Dci Brownsville

“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: 19001 Based on policy review, observation and interview, the facility failed to ensure hand hygiene was performed during the termination of dialysis treatments for a patient with a CVC access for 1 of 2 (RN #1) observations. The findings included: 1. Review of the facility policy “Hand Antisepsis” issued August 2014, revealed, “...Hand antisepsis will be followed per CDC guidelines...Use of an alcohol-based hand rub may be done in the following instances: After handling of equipment, supplies or environmental surfaces at the patient station, Before patient contact...” 2. Observations on 1/6/2025 at 3:05 PM, at Station #2, revealed RN #1 terminated treatment for RP #1. RN #1, with clean gloved hands, reinfused the extracorporeal circuit and touched the dialysis machine. RN #1 then cleaned the CVC connections with alcohol. RN #1 did not perform hand hygiene after touching the dialysis machine. 3. During an interview on 1/7/2025 at 8:01 AM, the NM verified staff should remove gloves, perform hand hygiene, and don clean gloves after touching a dialysis machine and before providing care to RP #1’s CVC access.”

“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: 19001 Based on observation and interview the facility failed to ensure staff disposed of fluids from prime waste container into a dirty sink for 1 of 2 (RN #1) observations during cleaning of the dialysis machine. The findings included: 1. Observations on 1/6/2025 beginning at 9:23 AM revealed RN #1 cleaned the dialysis machine at Station #2. RN #1 removed the prime waste container and disposed of the prime fluids in the designated clean sink. 2. During an interview on 1/6/2025 at 11:35 AM, the Nurse Educator stated there was no specific policy to address where staff should dispose of the prime waste. The Nurse Educator verified the prime fluids should be taken to a dirty sink instead of a clean sink when cleaning and disinfecting the dialysis machine. 3. During an interview on 1/7/2025 at 11:34 AM, the NM verified the expectation was for staff to dispose of the prime container fluids into the dirty sink.”

“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: 19001 Based on observation and interview, the facility failed to dispose of expired medication for 1 of 2 (medication refrigerator) medication storage areas. The findings included: 1. Observations of the medication refrigerator on 1/7/2025 at 1:16 PM revealed the following items were expired: Retacrit (erythropoiesis-stimulating agent (ESA), which is a prescription medicine used to treat anemia) 20,000 units/2 mL 9 vials expired on 12/31/2024. 2. During an interview on 1/7/2025 at 1:17 PM, the NM verified the medication should have been disposed. The surveyor requested the facility policy for disposing of expired medications. During an interview on 1/7/2025 at 1:37 PM, the NM stated she was unable to locate a policy for expired medication disposal. The NM further stated nurses were required to check it at the end of every month for expired medications. The NM stated nursing staff were also required to check a medication for the expiration date before administration.”

“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: 19001 Based on facility policy review, observation, and interview the facility failed to ensure CVC exit site care was performed according to policy for 2 of 2 (RN #1 and LPN #1) staff observed performing CVC care. The findings included: 1. Review of the facility policy “Central Venous Catheter Exit Site Care” issued June 2009, revealed, “... Place pre-printed label over dressing. This label should state the concentration and amount of Heparin instilled in each catheter lumen along with the date and initials of nurse changing the bandage ...” 2. Observations on 01/06/2025 of 2 of 2 patients receiving CVC Exit Site Care revealed the following: a. RP #1 received CVC Exit Site Care by RN #1 at 10:35 AM at Station #2. RN #1 did not place a label over the dressing at the end of site care. b. Patient #5 received CVC Exit Site Care by LPN #1 at 11:20 AM at Station #11. LPN #1 did not place a label over the dressing at the end of site care. 3. During an interview on 01/07/2025 at 9:15 AM with the NM, she stated there was an expectation that staff place a label on the CVC dressing every time the dressing was changed. The NM confirmed there are pre-printed labels available for staff use, and that occasionally a patient would refuse the label; however, that should be documented in the chart if that was the case.”

“CARBON ADSORPTION-TWO TANKS/SAMPLE PORTS CFR(s): 494.40(a) 5.2.5 Carbon adsorption: two tanks/sample ports Refer to RD62:2001, 4.3.9 Carbon adsorption media: Carbon adsorption systems shall be adapted specifically to the maximum anticipated water flow rate of the system. Two carbon adsorption beds shall be installed in a series configuration. 5.2.5 Carbon adsorption Two carbon beds shall be installed in series with a sample port following the first bed. A sample port shall also be installed following the second bed for use in the event of free chlorine or chloramine breaking through the first bed. This Standard is not met as evidenced by: 19001 Based on policy review, observation and interview, the facility failed to ensure 2 of 3 (RN #1 and CCHT#1) staff observed were competent in total chlorine testing for RO water to ensure patient safety. The findings included: 1. Review of the facility policy “R.O.Water Testing” issued 11/15/2023 revealed, “Purpose: To provide AAMI quality of water for hemodialysis...Total chlorine testing will be performed on the water after the first carbon tank at sample port S4...Procedure...Collect a fresh 100 ml sample of RO water in a plastic sample cup at S4. Remove the test strip from its foil package...Using timer for 60 seconds: dip the test strip in the water sample. Moving test strip back and forth at a constant rate...Remove the test strip after 60 seconds. Briskly shake the test strip once to remove excess water. Using the timer wait 20 seconds for the test strip to develop...After the 20 second wait period, immediately compare the test strip color to the color chart to determine total chlorine level of the sample...” 2. Observations on 1/6/2024 at 12:15 PM revealed RN #1 rinsed the sample cup three times with RO water, filled the cup to 90 mL, then swirled the test strip for 20 seconds. RN #1 then removed the test strip, shook the test strip to remove excess water and waited 60 seconds to read/ compare the test strip to the color chart to determine the total chlorine results. RN #1 did not follow the facility protocols for water testing. Observations on 1/6/2025 beginning at 3:15 PM revealed CCHT #1 rinsed the sample cup three times with water just past the water softener tank, filled the sample cup with 90 mL of water from the area used to check water hardness, not the S4 first carbon tank sample port. CCHT #1 then swirled the test strip for 1 minute and 20 seconds. CCHT #1 then removed the test strip, shook the excess water, and compared the strip to the color chart to determine the total chlorine results. CCHT #1 did not follow the facility protocols for water testing. 3. During an interview on 1/6/2025 at 3:50 PM, the Nurse Educator stated all clinical staff were trained upon hire and annually to determine competence for water testing. Personnel file review revealed both RN #1 and CCHT #1 had been trained in 2024 on the facility policy for water testing.”

“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: 19001 Based on policy review, medical record review and interview, the facility failed to ensure 5 of 5 (Patient #1, 2, 3, 4 and 5) sampled patients received the prescribed dialysis prescription for BFR and/or Heparin. The facility also failed to notify the physician of changes to the dialysis prescriptions. The findings included: 1. Review of the facility policy “Heparin” issued January 2019, revealed... “Administer dose per standing orders or by specific patient order per MD...” 2. Medical record review for Patient #1 revealed an admission date of 06/19/2024 with diagnoses which included Hypertensive Chronic Kidney Disease. A physician’s order dated 05/29/2024 revealed dialysis 3 times per week with a BFR of 400. A physician’s order dated 10/23/2024 revealed an hourly dose of IV Heparin 1000 units for 3 hours and 30 minutes during dialysis. Review of the 12/04/2024 Hemodialysis Flowsheet revealed the BFR was 350 from 6:54 AM to 8:05 AM and 300 from 8:05 AM until the treatment ended at 10:25 AM. The nurse documented 2500 units of Heparin was infused during the treatment. There was no documentation that revealed why the BFR was not delivered at the ordered rate of 400, or why 3500 units of Heparin was not infused. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate or the failure to administer Heparin as ordered. Review of the 12/06/2024 Hemodialysis Flowsheet revealed the BFR was 300 from 8:06 AM to 10:05 AM and 200 from 10:35 AM until the treatment ended at 10:37 AM. The nurse documented 2500 units of Heparin was infused during the treatment. There was no documentation that revealed why the BFR was not delivered at the ordered rate of 400, or why 3500 units of Heparin was not infused. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate or the failure to administer Heparin as ordered. Review of the 12/09/2024 Hemodialysis Flowsheet revealed the BFR was 300 from 9:31 AM to 12:42 PM and 200 from 12:42 PM until the treatment ended at 12:43 PM. At 10:37 AM, a note documented the BFR was decreased to 300 due to multiple alarms; however, no further documentation was found to explain the decrease from 300 to 200. RN #1 documented 2500 units of Heparin was infused during the treatment. There was no documentation that revealed why 3500 units of Heparin was not infused and no documentation that the physician was notified of the BFR not being administered at the prescribed rate or the failure to administer Heparin as ordered. Review of the 12/11/2024 Hemodialysis Flowsheet revealed the BFR was 350 from 6:54 AM to 8:05 AM and 300 from 8:05 AM until the treatment ended at 10:25 AM. At 8:06 AM, a note documented by RN #1 revealed the BFR was decreased to 350 due to arterial alarms; however, there was no further documentation that revealed why the BFR was not delivered at the ordered rate or that the physician was notified of the BFR not being administered at the prescribed rate. Review of the 12/13/2024 Hemodialysis Flowsheet revealed no documented Heparin administration of 1000 units per hour. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 12/16/2024 Hemodialysis Flowsheet revealed the BFR was 350 from 7:02 AM to 8:01 AM; 300 from 8:01 AM to 10:31 AM and 200 from 10:31 AM until the treatment ended at 10:51 AM. At 8:14 AM, a note documented the BFR was decreased to 300 due to multiple alarms and that the Charge Nurse was notified. The nurse documented 2500 units of Heparin was infused during the treatment. There was no documentation that revealed why 3500 units of Heparin was not infused, and no further documentation that revealed why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate or the failure to administer Heparin as ordered. Review of the 12/18/2024 Hemodialysis Flowsheet revealed the BFR was 300 from 7:31 AM to 10:01 AM and 200 from 10:01 AM until the treatment ended at 11:05 AM. At 7:43 AM a note documented the BFR was decreased to 300 due to multiple alarms. There was no further documentation that revealed why the BFR was not delivered at the ordered rate of 400 and changed to 200. The nurse documented 2500 units of Heparin was infused during the treatment. There was no documentation that revealed why 3500 units of Heparin was not infused and no documentation that the physician was notified of the BFR not being administered at the prescribed rate or the failure to administer Heparin as ordered. Review of the 12/20/2024 Hemodialysis Flowsheet revealed the BFR was 350 from 6:22 AM to 7:01 AM; 300 from 7:01 AM to 7:31 AM and 200 from 7:31 AM until the treatment ended at 10:00 AM. At 7:31 AM, a note documented the BFR was decreased to 200 and that the CN was notified; however, there was no documentation that revealed why the BFR was not delivered at the ordered rate of 400 and changed to 200 or that the charge nurse was notified of the change from 350 to 300. Review of the 12/27/2024 Hemodialysis Flowsheet revealed the BFR was 300 from 7:00 AM to 9:00 AM; 200 from 9:00 AM to 09:33 AM and 300 from 9:33 AM until the treatment ended at 10:24 AM. At 7:00 AM, a note documented by RN #1 revealed the BFR was lowered to 300 due to elevated arterial pressure; however, there was no documentation that revealed why the BFR was not delivered at the ordered rate of 400 and changed from 300 to 200 and then from 200 to 300 or that the physician was notified of the changes. Review of the 12/30/2024 Hemodialysis Flowsheet revealed the BFR was 200 from 6:09 AM to 6:30 AM; 350 from 6:30 AM to 8:00 AM; 300 from 8:00 AM to 9:30 AM and 200 from 9:30 AM until the treatment ended at 10:00 AM. At 8:14 AM, a note documented the BFR was decreased due to multiple alarms. There was no further documentation that revealed why the BFR continued to not be delivered at the ordered rate of 400. There was no documented Heparin administration of 1000 units per hour. There was no documentation the physician had been notified of the BFR not being administered at the ordered rate, or the failure to administer Heparin as ordered. Review of the 01/01/2025 Hemodialysis Flowsheet revealed the BFR was 300 from 7:00 AM to 9:00 AM and 200 from 9:00 AM until the treatment ended at 9:42 AM. At 7:16 AM, a note documented the BFR was decreased to 300 due to multiple alarms. There was no further documentation that revealed why the BFR continued to not be delivered at the ordered rate of 400. There was no documented Heparin administration of 1000 units per hour. There was no documentation the physician had been notified of the BFR not being administered at the ordered rate, or the failure to administer Heparin as ordered. 3. Medical record for Patient #2 revealed an admission date of 10/9/2024 with diagnoses which included Hypertension and Unspecified Renal Failure. A physician’s order dated 11/18/2024 revealed dialysis 3 times per week with a BFR of 500. A physician’s order dated 10/07/2024 revealed an hourly dose of Heparin 2000 units for 3 hours and 30 minutes during dialysis. Review of the 10/16/2024 Hemodialysis flowsheet revealed there was no documented Heparin administration of 2000 units per hour. There was no documentation stating why 6500 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 10/21/2024 Hemodialysis flowsheet revealed the BFR was 450 from 8:35 AM PM until the treatment ended at 11:16 AM. There was no documented Heparin administration of 2000 units per hour. There was no documentation stating why the BFR was not delivered at the ordered rate of 500, or why the Heparin was not administered as ordered. There was no documentation the physician was notified of the change in the BFR or the failure to administer Heparin as ordered. Review of the 10/23/2024 Hemodialysis flowsheet revealed there was no documented Heparin administration of 2000 units per hour. There was no documentation stating why 6500 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 10/25/2024 Hemodialysis flowsheet revealed there was no documented Heparin administration of 2000 units per hour. There was no documentation stating why 6500 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 10/28/2024 Hemodialysis flowsheet revealed there was no documented Heparin administration of 2000 units per hour. There was no documentation stating why 6500 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 10/30/2024 Hemodialysis flowsheet revealed there was no documented Heparin administration of 2000 units per hour. There was no documentation stating why 6500 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 11/1/2024 Hemodialysis flowsheet revealed there was no documented Heparin administration of 2000 units per hour. There was no documentation stating why 6500 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 11/4/2024 Hemodialysis flowsheet revealed there was no documented Heparin administration of 2000 units per hour. There was no documentation stating why 6500 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 11/6/2024 Hemodialysis flowsheet revealed the BFR was 300 from 8:01 AM PM until 8:31 AM, and was 400 from 8:31 AM until the treatment ended at 11:08 AM. There was no documented Heparin administration of 2000 units per hour. There was no documentation stating why the BFR was not delivered at the ordered rate of 500, or why the Heparin was not administered as ordered. There was no documentation the physician was notified of the change in the BFR or the failure to administer Heparin as ordered. Review of the 11/8/2024 Hemodialysis flowsheet revealed there was no documented Heparin administration of 2000 units per hour. There was no documentation stating why 6500 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 11/11/2024 Hemodialysis flowsheet revealed there was no documented Heparin administration of 2000 units per hour. There was no documentation stating why 6500 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. 4. Medical record review for Patient #3 revealed an admission date of 11/27/2024 with diagnoses which included Acute Kidney Failure. A physician’s order dated 11/22/2024 revealed dialysis 3 times per week with a BFR of 350. Review of the 12/6/2024 Hemodialysis Flowsheet revealed the BFR was 400 from 10:31 AM until 11:05 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the 12/9/2024 Hemodialysis Flowsheet revealed the BFR was 400 from 11:09 AM until 12:02 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the 12/16/2024 Hemodialysis Flowsheet revealed the BFR was 395 from 11:01 AM until 12:01 PM and 400 from 12:02 PM until 1:00 PM. There was no documentation why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the 12/23/2024 Hemodialysis Flowsheet revealed the BFR was 200 from 12:45 PM until 1:30 PM and 300 from 1:31 PM until 2:08 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. Review of the 1/3/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 11:32 AM until 12:01 PM and 200 from 1:02 PM until 1:31 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified. 5. Medical record review for Patient #4 revealed an admission date of 8/23/2024 with diagnoses that included ESRD. A physician’s order dated 8/23/2024 revealed dialysis 3 times per week with a BFR of 350. A physician’s order dated 10/18/2024 revealed an hourly dose of Heparin 1000 units for 4 hours during dialysis. Review of the 12/6/2024 Hemodialysis flowsheet revealed the BFR was 300 from 1:31 PM until the treatment ended at 3:01 PM. There was no documented Heparin administration of 1000 units per hour. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified of the change in the BFR or the failure to administer Heparin as ordered. Review of the 12/9/2024 Hemodialysis flowsheet revealed the BFR was 300 from 2:02 PM until the treatment ended at 3:18 PM. The nurse documented 3000 units of Heparin was infused during the treatment. There was no documentation stating why the BFR was not delivered at the ordered rate of 350, or why 4000 units of Heparin was not infused. There was no documentation the physician was notified of the change in the BFR or the failure to administer Heparin as ordered. Review of the 12/11/2024 Hemodialysis flowsheet revealed the BFR was 400 from 11:12 AM until 12:32 PM, and was 300 from 1:32 PM until the treatment ended at 3:17 PM. The nurse documented 3000 units of Heparin was infused during the treatment. There was no documentation stating why the BFR was not delivered at the ordered rate of 350, or why 4000 units of Heparin was not infused. There was no documentation the physician was notified of the change in the BFR or the failure to administer Heparin as ordered. Review of the 12/13/2024 Hemodialysis flowsheet revealed the BFR was 300 from 12:02 PM until the treatment ended at 3:20 PM. There was no documented hourly Heparin administration of 1000 units per hour. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified of the change in the BFR or the failure to administer Heparin as ordered. Review of the 12/16/2024 Hemodialysis flowsheet revealed there was no documented hourly Heparin administration of 1000 units per hour. There was no documentation stating why 4000 units of Heparin was not infused. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 12/18/2024 Hemodialysis flowsheet revealed the BFR was 250 from 12:02 PM until the treatment ended at 3:25 PM. There was no documented Heparin administration of 1000 units per hour. There was no documentation stating why the BFR was not delivered at the ordered rate of 350, or why 4000 units of Heparin was not infused. There was no documentation the physician was notified of the change in the BFR or the failure to administer Heparin as ordered. Review of the 12/26/2024 Hemodialysis flowsheet revealed the BFR was 400 from 8:49 AM until 12:04 PM. There was no documented Heparin administration of 1000 units per hour. There was no documentation stating why the BFR was not delivered at the ordered rate of 350, or why 4000 units of Heparin was not infused. There was no documentation the physician was notified of the change in the BFR or the failure to administer Heparin as ordered. Review of the 12/27/2024 Hemodialysis flowsheet revealed the BFR was 400 from 11:18 AM until the treatment ended at 3:22 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 350. There was no documentation the physician was notified of the change in the BFR. 6. Medical record review for Patient #5 revealed an admission date of 04/08/2022 with diagnoses that included ESRD. A physician’s order dated 05/29/2024 revealed dialysis 3 times per week with a BFR of 350. A physician’s order dated 05/06/2024 revealed a Heparin IV loading dose of 5000 units. Review of the 12/09/2024 Hemodialysis Flowsheet revealed the BFR was 450 from 9:50 AM to 11:31 AM and 200 from 11:31 AM until the treatment ended at 11:45 AM. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 12/16/2024 Hemodialysis Flowsheet revealed no documented Heparin loading dose administration of 5000 units. There was no documentation the physician was notified of the failure to administer Heparin as ordered. Review of the 12/18/2024 Hemodialysis Flowsheet revealed the BFR was 405 from 10:32 AM to 12:02 PM and 200 from 12:03 PM until the treatment ended at 12:04 PM. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 01/03/2025 Hemodialysis Flowsheet revealed the BFR was 400 from 9:43 AM to 12:44 PM and 195 from 12:44 PM until the treatment ended at 12:45 PM. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. Review of the 01/06/2025 Hemodialysis Flowsheet revealed the BFR was 315 from 11:26 AM to 11:32 AM; 350 from 11:32 AM to 12:04 PM; 200 from 12:04 PM to 1:02 PM; 350 from 1:02 PM to 1:03 PM and 200 from 1:03 PM until the treatment ended at 1:04 PM. There was no documentation the physician was notified of the BFR not being administered at the prescribed rate. 7. During an interview on 1/7/2025 at 9:00 AM, the NM stated the Heparin infusion had to be manually entered by the nurses on the dialysis flowsheets. The NM stated an internal audit had identified the nursing staff were not correctly documenting the hourly infusion of Heparin. The NM stated the hourly infusion was programmed into the machine and delivered correctly, but staff were failing to manually enter the infusion amounts on the dialysis flowsheets. During an interview on 1/7/2025 at 2:09 PM, the NM stated she was unable to locate a policy related to BFR. The NM stated if the BFR was adjusted during dialysis the staff should notify the charge nurse and document why the adjustment was made on the dialysis flowsheets.”