Davita Brownsville Dialysis

“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: 49570 Based on policy review, observation and interview, the facility failed to ensure staff utilized PPE appropriately on the treatment floor during 1 of 1 (3/31/2025) observation days. The findings included: 1.Review of facility policy, “Infection Control For Dialysis Facilities” revised April 2023 revealed, “ ...PPE (i.e., gown, gloves, eye protection, face shield) ...Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas ...” Review of facility policy, “AV Fistula or Graft Cannulation with [Brand Name] or [Brand Name] Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” revised April 2025 revealed, “ ...Put on PPE ...” 2. Observations on the treatment floor on 3/31/2025 at 8:45 AM, revealed RN #1 wearing a face shield that did not cover the mouth and nose area while performing patient care. RN #1 did not have on a face mask to cover those areas. 3. During an interview on 3/31/20205 at 2:15 PM, the FA confirmed staff were expected to wear appropriate PPE while on the treatment floor, and that face shields should cover the staff’s nose and mouth area.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure infection control measures were taken to prevent potential cross contamination between patients on 1 of 1 (3/31/2025) observation days. The findings included: 1. Review of the facility policy, “Infection Control For Dialysis Facilities” revised April 2023 revealed, “ ...Measures will be taken to prevent cross contamination between patients ...Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into station) and prior to returning to clean/designated area or removal from treatment area ...Non-disposable items are to be disinfected after each use, prior to removal from treatment area/station and if contaminated between uses...” 2. Observations at Station #4 on the treatment floor on 3/31/2025 at 9:50 AM, revealed CCHT #1 used an electronic thermometer to check a patient’s temperature, returned it to a common area, and did not clean the thermometer after contamination. 3. Observations at Station #18 on the treatment floor on 3/31/2025 at 10:20 AM, revealed LPN #1 used an electronic thermometer to check a patient’s temperature, returned it to a common area, and did not clean the thermometer after contamination. 4. During an interview on 3/31/2025 at 2:15 PM, the FA stated she would have to read the facility policies to know what the expectations were for cleaning of thermometers since the thermometer did not actually touch the patient’s skin.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 49570 Based on facility policy review, medical record review, and interview, the facility failed to ensure a patient’s POC included a physician’s order with parameters for how to effectively treat interdialytic hypotension and/or interdialytic hypertension and/or bradycardia for 4 of 5 (Patient #2, #3, #4, and #5) sampled patients. The findings included: 1. Review of facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” revised April 2024 revealed, “...To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge...Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately...The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status...Unless other abnormal parameters are established by the facility Governing Body and documented in Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ...the teammate who is observing or collecting information should report to the licensed nurse whenever there is a concern for the patient’s condition or the potential safety of initiating dialysis...Blood Pressure-Intradialytic...systolic greater than 180 mm/Hg or less than 90 mm/Hg...Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg...Heart or Pulse Rate Pre/Intra/Post...Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat...” Review of facility policy, “Hypotension” revised October 2023 revealed, “ ...Decrease ultrafiltration rate (UFR) or turn off UFR depending on patient’s condition. Administer normal saline bolus of 100-200 mL for severe hypotensive symptoms...Administer oxygen per physician’s order...Oxygen may be administered with a patient specific PRN panel or written/verbal order...Continue monitoring blood pressure...If patient continues to show signs and symptoms of hypotension, the licensed nurse will notify physician and follow physician’s orders. Document event, orders, treatment and patient response in the patient’s electronic health record.” Review of facility policy, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” revised October 2024 revealed, “To provide guidance for the development of patient assessment and plan of care for IDT teammates...The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care...Assessment criteria will include, but not be limited to, evaluation of: blood pressure...needs...The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition...” 2. Medical record review for Patient #2 revealed an admission date of 9/17/2010 with diagnoses which included ESRD, Transplant Complications: Kidney transplant failure, and Hypertension/Large Vessel Disease. Review of the Treatment Parameter orders for Patient #2 revealed patient specific Pre-Assessment and Post Assessment blood pressure parameters of SBP above 170 mmHg or below 90 mmHg and DBP above 95 mmHg or below 40 mmHG. Review of the Care Plan dated 10/14/2024 for Patient #2 revealed no interdialytic orders for parameters or interventions regarding hypotension, hypertension, bradycardia, or tachycardia while receiving in-center hemodialysis. It stated, “BP within range.” Review of the Comprehensive Encounter dated 11/13/2024 for Patient #2, Nurse Practitioner #1 documented, “Recent ED visit for symptomatic hypotension during home health visit, no infectious cause identified, now prescribed Midodrine [used to treat low blood pressure] 2.5 mg daily...” Review of the Comprehensive Encounter dated 12/09/2024 for Patient #2, Medical Doctor #1 stated, “Recent ED visit for symptomatic hypotension during home health visit, no infectious cause identified, now prescribed Midodrine 2.5 mg daily...” Review of the 2/24/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 10:43 AM, HR was low per facility policy at 49 bpm “ ...Treatment started without complications; Pt HR below 60; Pt asymptomatic” B. At 11:44 AM, HR was low at 43 bpm “Pt HR below 60; Pt asymptomatic” C. At 12:15 PM, BP was low at 79/29 “recheck” D. At 12:17 PM, BP and HR were low at 82/44 and 39 bpm “Pt BP brady; Pt asymptomatic” E. At 1:13 PM, BP and HR were low at 104/35 and 39 bpm “Pt diastolic bp brady; HR below 60; Pt asymptomatic” F. At 1:43 PM, BP was low at 131/15 “recheck” G. At 1:46 PM, BP and HR were low at 122/22 and 58 bpm “Pt diastolic bp brady; HR below 60; Pt asymptomatic” H. At 2:54 PM, BP and HR were low at 122/58 and 58 bpm “Manual Entry: Treatment terminated; Pt HR below 60; Pt asymptomatic” There was no documentation that the MD was notified, or any interventions were performed. Review of the 2/26/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 6:20 AM, BP was low at 116/33 “ ...Pt given Midodrine 2.5 mg due to low bp” B. At 6:51 AM, BP was low at 75/32 “Pt BP brady; pt asymptomatic” C. At 7:20 AM, BP was low at 76/41 “recheck” D. At 7:22 AM, BP was low at 80/45 “Pt systolic bp brady; HR elevated; Pt asymptomatic; cuff adjusted bp rechecked” E. At 7:53 AM, BP was low at 102/27 “Pt diastolic bp brady; HR elevated; Pt asymptomatic; goal decreased due to low bp” F. At 7:54 AM, BP and HR were low at 149/25 and 40 bpm “UF placed in min due to brady diastolic bp. HR below 60; Pt asymptomatic” G. At 7:56 AM, no vital signs were documented “UF turned off due to brady diastolic bp & HR; pt asymptomatic” H. At 8:21 AM, BP was low at 121/18 “VS noted cuff adjusted BP rechecked” I. At 8:27 AM, BP was low at 150/28 “DBP improved. Pt denied any c/o. will monitor” J. At 9:44 AM, BP was elevated, and HR was low at 155/121 and 53 bpm “Treatment terminated; Pt diastolic bp elevated; HR below 60; Pt asymptomatic” Review of the 2/28/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 7:16 AM, BP was low at 116/33 “ ...Treatment started without complications ...” B. At 7:56 AM, BP was low at 81/47 “Pt BP brady; Pt asymptomatic” C. At 8:16 AM, BP was low at 71/11 “bp rechecked” D. At 8:17 AM, BP was low at 46/26 “cuff repositioned bp rechecked” E. At 8:46 AM, BP was low at 80/19 “recheck” F. At 8:47 AM, BP was low at 61/30 “recheck” G. At 8:58 AM, no vital signs were documented “Pt BP brady; Pt asymptomatic” H. At 9:16 AM, BP was low at 66/47 “Patient awake; alert; and states no complaints at this time; bp rechecked with separate cuff 138/62 I. At 10:17 AM, BP was low at 99/16 “ ...manual bp recheck 75/42 ...” Review of the 3/3/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 6:48 AM, BP was low at 128/35 “Treatment started without complications ...rechecking bp ...” B. At 6:51 AM, no vital signs were documented “rn notified bp” C. At 6:52 AM, BP was low at 112/45 “Manual Entry: Patient monitored eyes closed; patient resting ...bp taken manual” D. At 7:19 AM, BP was low at 85/28 “rechecking bp” E. At 7:20 AM, BP was low at 104/37 “rechecking bp; manual; pt feet elevated rn notified drop in bp” F. At 7:22 AM, BP was low at 98/50 “Manual Entry: Patient appears to be tolerating treatment well at this time; feet elevated” G. At 7:25 AM, no vital signs were documented “Manual Entry: Pt BP decreasing; but within range; pt asymptomatic” H. At 7:49 AM, BP was low at 88/36 “rechecking manual” I. At 8:18 AM, BP was low at 92/37 “rechecking bp manual” J. At 9:18 AM, BP was low at 116/33 “ ...Treatment started without complications ...” K. At 9:49 AM BP was low at 86/36 “rechecked manual” L. At 9:56 AM, “rn aware bp” M. At 10:18 AM, BP was low at 59/29 “rechecking bp manual” N. At 10:35 AM, BP was low at 67/22 “recheck” O. At 10:43 AM, BP was low at 81/29 “Pt BP brady; pt asymptomatic” P. At 10:47 AM, BP was low at 92/22 “recheck” Review of the 03/05/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 6:55 AM, BP was low at 87/56 “ ...bp brady automatic cuff used ...” B. At 9:24 AM, BP was low at 71/46, and HR was high at 150 bpm “BP noted cuff adjusted rechecking BP. Pt states not feeling well UF in min.” C. At 10:24 AM, BP and HR were high at 164/131 and 102 bpm “Pt diastolic bp & HR elevated; pt asymptomatic” Review of the 3/7/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 10:56 AM, BP was high at 156/137 “ ...Treatment started without complications; bp recheck” B. At 11:01 AM, BP was low at 97/33 “Pt diastolic bp brady; pt asymptomatic” C. At 11:29 AM, BP was low at 114/41 “Pt diastolic bp brady; pt asymptomatic” D. At 11:56 AM, BP and HR were low at 58/33, and 49 bpm “recheck” E. At 11:56 AM, BP was low at 76/61 “Manual Entry: Pt systolic bp brady; Pt asymptomatic” F. At 12:26 PM, BP was low at 72/22 “recheck” G. At 12:57 PM, BP was low at 104/36, and HR was elevated at 104 bpm “Pt diastolic bp brady; HR elevated; pt asymptomatic H. At 1:26 PM. BP and HR were low at 95/74 and 49 bpm “HR brady: pt asymptomatic” I. At 1:27 PM, HR was low at 51 “ ...pt asymptomatic” J. At 1:36 P,M BP was low at 88/74 “Pt BP brady; pt stated that he feels weak; goal decreased; UF placed in min” K. At 1:38 PM, no vital signs were documented “HR below 60” L. At 1:47 PM, no vital signs were documented “O2 given at 2L BNC” M. At 2:05 PM, no vital signs were documented “Pt stated that he feels better; UF turned back on” N. At 2:08 PM, BP and HR were low at 93/21 and 58 bpm “Pt diastolic bp and HR brady; Pt stated that he does not feel good; UF placed in min” O. At 2:27 PM, BP was low at 155/27 “Pt diastolic bp brady ...Pt asymptomatic” P. At 2:30 PM, BP was high at160/102 and HR was low at 53 “Treatment terminated; Pt diastolic bp elevated; pt asymptomatic” Review of the 3/10/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 11:25 AM, BP was low at 112/38 “Pt diastolic bp brady; pt asymptomatic” B. At 12:25 PM, BP was low at 111/41, and HR was high at 104 bpm “Pt diastolic bp brady; HR elevated; pt asymptomatic” C. At 12:57 PM, HR was elevated at 104 bpm “ ...HR elevated: Pt asymptomatic” D. At 1:38 PM, BP was high at 121/109, and HR was low at 50 “ ...Manual Entry: Pt diastolic bp elevated; HR below 60; pt asymptomatic ...” E. At 1:57 PM, BP was high at 160/129 “Manual Entry: Pt diastolic bp and HR elevated; pt asymptomatic” F. At 2:35 PM, BP was high at 150/133, and HR was low at 54 “Manual Entry: Pt diastolic bp elevated; Pt asymptomatic; HR below 60” G. At 2:38 PM, no vital signs were documented “Manual Entry: Pt stated that he does not feel well; pt in reclined position; UF turned off” Review of the ICHD Comprehensive Note dated 3/10/2025 for Patient #2, Medical Doctor #1 stated, “...BP 112/38..asymptomatic, states it runs low all the time. Has vascular issues so likely inaccurate...” Review of the 3/12/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 11:01 AM, BP and HR were low at 116/51 and 49 bpm “Pt HR below 60: Pt asymptomatic” B. At 11:59 AM, BP was low at 97/68 “ ...pt asymptomatic” C. At 12:28 PM, BP was low at 78/57, and HR was high at 102 bpm “Pt BP brady; HR elevated; pt asymptomatic” D. At 12:50 PM, BP was low at 83/51 “VS noted cuff adjusted rechecking” E. At 1:30 PM, BP was low at 77/21 “VS noted cuff adjusted rechecking” F. At 1:47 PM, BP and HR were low at 49/30 and 59 bpm “F/U BP noted UF in min NS 200 ml given. Will monitor” G. At 1:49 PM, BP was low at 84/72 “F/U Bp improved. Pt states feeling better” H. At 1:56 PM, BP was low at 138/41 “Pt diastolic bp brady; pt asymptomatic” I. At 2:02 PM, BP was low at 83/29 “recheck” J. At 2:03 PM, BP was low at 80/17 “recheck” K. At 2:10 PM, BP and HR were low at 97/24 and 41 bpm “Pt diastolic bp & HR brady; Pt asymptomatic; Pt noted watching tv” Review of the Limited Note dated 3/12/2025 for Patient #2, Nurse Practitioner #1 documented, “...BP 97/68..asymptomatic, states it runs low all the time. Has vascular issues so likely inaccurate...” Review of the 3/14/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 7:04 AM, BP and HR were low at 98/39 and 45 bpm “Treatment started without complications: Normal saline prime given” B. At 8:08 AM, BP was low at 144/37 “no distress noted; CN aware of bp” C. At 8:11 AM, BP and HR were low at 86/74 and 50 bpm D. At 8:26 AM, no vital signs were documented “BP noted Patient asymptomatic of hypotension. BP within MD ordered limits. Legs elevated. No complaints voiced. Will continue to monitor” E. At 9:42 AM, BP was high at 143/118 “bp rechecked” F. At 9:46 AM, BP and HR were low at 60/34 and 39 bpm “ ...Bp cuff adjusted; BP rechecked” G. At 9:49 AM, BP and HR were low at 81/59 and 39 bpm “BP noted. BP within normal limits; Patient c/o feeling bad. Ufg decreased to 3600ml from 3970ml. patient placed in minimum for BP support. Will reassess in app 15 min” H. At 10:08 AM, HR is low at 50 bpm “BP improved. Pt voices he feels better. Patient asymptomatic. BP within MD normal limits. Pt uf taken out of minimum at this time. HR noted. HR rechecked manually and it is 60. No complaints voiced. Review of the 3/17/2025 Treatment Details Report revealed the following blood pressures and related documentation for Patient #2: A. At 7:31 AM, BP was low at 95/21 “rechecking” B. At 7:36 AM, BP was low at 100/44 “Patient monitored; watching tv no complications; VS Noted; CN aware of bp; will monitor” C. At 7:41 AM, no vitals were documented “Manual entry: bp noted; pt taking home Midodrine at this time; pt asymptomatic; will continue to monitor” D. At 8:01 AM, BP was low at 54/30 “Rechecking bp” E. At 8:03 AM, BP was low at 112/21 “Patient blood pressure low; turn pt uf goal off; CN AWARE; will monitor” F. At 8:05 AM, no vitals were documented “Manual entry: bp noted; pt asymptomatic; uf in min” G. At 8:32 AM, BP was low at 115/19 “bp noted; pt asymptomatic; recheck bp” H. At 8:34 AM, BP was high at 116/101 “manual bp 118/98; uf on; pt asymptomatic; will continue to monitor post midodrine and with fluid removal” I. At 9:03 AM, BP was low at 108/46 “Patient awake; alert; and states no complaints at this time” J. At 9:31 AM, BP was low at 115/40 “Patient awake; alert; and states no complaints at this time” K. At 10:01 AM, BP was low at 100/55 “Patient appears to be tolerating treatment well at this time; no distress noted” L. At 10:31 AM, BP and pulse were low at 82/71 and 41bpm “recheck bp” M. At 10:33 AM, BP was high at 131/115 “Treatment terminated” Review of the 3/19/2025 Treatment Details Report revealed the following blood pressures and related documentation for Patient #2: A. At 7:07 AM, BP was low at 94/38 “Patient access cannulated without difficulty; Treatment started without complications; cuff readjusted; bp rechecked” B. At 7:08 AM, BP was low at 105/42 “Pt diastolic bp brady; pt asymptomatic” C. At 7:37 AM, BP was low at 85/38 “Pt systolic bp brady; pt asymptomatic; bp rechecked” D. At 7:38 AM, BP was low at 64/15 “Pt bp low; pt asymptomatic; UF in min due to low bp” E. At 7:48 AM, BP was low at 93/53 “Pt BP improved turned back on; pt asymptomatic” F. At 8:07 AM, BP was low at 98/42 “Pt diastolic bp brady; pt asymptomatic” G. At 8:11 AM, no vitals were documented “cuff readjusted bp recheck” H. At 8:09 AM, BP was low at 69/33 “Pt BP brady; HR elevated; UF placed in min” I. At 8:22 AM, BP was low at 91/52 “Pt BP improved; pt asymptomatic; UF turned back on” J. At 8:37 AM, BP was low at 87/77 “UF in min due to low systolic bp, Pt asymptomatic” K. At 9:07 AM, BP was low at 108/25 “Pt diastolic bp brady; HR elevated; pt asymptomatic” L. At 9:35 AM, BP was low at 118/21 “Pt diastolic bp brady; pt asymptomatic” M. At 9:36 AM, BP was low at 97/69 with no documentation N. At 9:38 AM, No vitals documented “Pt bp improved; UF turned back on; pt asymptomatic” O. At 10:07 AM, BP was low at 100/37, and HR was high at 106 “Pt diastolic bp brady; HR elevated; pt asymptomatic” P. At 10:17 AM, BP was low at 98/26, and HR was high at 139 bpm “recheck” Q. At 10:18 AM, BP was low at 100/48 “Pt diastolic bp brady; HR elevated; Pt asymptomatic” R. At 10:37 AM, BP was low at 98/38 “Pt diastolic bp brady; pt asymptomatic” S. At 10:45 AM, BP was low at 99/47 “Manual entry: Treatment terminated” T. At 10:47 AM, No vitals were documented “Pt diastolic bp brady; HR elevated; pt asymptomatic” Review of the 3/24/2025 Treatment Details Report revealed the following blood pressures and related documentation for Patient #2: A. At 6:46 AM, BP was low at 132/29 “recheck; cuff readjusted” B. At 6:50 AM, BP was high at 144/118 “Pt diastolic bp elevated; pt asymptomatic” C. At 7:17 AM, BP was low at 122/53 “Patient appears to be tolerating treatment well at this time; Pt BP improving” D. At 7:47 AM, BP was low at 79/45 “recheck; pt asymptomatic” E. At 7:53 AM, BP was low at 77/66 “Pt UF in min due to low bp; pt asymptomatic” F. At 8:12 AM, BP was low at 68/19 “BP low UF in min; pt asymptomatic” G. At 8:13 AM, BP was low at 72/31 “BP low UF in min; pt asymptomatic” H. At 8:20 AM, BP was low at 105/20 “recheck” I. At 8:21 AM, BP was low at 84/30 “Pt BP low; Pt asymptomatic; goal decreased” J. At 8:47 AM, BP was low at 93/45 “Pt diastolic bp brady; pt asymptomatic” K. At 9:45 AM, BP was low at 97/45 “Patient appears to be tolerating treatment well at this time” L. At 10:15 AM, BP was low at 42/10 “recheck” M. At 10:18 AM, BP and HR were low at 52/32 and 59 bpm “cuff readjusted bp recheck” N. At 10:18 AM, BP and HR were low at 98/48 and 53 bpm “Treatment terminated; HR below 60; Pt asymptomatic” Review of the 3/26/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 6:26 AM, BP was low at 86/44 “ ...Treatment started without complications ...” B. At 6:49 AM, BP was low at 84/42 “Pt BP brady; pt asymptomatic” C. At 7:15 AM, BP was low at 74/36 “Cuff re adjusted bp rechecked” D. At 7:17 AM, BP was low at 81/34 “Pt BP brady; UF placed in min” E. At 8:47 AM, no BP was documented; “Manual entry: Pt stated that he feels bad; UF turned off; Pt being monitored ...” F. At 8:49 AM, BP was low at 96/18 “Recheck” G. At 8:50 AM, BP was low at 76/63 “O2 given @ 2L BNC due to low BP” H. At 9:33 AM, BP was low at 66/42 “Pt BP brady; pt asymptomatic.” I. At 9:34 AM, BP was low at 81/15 “recheck” J. At 9:36 AM, BP was low at 78/15 “Pt bp brady; HR elevated; pt asymptomatic” K. At 9:49 AM, BP was low at 84/22 “Pt diastolic bp brady; pt asymptomatic” L. At 10:20 AM, HR was low at 51 bpm “Treatment terminated; HR below 60; Pt asymptomatic” Review of the 3/28/2025 Treatment Details Report revealed the following abnormal vital signs and related documentation for Patient #2: A. At 10:07 AM, BP was low at 88/32 “ ...Pt bp brady; pt asymptomatic ...”, B. At 10:33 AM, BP was low at 80/26 “Pt BP brady; pt asymptomatic” C. At 11:02 AM, BP was low at 48/22 “Recheck; Pt asymptomatic” D. At 11:07 AM, BP was low at 88/54 “Manual Entry: Patient appears to be tolerating treatment at this time” E. At 11:51 AM, BP was low at 69/22 “Pt BP brady; HR elevated; UF in min.” F. At 12:22 PM, BP was low at 94/79 “UF turned off; Pt stated that he didn’t feel well; goal decreased ...” G. At 1:12 PM, BP was low at 81/23 “Pt bp brady; HR elevated; pt asymptomatic” 3. Medical record review for Patient #3 revealed an admission date of 5/30/2019 with diagnoses which included ESRD and Type 1 Diabetes Mellitus. Review of the Care Plan for Patient #3 revealed no interdialytic orders for parameters or interventions regarding hypotension or hypertension while receiving in-center hemodialysis. Review of the 3/17/2025 Treatment Details Report revealed the following blood pressures and related documentation for Patient #3: A. At 1:23 PM, BP was high at 148/111 “ ...Treatment started without complications ...” B. At 1:53 PM, BP was high at 148/109 “Patient appears to be tolerating treatment well at this time” C. At 2:54 PM, BP was high at 147/105 “Patient states no complaints at this time; HTN” 4. Medical record review for Patient #4 revealed an admission date of 12/06/2022 with diagnoses which included ESRD and Hypertension/Large Vessel Disease. Review of the Care Plan for Patient #4 revealed no interdialytic orders for parameters or interventions regarding hypotension or hypertension while receiving in-center hemodialysis. Review of the 3/12/2025 Treatment Details Report revealed the following blood pressures and related documentation for Patient #4: A. At 8:05 AM, BP was high at 195/106 “ ...Treatment started without complications ...” B. At 8:35 AM, BP was high at 192/98 “ ...bp noted; will continue to monitor ...” C. At 9:05 AM, BP was high at 190/100 “ ...patient resting; HTN ...” D. At 10:05 AM, BP was high at 206/105 “HTN; bp elevated; pt is alert and monitored talking on his phone” Review of the 3/14/2025 Treatment Details Report revealed the following blood pressures and related documentation for Patient #4: A. At 11:11 AM, BP was high at 206/110 “HTN; pt is monitored and alert and watching tv; no c/o” Review of the 3/19/2025 Treatment Details Report revealed the following blood pressures and related documentation for Patient #4: A. At 9:35 AM, BP was high at 183/101 “Patient appears to be tolerating treatment well at this time; late bp” B. At 10:05 AM, BP was high at 193/103 “Patient monitored; watching tv no complications” 5. Medical record review for Patient #5 revealed an admission date of 2/21/2025 with diagnoses which included HIV disease. The Care Plan for Patient #5 had not been developed at the time of survey; however, no documentation could be found for interdialytic orders for parameters or interventions regarding hypotension or hypertension while receiving in-center hemodialysis. Review of the 2/24/2025 Treatment Details Report revealed the following blood pressures and related documentation for Patient #4: A. At 1:43 PM, BP was low at 94/69 “VS noted cuff adjusted rechecking BP” B. At 2:12 PM, BP was low at 47/37 “BP noted cuff adjusted rechecking BP” C. At 2:14 PM, BP was low at 47/37 “F/U BP noted UF in min. Pt coughing excessive. Will monitor” D. At 2:42 PM, BP was low at 73/55 “BP noted rechecking” E. At 2:52 PM, no vital signs were documented O2 @ 2L BNC started for BP support. CN aware F. At 3:15 PM, BP was low at 84/60 “BP noted UF in min. will monitor” G. At 3:38 PM, BP was low at 91/58 “Manual Entry: Treatment terminated; Normal Saline prime given” Review of the 2/26/2025 Treatment Details Report revealed the following blood pressures and related documentation for Patient #4: A. At 12:49 PM BP and HR were high at 219/197 and 105 bpm “Pt BP and HR elevated; Pt asymptomatic” B. At 12:56 PM BP was high at 184/158, and HR was low at 49 bpm “Pt BP elevated; Pt continues to move around in chair; Pt asymptomatic.” C. At 1:18 PM, BP was high at 156/129 “BP noted rechecking” D. At 1:49 PM, BP was high at 132/104, and HR was low at 42 bpm “BP improved. Pt resting with eyes closed ...” E. At 2:25 PM, BP was high at 120/107 “Patient awake; alert; and states no complaints at this time; VS noted” F. At 2:53 PM, HR was high at 101bpm “ ...HR elevated; pt asymptomatic” G. At 3:08 PM, HR was low at 66/29 “BP noted UF in min NS 200 ML given rechecking BP” H. At 3:11 PM, BP was low at 71/52 “F/U BP noted cuff adjusted rechecking” I. At 3:12 PM, BP was low at 78/48 “Pt BP brady, Pt asymptomatic” J. At 3:15 PM, BP was low at 76/38 “VS noted cuff adjusted rechecking” 6. During an interview on 4/1/2025 at 11:00 AM, the Manager of Clinical Services stated that there was “no interdialytic blood pressure parameters for really any patients anymore. We go by policy 1-03-08. The nurses have to use their judgement about when to call the MD. The policy is vague just the way we [facility name] like it. Nurses know their patients and just get lax.” During an interview on 4/1/2025 at 11:45 AM, the Manager of Clinical Services and FA were asked what parameters were being used on Patient #2’s chart when it was documented on 3/14/2025 that vital signs were “within MD ordered limits.” Neither the MCS nor the FA could produce documentation that revealed the MD ordered limits for Patient #2. When asked why that was documented, they both replied, “No idea.” During an interview on 4/1/2025 at 2:15 PM, the FA stated there was no policy that stated when the MD needed to be notified related to interdialytic findings. She stated the staff went by policy 1-03-08 [Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment] because that policy stated that staff should notify the RN of any abnormal finding,s and then the RN would use their discretion as to whether to call the MD.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure appropriate measures were taken by 2 of 2 (LPN #1 and LPN #2) nurses to effectively evaluate access and prevent infection before cannulation of an AVF and/or AVG prior to initiation of hemodialysis. The findings included: 1. Review of the facility policy, “AV Fistula or Graft Cannulation with [Brand Name] or [Brand Name] Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” revised April 2025 revealed, “ ...Perform inspection, auscultation and palpation on entire length of access. Determine presence of bruit and thrill ...If bruit or thrill is not present ...do not cannulate ...Determine the direction of access flow by gentle manual compression at the midpoint of the access. If unable or unsure of flow direction, do not cannulate ...Locate and palpate the needle cannulation sites prior to skin preparation ...Do not palpate insertion site once area has been prepped ...Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation ...” 2. Observations at Station #18 on the treatment floor on 3/31/2025 at 10:20 AM, revealed LPN #1 initiated hemodialysis on RP #1 via an AVF/AVG. LPN #1 failed to palpate the access site per facility policy and failed to reclean the access site after it was re-contaminated by RN #1 while performing an assessment on RP #1. RN #1 placed a stethoscope on the access sites for auscultation and palpated both access sites. LPN #1 had been at another station performing care and had not been aware the area was re-contaminated. 3. Observations on the treatment floor on 3/31/2025 at 11:34 AM, revealed LPN #2 initiated hemodialysis on Patient #1 via an AVF/AVG. LPN #2 failed to palpate the access site per facility policy before initiating hemodialysis. 4. During an interview on 3/31/2025 at 2:15 PM, the FA confirmed staff was expected to follow the facility policy for initiation of dialysis with an AVG/AVF. She stated staff should always look, listen and feel of the access sites before cannulation was attempted and stated that sites should always be recleaned if they were re-contaminated after cleaning.”