Davita Memphis Southeast Dialysis

“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: 33763 Based on policy review, observation, and interview, the facility failed to ensure hand hygiene to prevent the potential spread of infectious bacteria was performed per facility policies by 4 of 7 (PCT #1, CCHT #1, RN #1, and RN #2) staff members observed providing direct patient care on the treatment floor. The findings included: 1. Review of the facility’s “Infection Control for Dialysis Facilities” policy revised April 2023 revealed, “...All teammates, Physicians and non-Physician...will perform hand hygiene...prior to gloving and immediately after removal of gloves...after patient and dialysis delivery system contact...before touching clean areas such as supplies, supply cart and chairside keyboard/mouse...” Review of the facility’s “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” policy revised October 2022 revealed, “...Have patient wash access site with appropriate antibacterial soap, if able. If patient unable to wash access site, patient care teammate will clean access extremity with skin cleansing agent and pat dry...Locate and palpate the needle cannulation sites prior to skin preparation...While maintaining aseptic technique, cleanse the site...Remove gloves, perform hand hygiene and put on clean gloves prior to cannulation...” Review of the facility’s “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” policy revised October 2024 revealed, “...Perform hand hygiene...Set up clean field with all appropriate supplies on a clean, moisture proof barrier...Remove old dressing and discard...Remove gloves and discard. Perform hand hygiene per procedure and re-glove...Clean each CVC limb/cap with a new Large alcohol prep pad...Remove gloves and discard, perform hand hygiene per procedure and re-glove...Place sterile 2 x 2 gauze over the catheter exit site leaving connections accessible...Apply label to the dressing...Remove gloves and discard, perform hand hygiene per procedure and re-glove...Disinfect each CVC hub...” 2. Observations on the treatment floor at Station #3 on 2/24/2025 at 9:42 AM, revealed PCT #1 cannulating and initiating hemodialysis treatment via an AVG/AVF to Random Patient #2. PCT #1 performed hand hygiene, donned gloves, then palpated and assessed the Patient’s unwashed access cite with her gloved hand. Without removing the gloves, performing hand hygiene, and donning new gloves, PCT #1 cleaned the access sites with alcohol swabs then proceeded with cannulation. PCT #1 failed to remove her gloves, perform hand hygiene and don new gloves, after assessing the unwashed access site and before cleaning and cannulating the sites. 3. Observations on the treatment floor at Station #23 at 9:52 AM, revealed CCHT #1 discontinuing hemodialysis treatment via an AVG/AVF on Random Patient #3. CCHT #1 performed hand hygiene, donned gloves, disconnected the blood line and began reinfusing the extracorporeal circuit. The CCHT removed the gloves, performed hand hygiene and entered information on the computer keyboard at the station. CCHT #1 obtained a clamp, then donned gloves and removed the needles from the Patient’s access sites. CCHT #1 failed to perform hand hygiene after typing on the keyboard and before donning gloves. 4. Observations on the treatment floor at Station #22 on 2/24/2025 at 11:00 AM, revealed RN #1 performing CVC exit site care and initiating hemodialysis treatment on Random Patient #1. RN #1 performed hand hygiene, donned gloves, and removed the old dressing from the CVC site. Without removing gloves, performing hand hygiene, and donning new gloves, the RN proceeded to clean the exit site, and CVC limbs, then applied a new dressing to the exit site. While still wearing the same gloves, RN #1 removed the CVC catheter caps, scrubbed the hubs, then connected the syringes to the CVC limbs, withdrew the indwelling heparin, flushed the limbs with saline, then connected the dialysis tubing and initiated the treatment. RN #1 failed to remove her gloves, perform hand hygiene, and don new gloves when moving from dirty to clean areas repeatedly. 5. Observations on the treatment floor at Station #10 on 2/24/2025 at 11:10 AM, revealed RN #2 performing CVC exit site care and initiating hemodialysis treatment on Random Patient #6. RN #2 did not perform hand hygiene, donned gloves, and removed the old dressing from the CVC site. RN #2 then removed gloves, performed hand hygiene, and donned new gloves, the RN proceeded to clean the exit site, and CVC limbs, then applied a new dressing to the exit site. RN #2 removed the gloves and typed on the keyboard. Without performing hand hygiene, RN #2 donned new gloves, placed a clean field under the CVC ports, removed the CVC catheter caps, scrubbed the hubs, connected the syringes to the CVC limbs, withdrew the indwelling heparin, flushed the limbs with saline, then connected the dialysis tubing and initiated the treatment. RN #2 failed to remove remove her gloves, perform hand hygiene, and don new gloves when moving from dirty to clean areas repeatedly. 6. During an interview on 2/25/2025 at 1:34 PM, the FA stated staff were expected to perform hand hygiene after removing gloves and before donning new gloves.”

“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: 33763 Based on review of the package insert titled, “Tuberculin Purified Protein Derivative (Mantoux) Tubersol,” facility policy review, observation and interview, the facility failed to ensure open multi-dose vials of medications were labeled and not expired medications and available for use in 1 of 2 (Medication Storage Refrigerator #1) medication storage refrigerators observed. The findings included: 1. Review of the package insert titled, “Tuberculin Purified Protein Derivative (Mantoux) Tubersol,” revealed, “...A vial of Tubersol which has been entered and in use for 30 days should be discarded...do not use after expiration date...” 2. Review of the facility’s “Medication Policy” revised October 2023 revealed, “...All open or unopened medication packages...are stored according to the manufacturer’s directions. Do not use any medication that has been stored improperly or has expired...Medications containing a preservative must be discarded 28 days after opening or accessed...Each vial is labeled with the initials of the person opening the vial and the expiration date...All medications are checked monthly for expiration dates...” 3. Observations on the treatment floor in Medication Refrigerator #1 on 2/24/2025 at 10:45 AM, revealed 1 open and unlabeled vial of Tuberculin Purified Protein Derivative (PPD) and 1 open vial of PPD with an open date of 6/21/2024. 4. During an interview on 2/24/2025 at 10:59 AM, RN 2 was asked when both vials of PPD expired. The RN stated well, “there’s no open date on that one, and I opened the other one on 6/21/2025.” RN #2 was asked how long an open vial of PPD should be kept before being discarded. The RN stated, “3 months, I think.” During an interview on 2/25/2025 at 1:34 PM, the FA stated all open multidose vials of medications should be labeled with the date opened and the initials of the person that opened the vial. The FA was asked how long an open multi-dose vial of PPD should be kept before being discarded. The FA stated, “28 to 30 days.””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 33763 Based on policy review, observation, and interview, the facility failed to ensure visibility of access sites during treatment for 2 of 15(Random Patient #5 and Random Patient #6) patients observed on the treatment floor. The findings included: 1. Review of the facility’s “Pre-Intra-Post Treatment Data collection, Monitoring and Nursing Assessment” policy revised April 2023 revealed, “...The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment...” 2. Observations on the treatment floor at Station #5 on 2/24/2025 from 10:01 AM until 10:21 AM, revealed Random Patient #4’s access site and tubing connections were covered by a blanket and not visible. Observations on the treatment floor at Station #6 on 2/24/2025 from 10:01 AM until 10:32 AM, revealed Random Patient #5’s access site and tubing connections were covered by a blanket and not visible. 3. During an interview on 2/25/2025 at 2:07 PM, the FA verified access sites and tubing connections should be uncovered and visible at all times.”

“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: 33763 Based on policy review, facility document review, medical record review, and interview, the facility failed to implement measures to address hypertensive episodes during hemodialysis for 1 of 5 (Patient #2) sampled patients and failed to ensure patients undergoing hemodialysis treatments were monitored every 30 minutes per facility policy for 1 of 5 (Patient #4) sampled patients. The findings included: 1. Review of the facility’s “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” policy revised April 2024 revealed, “...Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes...Vital signs and treatment monitoring...Treatment checks should be completed at least every 30 minutes...At a minimum, obtain and document the following...Blood pressure...Heart or pulse rate...Unless other abnormal parameters are established by the facility Governing Body and documented in the 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...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...Blood Pressure Post Treatment...Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg...Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg...Sitting BP for patients that cannot stand...Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg...Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg...” Review of the facility’s “Hypertension Protocol for [Named facility]” document revealed, “Pretreatment Hypertension If pre pre-treatment SBP is greater than 200 MD must be notified prior to the initiation of treatment. If SBP is less than 200 and patient is asymptomatic than start dialysis, treat for 60 minutes, and if SP is greater than 170 follow intradialytic order. Intradialytic Hypertension Give 0.1 mg tablet of clonidine for SBP greater than or equal to 170 and/or diastolic greater than or equal to 100. Recheck BP in 60 minutes, if no response. Notify MD Post Treatment Hypertension MD must be notified if BP is greater than or equal to 180/90 Patient may be discharged from facility if BP is less than 180/90...” 2. Medical record review for Patient #2 revealed an admission date of 5/19/2023 with diagnoses which included Hypertensive Chronic Kidney Disease and ESRD. Review of the physician’s orders dated 1/21/2025 revealed the Patient was to receive hemodialysis treatments 3 times a week. Review of the Treatment Details Report dated 2/3/2025 revealed Patient #2’s pre-treatment BP was 191/122 at 9:19 AM. At 9:46 AM the treatment was initiated, and the BP was 167/121 and CCHT #1 documented, “blood pressure is elevated; RN is notified...” At 10:12 AM the Patient’s BP was 174/114 and RN #3 documented, “BP remains elevated...monitoring...” At 10:37 AM the Patient’s BP was 182/124 and CCHT #1 documented, “...blood pressure is elevated; still monitoring...” At 11:07 AM the Patient’s BP was 171/117 and CCHT #1 documented, “...blood pressure is elevated; Legs remains down...” At 11:36 AM the Patient’s BP was 160/101 and PCT #1 documented, “...appears to be tolerating treatment well...BP diastolic notes; RN aware...” At 12:07 PM the Patient’s BP was 151/91. At 12:36 PM the Patient’s BP was 154/90. At 1:07 PM the Patient’s BP was 159-95 and RN #3 documented, “...no complaints at this time...” At 1:27 PM the Patient’s BP was 174/103 and the treatment was terminated. There was no documentation Patient #2’s elevated blood pressure was treated with clonidine per protocol and no documentation the physician was notified. Review of the Treatment Details Report dated 2/10/2025 revealed Patient #2’s pre-treatment BP was 177/112 at 10:46 AM. At 11:15 AM the treatment was initiated, and the BP was 189/113. At 11:32 AM the Patient’s BP was 171/116 and PCT #1 documented, “...BP diastolic noted; RN aware...” At 12:02 PM the Patient’s BP was 174/113 and PCT#1 documented, “BP diastolic noted; RN aware...” At 12:32 PM the Patient’s BP was 171/115 and PCT #2 documented, “...Diastolic BP high; Pt stated that he eels [feels] fine; BP rechecked...” At 12:33 PM the Patient’s BP was 169/114. At 1:01 PM the Patient’s BP was 188/121 and RN #2 documented, “...BP elevated assessed patient again patient states he feels fine...retook BP...” At 1:02 PM, the Patient’s BP was 164/93. At 1:32 PM the Patient’s BP was 173/108 and PCT #1 documented, “BP diastolic noted; RN aware...” At 1:44 PM RN #2 documented, “ noted blood pressure assessed patient is asymptomatic readjusted cuff and retook BP...” At 1:46 PM the Patient’s BP was 173/99 and RN #2 documented “blood pressure improved.” At 2:02 PM the Patient’s BP was 187/110 and RN #2 documented “...noted blood pressure patient is upset. readjust cuff will reassess in 30 minutes.” At 2:32 PM the Patient’s BP was 182/106. At 2:36 PM the Patient’s BP was 184/105. At 2:47 PM the Patient’s BP was 182/107 and the treatment was terminated. At 2:53 PM the Patient’s post-treatment BP was 182/111. There was no documentation Patient #2’s elevated blood pressure was treated with clonidine per protocol and no documentation the physician was notified. Review of the Treatment Details Report dated 2/17/2025 revealed Patient #2’s pre-treatment BP was 172/109 at 1:11 PM. At 1:27 PM the treatment was initiated, and the BP was 188/120. At 1:34 PM the Patient’s BP was 173/107 and PCT #3 documented, “...monitoring BP; rn aware of BP.” At 2:04 PM the Patient’s BP was 178/112. At 2:05 PM the Patient’s BP was 184/106. At 2:34 PM the Patient’s BP was 168/104. AT 3:04 PM the Patient’s BP was 195/110 and CCHT #2 documented, “...blood pressure is elevated.” At 3:05 PM the Patient’s BP was reassessed and was 198/115 and CCHT #2 documented, “...blood pressure is elevated; cuff readjusted; BP retaken” At 3:08 PM the Patient’s BP was 194/119 and CCHT #2 documented, “...blood pressure is elevated; nurse notified of BP change.” At 3:54 PM the Patient’s BP was 188/118. At 4:05 PM the Patient’s BP was 192/112 and CCHT #1 documented, “...blood pressure is elevated.” At 4:34 PM the Patient’s BP was 191/121 and the treatment was terminated. At 5:13 PM the Patient’s post-treatment BP was 191/105. There was no documentation Patient #2 was reassessed by an RN during the treatment, no documentation Patient #2’s elevated blood pressure was treated with clonidine per protocol, and no documentation the physician was notified. Review of the Treatment Details Report dated 2/19/2025 revealed Patient #2’s pre-treatment BP was 175/115 at 10:45 AM. At 11:01 AM the treatment was initiated, and the BP was 184/111 and RN #1 documented, “...BP likely to decrease with UF. Continue to monitor.” At 11:30 AM the Patient’s BP was 187/112 and CCHT #3 documented, “...blood pressure is elevated; Rn notified.” At 11:48 AM the Patient’s BP was 157/84 and RN #2 documented, “patient asymptomatic” and CCHT #1 documented, “retook BP BP improved.” At 12:01 PM the Patient’s BP was 169/86. At 12:30 PM the Patient’s BP was 181/104. At 1:00 PM the Patient’s BP was 180/109 and RN #2 documented, “Patient appears to be tolerating treatment well...” At 1:30 PM the Patient’s BP was 183/115 and RN #2 documented, “noted BP assessed pt asymptomatic, retook BP.” At 1:38 PM the Patient’s BP was 178/95 and RN #2 documented, “BP improved.” At 2:01 PM the Patient’s BP was 201/119 and the treatment was terminated. At 2:06 PM the Patient’s post-treatment BP was 187/107. There was no documentation Patient #2’s elevated blood pressure was treated with clonidine per protocol and no documentation the physician was notified. During an interview on 2/25/2025 at 1:24 PM, the FA was asked when staff should address and treat hypertension. The FA stated “I think at 150/90, and it was on a case by case basis. During an interview on 2/25/2025 at 1:25 PM, the Manager of Clinical Services stated, “There is a protocol at the stations they are supposed to follow” when addressing hypertension. 3. Medical record review for Patient #4 revealed a readmission date of Hypertension and ESRD. Review of the physician’s orders dated 2/3/2025 revealed the Patient was to receive hemodialysis treatments 3 times a week. Review of the Treatment Details Report dated 2/5/2025 revealed the treatment was initiated at 6:10 AM and terminated at 10:16 PM. There was no documentation Patient #4 was assessed by any staff member during the treatment from 8:04 AM until 10:16 AM, a total of 2 hours and 12 minutes. Review of the Treatment Details Report dated 2/17/2025 revealed the treatment was initiated at 11:01 AM and terminated at 2:05 PM. There was no documentation Patient #4 was assessed by any staff member during the treatment from 11:31 AM until 12:32 PM, a total of 1 hour and 1 minute. During an interview on 2/25/2025 at 1:15 PM, the FA stated patients should be assessed every 30 minutes during treatment.”

“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: 33763 Based on policy review, medical record review, and interview, the facility failed to ensure physician’s orders for prescribed for BFR and/or DFR were followed for 4 of 5 (Patient #1, #2, #4, and #5) sampled hemodialysis patients. The facility also failed to notify the physician of changes to the dialysis prescriptions. The findings included: 1. Review of the facility’s “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” policy revised April 2024 revealed, “...Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes...Blood and dialysate flows...If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood low rate) the reason will be documented and the licensed nurse informed...Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately...Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician...is necessary...” 2. Medical record review for Patient #1 revealed an original admission date of 12/2/2024 with diagnoses which included Acute Kidney Injury. Review of the physician’s orders dated 1/21/2025 revealed a BFR of 400 and a DFR of 600. Review of the Treatment Details Report dated 2/7/2025, revealed the BFR was 350 from 9:06 AM until 11:06 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400. There was no documentation the physician was notified. Review of the Treatment Details Report dated 2/17/2025 revealed the BFR was 350 from 11:00 AM until 2:08 PM and the DFR was 500 from 12:00 PM until 1:08 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400 or why the DFR was not delivered at the ordered rate of 600. There was no documentation the physician was notified. 3. Medical record review for Patient #2 revealed an admission date of 5/19/2023 with diagnoses which included Hypertensive Chronic Kidney Disease and ESRD. Review of the physician’s orders dated 1/21/2025 revealed a BR o 400 and a DFR of 800. Review of the Treatment Details Report dated 1/29/2025 revealed the DFR was 600 from 8:55 AM until 12:34 PM. There was no documentation stating why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 1/31/2025 revealed the DFR was 700 from 10:02 AM until 1:52 PM. There was no documentation stating why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 2/5/2025 revealed the DFR was 700 from 9:40 AM until 1:02 PM. There was no documentation stating why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 2/10/2025 revealed the DFR was 700 from 12:32 PM until 2:47 PM. There was no documentation stating why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 2/12/2025 revealed the DFR was 500 from 11:40 AM until 3:21 PM. There was no documentation stating why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 2/17/2025 revealed the BFR was 300 from 3:04 PM until 4:05 PM and the DFR was 600 from 1:27 PM until 4:34 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400 or why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 2/19/2025 revealed the DFR was 700 from 11:30 AM until 2:011 PM. There was no documentation stating why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. 4. Medical record review for Patient #4 revealed an original admission date of 10/22/2013 and a readmission date of 6/9/2016 with diagnoses which included Hypertension and ESRD. Review of the physician’s orders dated 1/21/2025 and 2/3/2025 revealed a BFR of 450 and a DFR of 800. Review of the Treatment Details Report dated 1/29/2025 revealed the BFR was 500 from 8:02 AM until 10:20 PM and the DFR was 700 from 8:02 AM until 10:20 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450 or why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 1/31/2025 revealed the DFR was 700 from 6:44 AM until 10:20 AM. There was no documentation stating why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 2/3/2025 revealed the BFR was 500 from 6:26 AM until 10:35 AM. There was no documentation stating why the BFR was not delivered at the ordered rate of 450. There was no documentation the physician was notified. 5. Medical record review for Patient #5 revealed an original admission date of 7/26/2024 and a readmission date of 2/14/2025 with diagnoses which included ESRD. Review of the physician’s orders dated 2/14/2025 revealed a BFR of 400 and a DFR of 800. Review of the Treatment Details Report dated 2/14/2025 the DFR was 700 from 1:34 PM until 3:421 PM. There was no documentation stating why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 2/17/2025 revealed the BFR was 350 from 11:59 AM until 3:02 PM and the DFR was 500 from 11:59 AM until 3:11 PM. There was no documentation stating why the BFR was not delivered at the ordered rate of 400 or why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. Review of the Treatment Details Report dated 2/21/2025 revealed the DFR was 700 from 12:21 PM until 3:48 PM. There was no documentation stating why the DFR was not delivered at the ordered rate of 800. There was no documentation the physician was notified. 6. During an interview on 2/25/2025 at 1:15 PM, the FA verified staff should make a note in the medical record and notify the physician document anytime the prescribed BFR and/or DFR were not followed.”

“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: 33763 Based on policy review, observation, and interview, the facility failed to ensure measures to reduce the risk of infection during cannulation of an AVF and/or AVG were followed by 1 of 2 (PCT #1) staff members observed initiating hemodialysis via an AVG or AVF. The findings included: 1. Review of the facility’s “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” policy revised October 2022 revealed, “...Have patient wash access site with appropriate antibacterial soap, if able. If patient unable to wash access site, patient care teammate will clean access extremity with akin cleansing agent and pat dry...” Observations on the treatment floor on 2/24/2025 at 9:42 AM, revealed PCT #1 was observed wheeling Random Patient #3 into the treatment area and onto the scales. After weighing the Patient, the PCT wheeled the Patient past the handwashing sink to Station #3. Without washing the Patient’s access site, the PCT assessed the access sites and cleaned the area with alcohol, then proceeded with cannulation. PCT #1 failed to ensure Random Patient #2 washed his access and/or assisted the Patient to wash his access site prior to cannulation. During an interview on 2/24/2025 at 9:45 AM, Random Patient #2 verified he failed to wash his access site prior to entering the treatment floor and stated, “I must have forgot.” During an interview on 2/25/2025 at 1:15 PM, the FA verified patients are expected to wash their access sites prior to entering the treatment floor and staff should assist those unable to wash their access sites prior to cannulation.”