution to the ports, and placing endcaps. During an interview on 5/29/24 at 12:24 PM, RN #4 verified the observation. Observation on 5/29/24 at 1:38 PM revealed Patient Care Technician (PCT) #3 at station 6, machine #0971, setting up the machine for the next patient after a dialysis treatment had finished. PCT #3 had a packaged dialyzer under her/his arm and went to station 7 (where a patient was dialyzing), touched the patient, donned one glove, touched the machine at station 7, got another glove from a clean supply cart, removed one glove and/or perform hand hygiene, then got another glove from the clean supply cart. PCT #3 donned 2 gloves without performing hand hygiene first, then went back to station 6 where s/he opened the dialyzer and continued setup of the machine. PCT #3 did not perform hand hygiene after touching the patient and machine at station 7 and before donning gloves to setup the machine at station 6. During an interview on 5/29/24 at 1:44 PM, PCT #3 verified the observation. Facility policy, entitled “Hand Hygiene” revealed, “Staff should wash hands or use alcohol based hand rub before and after direct contact with patients, before performing any invasive procedure such as vascular access cannulation, immediately after removing gloves, after contact with body fluids or excretions, and after contact with inanimate objects near the patient...”.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 28883 Based on observations and interview, the dialysis clinic’s nursing staff failed to ensure clean supplies were stored in clean areas and dirty supplies were stored in dirty areas. The findings include: Observation on 5/28/24 at 11:42 AM revealed a container of “clean” bleach solution with cloths in it used for cleaning/disinfecting equipment, being stored on the “dirty” counter area next to the “dirty” sink. Observation on 5/28/24 at 11:59 AM revealed Patient Care Technician (PCT) #2 getting a bleach cloth from a bleach solution container located on the “dirty” counter next to the “dirty” sink and PCT #2 used the bleach cloth to clean the machine and chair at station 3 which the clean bleach solution with clean cloths should be on the “clean” side of the counter. Observation on 5/29/24 at 12:25 PM revealed a container full of bleach solution (with “dirty” blue and white clamps soaking in the bleach solution for disinfection) on the clean counter next to the clean sink and clean bleach cloths which the container should be on the “dirty” side since it contained items being disinfected. During an interview on 5/29/24 at 1:48 PM, PCT’s #2 and #4 verified the observations from 5/28/24 and 5/29/24. They stated they would move the “clean” bleach solution to the clean counter and the bleach solution containing “dirty” items being disinfected to the “dirty” counter.”

“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: 28883 Based on observations, interviews, and review of the facility policy “Cleaning and Disinfecting the Dialysis Station”, the dialysis clinic failed to ensure 2 of 4 Patient Care Technicians (PCT’s) prevented potentially contaminated equipment from being in contact with hemodialysis machines that had been disinfected. (PCT’s #3 and #5). The findings include: Observation on 5/29/24 at 12:32 PM of the treatment room floor revealed Patient Care Technician (PCT) #5 at station 13, cleaning the hemodialysis machine after a dialysis treatment. A blue hemodialysis clamp was still hanging on the IV pole and the technician took a bleach cloth and reached up and wiped the hemodialysis clamp. PCT #5 picked up a blue hemodialysis clamp from the top of the machine and briefly wiped it with the bleach cloth before hanging it on the IV pole with the other hemodialysis clamp. PCT #5 did not contact all surfaces of the blue clamps with the bleach cloth to ensure appropriate disinfection of the hemodialysis clamps. PCT #5 left the clamps on the IV pole and did not clean/disinfect the prime rinse bucket before setting the machine up for the next patient. During an interview on 5/29/24 at 12:45 PM, PCT #5 verified the findings and stated s/he doesn’t soak the blue clamp in the bleach solution until the end of the day. Observation on 5/29/24 at 1:34 PM revealed Patient Care Technician (PCT) #3 at station #6, machine #0971, cleaning the machine after use but PCT #3 did not clean/disinfect the prime rinse bucket before setting up the machine for the next patient. During an interview on 5/29/24 at 1:44 PM, PCT #3 verified the finding. Facility policy, entitled “Cleaning and Disinfecting the Dialysis Station”, revealed “...The Centers for Medicare and Medicaid Services (CMS) had regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses....The dialysis station could become contaminated with blood and other body fluids during treatment. After use, any non-disposable equipment and supplies brought into the dialysis station must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station...Externally disinfect the dialysis machine with 1:100 bleach solutions after each dialysis treatment...”.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 28883 Based on record review, interview, and review of facility policy “Special Considerations: Heplisav-B Vaccination for Patients”, the dialysis clinic nursing staff failed to ensure one of two patients reviewed with orders for the Heplisav-B vaccine received all ordered doses. (Patient #2) The findings include: The dialysis clinic admitted Patient #2 on 6/13/23 with a diagnoses including End Stage Renal Disease. Review of physician orders on 5/29/24 at 9:58 AM revealed orders for the Heplisav-B vaccine, 20 micrograms (mcg), to be administered on 6/22/23, 7/20/23, and 10/19/23. Further review of nurses notes, medication administration documentation, and treatment sheets revealed Patient #2 had not come for dialysis those days so s/he had not received the dose; and the vaccine dose had not been rescheduled causing the patient to miss all but one of four doses. Review of the facility policy “Special Considerations: Heplisav-B Vaccination for Patients” revealed, “Dialysis dependent patients receive Heplisav-B 20 mcg at a schedule of 0, 1, 2, and 4 months”. During an interview on 5/30/24 at 11:20 AM, the Clinic Manager verified the findings.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 28883 Based on observations, interviews, and review of the APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Healthcare (2016), the dialysis clinic failed to ensure 1 of 4 Registered Nurses (RN’s) observed providing CVC (Central Venous Catheter) care performed aseptic technique during the administration of normal saline to a patient’s catheter ports, prevented the syringe tip from touching the chux to keep it sterile and stored normal saline syringes out of the packaging (RN #2) and 1 of 2 RN’s observed preparing intravenous medication for administration, failed to clean the septum of the medication vial with alcohol prior to drawing it up in a needle/syringe. (RN #3). The findings include: Observation on 5/28/24 at 10:32 AM of a medication storage drawer revealed (10) milliliter syringes containing normal saline for intravenous administration that were out of the packaging. There was no label/indication as to how long they had been stored that way. During an interview on 5/28/24 at 10:33 AM, Registered Nurse #1 verified the finding. Review of the APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Healthcare (2016) revealed information to “Remove needle, cannula, syringe and/or accessory items from sterile packaging immediately before use....”. Observation on 5/28/24 at 12:52 PM revealed Registered Nurse (RN) #2 discontinuing a dialysis treatment for a patient with a Central Venous Catheter (CVC) at machine #0593, station #15. The nurse removed the packaging from (2) 10 milliliter syringes filled with normal saline, removed the caps from the tips and placed the syringes with the sterile tips touching the clean chux pad which caused the sterility of the tips of the saline syringes to be compromised. The nurse used the normal saline syringes to flush both the CVC ports. During an interview on 5/28/24 at 1:00 PM, RN #2 verified the observation. Review of the APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Healthcare (2016) revealed information to “Avoid having nonsterile contact with sterile areas of devices, containers and drugs...”. Observation on 5/29/24 at 8:46 AM revealed Registered Nurse (RN) #3 popping the cap off a vial of Epogen. RN #3 did not clean/disinfect the septum of the vial before inserting the needle into the vial to draw up the medication. During an interview on 5/29/24 at 8:47 AM, RN #3 stated s/he did not need to disinfect the septum because it was a new vial. Review of the APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Healthcare (2016) revealed information to “Disinfect the rubber stopper of medication vials and the neck of glass ampuls with sterile 70% alcohol before inserting a needle or breaking the ampule...”.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 28883 Based on observations, interviews, and review of facility policy “Patient & Care Partner Central Venous Catheter (CVC) Skills Self-Care Checklist”, the dialysis facility failed to ensure 2 of 4 Registered Nurses (RN) observed performing catheter care ensured the patients’ nose and/or mouth were covered by a mask to prevent possible contamination of the Central Venous Catheter (CVC) exit site or catheter ports. (RN #2 and #3) The findings include: Observation on 5/28/24 at 11:08 AM of the treatment room floor revealed Registered Nurse (RN) #2 station #4, performing a Central Venous Catheter (CVC) dressing change for a patient and accessing the patient’s catheter for dialysis. Observation further revealed the patient’s face mask was not covering his/her nose during the dressing change or upon accessing the catheter for the dialysis treatment. This exposed the patient’s CVC exit site and catheter ports to possible contamination by nasal secretions. Observation on 5/29/24 at 1:06 PM of the treatment room floor revealed Registered Nurse (RN) #3 initiating a dialysis treatment for a Patient with a CVC at station # 3. While removing the two syringes from the catheter ports and attaching the dialysis lines, the patient did not have his/her mask covering the nose or mouth as the mask was pulled down below his/her chin allowing possible droplet exposure/contamination to the catheter ports. During an interview on 5/29/24 at 1:13 PM, RN #3 verified the findings. Facility policy, entitled “Patient & Care Partner Central Venous Catheter (CVC) Skills Self-Care Checklist” revealed that “Prior to the catheter dressing change or when accessing the catheter for treatment initiation; the patient should apply a mask”.”

“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: 28883 Based on observation, interview, and review of the facility policy “Storage of Supplies”, the dialysis clinic failed to ensure expired solutions used in the water treatment room had been removed from staff access. The findings include: Observation on 5/28/24 at 10:05 AM in the water treatment room revealed (2) 32 ounce bottles of Myron Standard Solution that expired on 5/16/24 and (2) 16 ounce bottles of Mesa labs 10.0 pH Standard Solution expired on 5/9/24. During an interview on 5/28/24 at 10:10 AM, the Biomedical Technician verified the finding. Facility policy, entitled “Storage of Supplies” revealed, “Information to 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 reviews, interview, and review of facility policy, the dialysis facility failed to ensure patient blood pressures and/or intradialytic weight gains were addressed by the Interdisciplinary Team for 1 of 2 patient records reviewed for fluid management. (Patient #6). The findings include: Facility policy, entitled, “Patient Assessment and Monitoring,” revealed, “Document findings and interventions in the medical record. Report to the nurse: systolic blood pressures greater than 180 millimeters mercury (mmHg), diastolic blood pressures greater than 100 mmHg or systolic blood pressures less than or equal to 100 mmHg. Contact the physician as needed for additional orders based on assessment findings and clinical judgement”. Record review on 5/28/24 12:00 PM for Patient #6 revealed a diagnosis of Lupus and End Stage Renal Disease. The Estimated Dry Weight (EDW) for the patient was 67.5 kilograms. Review of a treatment sheet dated 5/09/24 showed the patient’s pre-treatment weight was 70.0 kilograms. At 7:43 AM the blood pressure was 225/140 mmHg, at 8:57 AM the blood pressure was 213/136 mm hg (millimeter of mercury), at 10:28 AM the blood pressure was 192/123 mmHg, and at 11:38 AM the blood pressure was 193/121 mmHg. Record review on 5/28/24 of the treatment sheet for Patient #6 dated 5/11/24 showed the EDW was 67.5 kilograms, the patient’s pre-treatment weight was 70.4 kilograms. The patient’s blood pressure at 7:26 AM is 194/mmHg, at 7:56 AM the blood pressure is 196/130 mmHg, at 8:30 AM the blood pressure is 187/118 mmHg. Record review on 5/28/24 of the treatment sheet for Patient #6 dated 5/14/24 at 7:11 AM showed the patient’s EDW was 67.5 kilograms, the patient’s pre-treatment weight was 73.2 kilograms. At 7:11 AM the patient’s initial blood pressure was 201/123 mmHg, at 7:25 AM was 179/106 mmHg, at 7:50 AM the patient’s blood pressure was 190/113 mmHg, at 8:19 AM the blood pressure was 188/109 mmHg, at 10:18 AM the patient’s blood pressure was 188/112 mmHg, at 10:40 AM the blood pressure was 216/120 mmHg, at 10:51 AM the blood pressure was 211/115 mmHg, at 11:19 AM the blood pressure was 180/129 mmHg, and at 11:31 AM the blood pressure was 214/132 mmHg. Record review on 5/28/24 of the treatment sheet for Patient #6 dated 5/16/24 showed the patient’s EDW was 67.5 kilograms. The patient’s weight was 72.0 kilograms. The blood pressure at 7:35 AM was 219/138 mmHg, at 7:56 AM the patient’s blood pressure was 213/117 mmHg, at 8:26 AM the patient’s blood pressure was 189/115 mmHg. Record review on 5/28/24 for Patient #6 treatment sheets dated 5/18/24 at 7:27 AM the patient’s EDW was 67.5 kilograms, the patient’s pre-treatment weight was 72.3 kilograms. At 7:18 AM the patient’s blood pressure was 239/155 mmHg and verified, at 7:57 AM the patient’s blood pressure was 238/146 mmHg, at 8:27 AM the patient’s blood pressure was 222/146 mmHg, at 8:46 AM the blood pressure was 222/132 mmHg, at 9:17 AM the blood pressure was 202/119 mmHg, at 9:45 AM the blood pressure was 231/148 mmHg, at 10:07 AM the blood pressure was 218/143 mmHg verified, at 10:32 AM the blood pressure was 206/140 mmHg verified, at 11:02 AM the blood pressure was 222/131 mmHg and at 11:34 AM the blood pressure was 203/124 mmHg. There was no documentation in the nurses notes, physician notes, dietitian notes or the Interdisciplinary Team notes to address the high blood pressures or intradialytic weight gains. During an interview on 5/28/24 at 1:35 PM, the Clinical Manager was unable to find any documentation.”

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 28883 Based on record reviews, interview, and review of facility policy “Oral Nutritional Supplements Program (ONSP)” the Registered Dietitian failed to ensure 2 of 5 patients reviewed for nutritional status had interventions put in place for low Albumin levels or additional interventions put in place due to lack of improvement. ( Patients #2 and #4) The findings include: Review of the medical record on 5/29/24 at 10:02 AM revealed the dialysis clinic admitted Patient #2 on 6/13/23. Review of Patient #2’s chart revealed the patient’s Albumin level was low; 3.1 g/dl (grams per deciliter) on 3/7/24, 3.5 g/dl on 4/11/24, and 3.6 g/dl on 5/2/24. Further review revealed an Albumin level of 3.2 g/dl on 2/15/24, and 3.1 g/dl on 1/2/24. Review of nutrition notes from 12/12/2023 through 4/30/24 by the Registered Dietitian revealed no intervention for the low Albumin and no physician orders for a protein supplement. Review on 5/29/24 at 11:06 AM of the Plan of Care dated 11/3/23 revealed the goal was to have an Albumin level greater than or equal to 4.0 g/dl with a notation to initiate or continue oral nutritional supplement per policy. During an interview on 5/30/24 at 8:30 AM, Registered Dietitian #1 reviewed the record and verified the findings above and stated “The Oral Nutrition Supplements Program should be initiated in-center for patients with an Albumin less than 3.5 mg/dl”. Facility policy, entitled “Oral Nutritional Supplements Program (ONSP)” revealed that the purpose of the policy is to improve nutritional status, ensure compliance with oral intake, and reduce the risk of morbidity and mortality. It included information that “Oral nutritional supplements are given in addition to the patient’s usual nutrition sources; they are not a replacement for usual sources of nutrition. Criteria for starting nutritional supplements included having an Albumin of 3.5 g/dl or less. Patients greater than 1 year of age may be considered for ONSP. A documented physician’s order would include the specific type of supplement with the patient able to receive 1 serving up to three times a week until the patient attains either a stabilized albumin which would be a level of 4 g/dl or higher for 3 consecutive monthly albumin lab draws, or the patient consumed less than 50% of the supplement for more than 2 consecutive weeks, upon physician order to stop, or it is one year from date of order. If more than one year review the patient status and renew order as necessary if a stabilized albumin has not been achieved”. The dialysis clinic admitted Patient #4 on 1/3/24. Review of the comprehensive assessment dated 2/5/24 documented by the Registered Dietitian (RD) revealed an Albumin level less than 3.0 g/dl, indicating severe protein depletion. The RD documented s/he would send a note to the nursing home to start Ensure or Boost once daily. There were physician orders dated 2/5/24 for the patient to receive a Jimmy protein bar 3 times a week at dialysis. Review of labs revealed Albumin levels had not improved and were in decline currently with the following results: 3/6/24-Albumin 2.8 g/dl, 3/13/24- Albumin 2.8 g/dl, 3/15/24- Albumin 3.0 g/dl, 3/18/24- Albumin 2.7 g/dl, 4/3/24- Albumin 2.6 g/dl, 5/1/24- Albumin 2.7 g/dl. Review of nutrition notes documented by the RD dated 3/29/24 and 4/29/24 revealed no documentation of interventions though the Albumin level had not improved. There was no documentation about whether the patient was receiving supplements at the nursing home. During an interview on 5/30/24 at 8:40 AM, the RD reviewed the record and verified the above findings. The RD was asked if the nursing home had started any protein supplements and s/he did not know.”

“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: 28883 Record review on 5/30/24 at 9:27 AM of Patient #1 revealed Patient #1 was admitted on 10/5/21. Review of Patient #1’s physician orders revealed a dialysate flow rate at autoflow 1.5, which is 1.5 times the patient’s blood flow rate. Review of treatment sheets dated 5/23/24, 5/21/24, 5/16/24, 5/14/24, 5/7/24, 5/11/24, revealed a dialysate flow rate of 800; when the blood flow rate for the treatments was 450. During an interview on 5/30/24 at 11:20 AM, the Clinic Manager verified the finding. 22313 Based on record reviews, interviews, and review of facility policy, the dialysis facility staff failed to ensure that high or low blood pressures had been reported to the nurse for possible assessment/intervention for 2 of 7 patients reviewed (Patients #5 and #6) and nursing staff failed to ensure Patient #1’s Dialysate Flow Rate (DFR) was as ordered during 6 of 10 hemodialysis treatments reviewed. Findings include: Facility policy, entitled, “Patient Assessment and Monitoring,” reads, “Report to the nurse systolic blood pressures greater than 180 mmHg (millimeters of mercury), diastolic blood pressures greater than 100 mmHg or systolic blood pressures less than or equal to 100 mmHg”. Record review for Patient #5 on 5/29/24 at 10:00 AM revealed a diagnosis of Chronic Kidney Disease. Review of treatment sheets revealed the patient’s blood pressure on 5/16/24 at 6:34 AM at 184/68 millimeters of mercury (mmHg). On 5/18/24 at 7:21 AM, the blood pressure is 163/115 mmHg, at 7:51 AM blood pressure is 187/63 mmHg, and at 8:46 AM the blood pressure is 90/51 mmHg. On 5/28/24 at 6:41 AM, the blood pressure is 95/25 mmHg, at 9:49 AM, the patient’s sitting blood pressure is 91/36 mmHg. Record review for Patient #6 on 5/28/24 at 12:01 PM revealed a diagnosis of Lupus, Renal Failure, and a recent history of infection/clotted access. Review of treatment sheets revealed the patient’s blood pressure on 5/09/24 at 7:43 AM was 219/143 mmHg and at 8:57 AM the patient’s blood pressure was 213/136 mmHg, at 10:28 AM the blood pressure of 192/123 mmHg. Record review for Patient #6 on 05/28/24 of treatment sheets revealed the patient’s blood pressure on 05/11/24 at 7:17 AM is 190/127 mmHg, at 7:56 AM the blood pressure is 196/130 mmHg, at 8:30 AM the blood pressure is 187/118 mmHg. Record review for Patient #6 on 05/28/24 of treatment sheets revealed the patient’s blood pressure on 05/14/24 at 7:11 AM is 201/123 mmHg, at 7:25 AM the blood pressure is 179/106 mmHg, at 7:50 AM the blood pressure is 190/113 mmHg, at 8:19 AM the blood pressure is 188/109 mmHg, at 10:18 AM the blood pressure is 188/112 mmHg, at 10:40 AM the blood pressure is 216/120 mmHg, at 10:51 AM the blood pressure is 211/115 mmHg, at 11:19 AM the blood pressure is 180/129 mmHg, and at 11:31 AM the blood pressure is 214/132 mmHg. Record review for Patient #6 on 05/28/24 of treatment sheets revealed the patient’s blood pressure on 05/16/24 at 7:24 AM is 218/144 mmHg, at 7:56 AM the blood pressure is 213/117 mmHg, at 8:26 AM the blood pressure is 189/115 mmHg. Record review for Patient #6 on 05/28/24 of treatment sheets revealed the patient’s blood pressure on 5/18/24 at 7:18 AM is 239/155 mmHg verified, at 7:27 AM the blood pressure is 238/146 mmHg, at 7:57 AM the blood pressure is 236/145 mmHg, at 8:27 AM the blood pressure is 222/146 mmHg, at 8:46 AM the blood pressure is 222/132 mmHg, at 9:17 AM the blood pressure is 202/119 mmHg, at 9:45 AM the blood pressure is 231/148 mmHg, at 10:07 AM the blood pressure is 218/143 mmHg, at 10:32 AM the blood pressure is 206/140 mmHg and verified, at 11:02 AM the blood pressure is 222/131 mmHg and at 11:34 AM the blood pressure is 203/124 mmHg. Record review for Patient #6 on 05/28/24 of treatment sheets revealed the patient’s blood pressure on 05/21/24 at 7:09 AM is 168/106 mmHg, at 7:51 AM the blood pressure is 185/117 mmHg, at 8:21 AM the blood pressure is 187/109 mmHg, at 8:48 AM the blood pressure is 185/100 mmHg, at 9:51 AM the blood pressure is 168/109 mmHg, at 10:20 AM the blood pressure is 154/102 mmHg, at 10:52 AM the blood pressure is 154/107 mmHg, at 11:20 AM the blood pressure is 166/103 mmHg, at 11:25 AM the blood pressure is 179/102 mmHg. Record review for Patient #6 on 05/28/24 of treatment sheets revealed the patient’s blood pressure on 5/23/24 at 7:22 AM is 130/109 mmHg, at 7:30 AM the blood pressure is 210/141 mmHg, at 7:58 AM the blood pressure is 163/126 mmHg, at 8:28 AM the blood pressure is 235/146 mmHg, at 8:51 AM the blood pressure is 240/131 mmHg, at 9:16 AM the blood pressure is 204/13 mmHg, at 9:30 AM the blood pressure 227/132 mmHg, at 10:22 AM the blood pressure is 213/163 mmHg, and at 11:24 AM, the blood pressure is 194/133 mmHg. Record review for Patient #6 on 05/28/24 of treatment sheets revealed the patient’s blood pressure on 5/25/24 7:22 AM is 184/116 mmHg, at 7:52 AM the blood pressure is 186/123 mmHg, at 8:23 AM the blood pressure is 178/115 mmHg, at 8:53 AM the blood pressure is not recorded, at 9:25 AM the blood pressure is not recorded, at 9:51 AM the blood pressure is 177/138 mmHg, at 10:21 AM the blood pressure is 165/105 mmHg, and at 11:00 AM the blood pressure is 140/100 mmHg. Record review for Patient #6 on 5/28/24 of treatment sheets revealed the patient’s blood pressure on 5/28/24 at 8:28 AM is 208/129 mmHg, at 8:53 AM the blood pressure is 190/123 mmHg, at 9:17 AM the blood pressure is 219/102 mmHg, at 9:47 AM the blood pressure is 174/117 mmHg, at 10:17 AM the blood pressure is 171/108 mmHg. Record reviews revealed that the the Patient Care Technician (PCT) did not verify the readings or notify the nurse of high readings per policy. During an interview on 5/20/24 at 1:45 PM, the Clinic Manager verified the findings and stated “That’s right..that is what is recorded”.”