Davita Bartlett Renal Center

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 33763 Based on policy review, document review, observation and interview, the facility failed to ensure staff utilized measures to decrease the potential spread of infection by failing to perform hand hygiene between glove changes prior to and during patient care, when moving from dirty tasks to clean tasks, failing to ensure fingernails were maintained per facility policy; failing to ensure reusable equipment was disinfected between patients; failing to ensure aseptic technique was maintained when preparing and administering IV medications; and failing to maintain aseptic technique when caring for patients with CVCs. The findings included: 1. Review of the facility’s “Infection Control for Dialysis Facilities” policy revised April 2023 revealed, “...All teammates... 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... It is a requirement for all... teammates whose primary location is working in a facility to have only natural nails and fingernail length should not extend more than 1/4 inch...” Review of the “Monthly Infection Control Audit” dated August 2023 revealed, “...TMs (includes non-direct care TMs) have only natural nails and length does not extend more than 1/4 inch...N [no]...Artificial nails noted...” The facility failed to ensure hand hygiene and other measures to prevent the spread of potentially infectious bacteria were followed per facility policy by 2 of 4 (CCHT #1 and RN #1) staff members observed providing direct patient care on the treatment floor. Observations on the treatment floor on 12/4/2023 revealed CCHT #1 failed to perform hand hygiene between glove changes and when moving from dirty tasks to clean tasks. CCHT #1 was also observed wearing long, press-on fingernails on 2 of 3 (12/4/2023 and 12/6/2023) days of the survey. Observations on the treatment floor on 12/4/2023 revealed RN #1 failed to perform hand hygiene prior to preparing medications for IV administration. Observations on the treatment floor on 12/4/2023 at 9:04 AM and at 9:40 AM, revealed CCHT #1 failed to remove her gloves, perform hand hygiene and don new gloves after emtpyint the prime waste receptacle and before disinfecting the dialysis machines. In an interview on 12/6/2023 at 10:47 AM, the FA stated fingernails should be no longer than 1/4 inch long and must be natural nails, “no press-on or artificial nails” allowed. In an interview on 12/6/2023 at 11:12 AM, the FA stated hand hygiene should be performed before and after glove use and before preparing medications. Refer to V113. 2. Review of the facility’s “Infection Control for Dialysis Facilities” policy revised April 2023 revealed, “...At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g...blood pressure cuffs)... Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 bleach solution...” Observations on the treatment floor at station #5 on 12/4/2023 at 10:25 AM, revealed CCHT #2 failed to clean the blood pressure cuff when disinfecting the dialysis station. In an interview on 12/6/2023 at 12:15, the FA stated staff are “supposed to clean anything in the area including the blood pressure cuff, table, IV pole; anything the patient could have used or touched.” Observations on the treatment floor on 12/4/2023 from 9:04 AM until 10:05 AM, revealed RN #1 used his stethoscope to assess a total of 7 patients. The RN failed to clean his stethoscope at any time during the observations. In an interview on 12/6/2023 at 11:12 AM the FA staff stated staff are supposed to clean their stethoscopes with alcohol when going from one patient to another or when going from a dirty area to a clean area. The facility failed to ensure non-disposable items taken to the dialysis stations were properly disinfected and stored by 2 of 4 (RN #1 and CCHT #2) staff members observed performing direct patient care on the treatment floor. Refer to V116. 3. Review of the facility’s “Medication Policy” revised October 2023 revealed, “...All teammates administering medications must utilize aseptic technique...” Observations on the treatment floor on 12/4/2023 revealed RN #1 failed to clean the top of a vial of Heparin before inserting the needles to withdraw the medication a total of 3 times. In an interview on 12/6/2023 at 11:12 AM, the FA verified the RN should have cleaned the top of the Heparin vial with alcohol prior to inserting the needles and withdrawing the medication. The facility failed to ensure aseptic technique was maintained during preparation of intravenous medications by 1 of 2 (RN #1) nurses observed during medication administration. Refer to V143. 4. Review of the facility’s “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” policy revised October 2023 revealed, “...Use Dialysis Precautions and aseptic technique throughout procedure... Perform hand hygiene per procedure... Place the second moisture proof barrier under catheter limbs... Remove old dressing and discard... Remove gloves and discard. Perform hand hygiene per procedure and re-glove... Holding catheter with the non-dominant hand and using aseptic technique, clean exit site... air dry... Clean each CVC limb/cap with a new Large alcohol prep pad, starting close to the exit site and finishing with the cap... 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... Holding catheter with non-dominant hand, use other hand to place sterile 4 x 4 under catheter limbs. Minimize contact with the 4 x 4 gauze... Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried... Attach sterile 10 ml syringes to the arterial and venous limbs... Upon Completion of Dialysis... Set-up new clean field with appropriate supplies on a new clean, moisture proof barrier... Discard used barrier that was used during treatment and place a new clean, moisture proof barrier under catheter to prevent contamination...” Observations on the treatment floor at station #9 on 12/4/2023 beginning at 9:30 AM, revealed, RN #1 removed the caps from the CVC limbs, cleaned them with alcohol and left them uncapped on the barrier while removing the old CVC dressing, cleaning the CVC site and replacing the CVC dressing. In an interview on 12/6/2023 at 11:17 AM, the FA stated the RN should have removed the old CVC dressing and performed site care before removing the caps from the CVC limbs. The FA continued and verified the RN should have attached a sterile syringe to each uncapped CVC limb immediately after scrubbing the hubs. The FA verified the uncapped CVC limbs should not have been left open during the procedure. Observations on the treatment floor at station #4 on 12/4/2023 beginning at 10:37 AM revealed, RN #1 failed to place a clean barrier under the CVC limbs prior to discontinuing the dialysis treatment. In an interview on 12/6/2023 at 12:06 PM, the FA verified RN #1 should have placed a clean barrier under the CVC limbs prior to the procedure. The facility failed to ensure measures to prevent CVC infections were followed by 1 of 2 (RN #1) nurses observed performing CVC site care. Refer to V147.”

“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, document review, observation and interview, the facility failed to ensure hand hygiene and other measures to prevent the spread of potentially infectious bacteria were followed per facility policy by 2 of 4 (CCHT #1 and RN #1) 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-Physicians (NPP) 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... It is a requirement for all [named ESRD clinic’s parent company] teammates whose primary location is working in a facility to have only natural nails and fingernail length should not extend more than 1/4 inch...” 2. Review of the “Monthly Infection Control Audit” dated August 2023 revealed, “...TMs (includes non-direct care TMs) have only natural nails and lenght does not extend more than 1/4 inch... N [no]... Artifical nails noted...” 3. Observations on the treatment floor at Station #2 on 12/4/2023 beginning at 9:04 AM, revealed CCHT #1 was discontinuing dialysis and performing post dialysis access care for a patient with an AVF. After starting the rinse back, the CCHT removed her gloves, performed hand hygiene and entered data into the computer. The CCHT’s fingernails appeared to be very long and did not appear to be natural nails. Without performing hand hygiene, the CCHT donned new gloves and completed the procedure. 4. Observations on the treatment floor at the medication cart on 12/4/2023 at 9:28 AM revealed RN #1 failed to perform hand hygiene prior to gathering supplies and withdrawing heparin into a syringe. 5. Observations on the treatment floor at Station 3 on 12/4/2023 beginning at 9:40 AM revealed CCHT #1 was disinfecting the dialysis station. The CCHT performed hand hygiene, donned gloves and removed all blood lines and disposable equipment. The CCHT then removed the prime waste receptacle, emptied its contents into the dirty sink and cleaned it with bleach solution wipes and put it back in place on the dialysis machine. The CCHT then began wiping down the dialysis machine with the bleach wipe. CCHT #1 failed to remove her gloves, perform hand hygiene and don new gloves after emptying the prime waste receptacle and before disinfecting the receptacle and machine. 6. Observations on the treatment floor at Station #1 on 12/4/2023 beginning at 10:55 AM revealed CCHT #1 was disinfecting the dialysis station. The CCHT performed hand hygiene, donned gloves and removed all blood lines and disposable equipment. The CCHT then removed the prime waste receptacle, emptied its contents into the dirty sink and cleaned it with bleach solution wipes and put it back in place on the dialysis machine. The CCHT then began wiping down the dialysis machine with the bleach wipe. CCHT #1 failed to remove her gloves, perform hand hygiene and don new gloves after emptying the prime waste receptacle and before disinfecting the receptacle and machine. In an interview on 12/6/2023 at 11:12 AM, the FA stated hand hygiene should be performed before and after glove use and before preparing medications. 7. Observations on the treatment floor on 12/6/2023 at 10:17 AM revealed CCHT #1 entered the treatment floor and immediately put her hands into her pockets. The CCHT then turned and put her gown on while keeping her hands out of view. CCHT #1 walked to the nurses’ station, sat down and appeared to hide her hands. The CCHT was asked if she was wearing artificial nails. CCHT #1 stretched out her hands revealing long decorated nails and stated, “No, these are press-on nails.” In an interview on 12/6/2023 at 10:47 AM, the FA stated fingernails should be no longer than 1/4 inch long and must be natural nails, “no press-on or artificial nails” allowed.”

“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: 33763 Based on policy review, observation and interview, the facility failed to ensure non-disposable items taken to the dialysis stations were properly disinfected and stored by 2 of 4 (CCHT #2 and RN #1) staff members observed performing 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, “...Measures will be taken to prevent cross contamination between patients... Disinfection... At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs)... Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station... Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 bleach solution...” 2. Observations on the treatment floor at station #5 on 12/4/2023 at 10:25 AM, revealed CCHT #2 failed to clean the blood pressure cuff when disinfecting the dialysis station. In an interview on 12/6/2023 at 12:15, the FA stated staff are “supposed to clean anything in the area including the blood pressure cuff, table, IV pole; anything the patient could have used or touched.” 3. Observations on the treatment floor on 12/4/2023 from 9:04 AM until 10:05 AM, revealed RN #1 used his stethoscope to assess the patient at Station #2. After assessing the patient, the RN placed the stethoscope around his neck. The RN then went to Station #3, removed the stethoscope from his neck and used it to assess the patient. After assessing the patient, the RN placed the stethoscope back around his neck. RN #1 then went to Station #6, removed the stethoscope from his neck and used it to assess the patient. After assessing the patient, the RN placed the stethoscope back around his neck. RN #1 then went to Station #9, removed the stethoscope from around his neck and used it to assess the patient. After assessing the patient, the RN placed the stethoscope back around his neck. RN #1 then went to Station #3, removed the stethoscope from around his neck and used it to assess the patient. After assessing the patient, the RN placed the stethoscope back around his neck. RN #1 then went to Station #1, removed the stethoscope from around his neck and used it to assess the patient. After assessing the patient, the RN placed the stethoscope back around his neck. RN #1 then went to Station #7, removed the stethoscope from around his neck and used it to assess the patient. After assessing the patient, the RN placed the stethoscope back around his neck. RN #1 then walked to the entrance of the treatment floor where a patient was checking in and being weighed. The RN removed the stethoscope from around his neck and used it to assess the patient. After assessing the patient, the RN placed the stethoscope back around his neck and returned to the treatment floor. RN #1 failed to clean his stethoscope at any time after contact with the patient during the observations. In an interview on 12/6/2023 at 11:12 AM the FA stated staff are supposed to clean the stethoscopes with alcohol when going from one patient to another or when going from a dirty area to a clean area.”

“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 policy review, observation and interview, the facility failed to ensure aseptic technique was maintained during preparation of IV medications by 1 of 2 (RN #1) nurses observed during medication administration. The findings included: 1. Review of the facility’s “Medication Policy” revised October 2023 revealed, “...All teammates administering medications must utilize aseptic technique...” 2. Observations on the treatment floor on 12/4/2023 at 9:28 AM revealed RN #1 removed the cap off of a vial of heparin. RN #1 inserted the needle and withdrew the medication from the vial. RN #1 administered the medication IV to Random Patient #2. RN #1 failed to clean the rubber stopper of the vial with alcohol before inserting the needle to withdraw medication. 3. Observations on the treatment floor on 12/4/2023 at 10:05 AM revealed, RN #1 inserted 2 needles into the open vial of heparin and withdrew the medication from the vial. The RN labeled one syringe and placed it on the medication cart. RN #1 administered the other syringe of the medication to Patient #3. RN #1 failed to clean the top of the vial with alcohol prior to inserting the needles. In an interview on 12/6/2023 at 11:12 AM, the FA verified the RN should have cleaned the top of the heparin vial with alcohol prior to inserting the needles and withdrawing the medication.”

“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: 33763 Based on policy review, observation and interview, the facility failed to ensure measures to prevent CVC infections were followed by 1 of 2 (RN #1) nurses observed performing CVC site care. The findings included: 1. Review of the facility’s “Central Venous Catheter With Clearguard HD Antimicrobial End Caps Procedure” policy revised October 2023 revealed, “...Use Dialysis Precautions and aseptic technique throughout procedure... Perform hand hygiene per procedure... Set up clean field with all appropriate supplies on a clean, moisture proof barrier... Place the second moisture proof barrier under catheter limbs... Remove old dressing and discard... Remove gloves and discard. Perform hand hygiene per procedure and re-glove... Holding catheter with the non-dominant hand and using aseptic technique, clean exit site... air dry... Clean each CVC limb/cap with a new Large alcohol prep pad, starting close to the exit site and finishing with the cap... 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... Holding catheter with non-dominant hand, use other hand to place sterile 4 x 4 under catheter limbs. Minimize contact with the 4 x 4 gauze... Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried... Attach sterile 10 ml syringes to the arterial and venous limbs... Upon Completion of Dialysis... Set-up new clean field with appropriate supplies on a new clean, moisture proof barrier... Discard used barrier that was used during treatment and place a new clean, moisture proof barrier under catheter to prevent contamination...” 2. Observations on the treatment floor at station #9 on 12/4/2023 beginning at 9:30 AM, revealed, RN #1 performed hand hygiene, donned gloves and placed a moisture proof barrier under the patient’s CVC limbs and put all supplies on a barrier on the chairside table. The RN removed the gauze wrapped around the patient’s CVC limbs and laid the uncovered limbs on the barrier and cleaned them with alcohol. RN #1 removed the caps from the CVC limbs, scrubbed them vigorously with an alcohol swab then laid the uncapped CVC limbs back on top of the barrier. While leaving the CVC limbs uncapped, the RN removed the old dressing covering the CVC access site and cleaned the site. RN #1 removed his gloves, performed hand hygiene, donned new gloves and placed a new dressing on the access site. RN #1 picked up the uncapped CVC limbs and attached a syringe to each port. In an interview on 12/6/2023 at 11:17 AM, the FA stated the RN should have removed the old CVC dressing and performed site care before removing the caps from the CVC limbs. The FA continued and verified the RN should have attached a sterile syringe to each uncapped CVC limb immediately after scrubbing the hubs. The FA verified the uncapped CVC limbs should not have been left open during the procedure. 3. Observations on the treatment floor at station #4 on 12/4/2023 beginning at 10:37 AM revealed, RN #1 was preparing to discontinue the patient’s treatment via CVC. RN #1 performed hand hygiene, donned gloves and disconnected the dialysis tubing from the patient’s venous line, flushed the port with saline, then connected the tubing to the dialysis machine and started the rinse back process. The RN removed his gloves, donned new gloves and disconnected the tubing from the patient’s arterial line and flushed with saline. The RN then removed the syringes and cleaned the catheter ends with alcohol and applied new caps to each end. RN #1 failed to place a clean barrier under the CVC limbs prior to starting the procedure. In an interview on 12/6/2023 at 12:06 PM, the FA verified RN #1 should have placed a clean barrier under the CVC limbs prior to the procedure.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 33763 Based on policy review, medical record review and interview, the facility failed to ensure an initial comprehensive assessment was performed on all new patients within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session for 1 of 1 (Patient #1) sampled patients. The findings included: 1. Review of the facility’s “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” policy revised July 2023 revealed, “...A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment...” 2. Medical record review for Patient #1 revealed an admission date of 9/6/2023 with diagnoses which included Acute Kidney Failure. The initial comprehensive assessment was completed by the IDT on 10/25/2023, a total of 49 days after admission. In an interview on 12/6/2023 at 10:05 AM the FA verified the initial comprehensive assessment was not completed within 30 days or 13 treatments for Patient #1.”

“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, medical record and interview, the facility failed to ensure patients were assessed by an RN prior to hemodialysis treatments and following hemodialysis treatments to determine baseline information for 4 of 5 (Patient #1, #2, #3, and #4) sampled patients and failed to ensure vital signs were assessed every 30 minutes during hemodialysis treatments for 2 of 5 (Patient #1 and #3) sampled patients. The findings included: 1. Review of the facility’s “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” policy revised October 2023 revealed, “...The Nursing assessment will be performed and documented by a licensed nurse: specifically, a Registered Nurse (RN) prior to the start of the dialysis treatment and prior to the patient being discharged from the facility post dialysis...” 2. Medical record review for Patient #1 revealed an admission date of 9/6/2023 with diagnoses which included Acute Kidney Failure. The physician’s orders dated 9/16/2023 revealed the patient was to receive hemodialysis treatments 3 times a week via a CVC. The Treatment Details Report dated 11/3/2023 revealed the hemodialysis treatment was from 9:53 AM until 1:32 PM. The pre-treatment assessment was documented as completed at 10:40 AM, 47 minutes after the treatment was initiated. The Treatment Details Report dated 11/6/2023 revealed the hemodialysis treatment was from 10:30 AM until 2:08 PM. The pre-treatment assessment was documented as completed at 2:37 PM, 4 hours and 7 minutes after the treatment was initiated. The Treatment Details Report dated 11/8/2023 revealed the hemodialysis treatment was from 9:35 AM until 1:19 PM. The pre-treatment assessment was documented as completed at 9:54 AM, 19 minutes after the treatment was initiated. The Treatment Details Report dated 11/10/2023 revealed the hemodialysis treatment was from 5:45 AM until 9:16 AM. The pre-treatment assessment was documented as completed at 6:11 AM, 26 minutes after the treatment was initiated. Further review revealed the patient’s vital signs were not assessed during the treatment from 8:02 AM until 9:02 AM, a total of 1 hour. The Treatment Details Report dated 11/19/2023 revealed the hemodialysis treatment was from 5:20 AM until 8:59 AM. The pre-treatment assessment was documented as completed at 11:15 AM, 5 hours and 55 minutes after the treatment was initiated. The post-treatment assessment was documented as completed at 11:15 AM, 2 hours and 16 minutes after the treatment ended and the same time the pre-treatment assessment was documented as completed. The Treatment Details Report dated 11/29/2023 revealed the hemodialysis treatment was from 9:15 AM until 12:55 PM. The pre-treatment assessment was documented as completed at 9:32 AM, 17 minutes after the treatment was initiated. 4. Medical record review for Patient #2 revealed an admission date of 7/6/2023 with diagnoses which included ESRD. The physician’s order dated 11/10/2023 revealed the patient was to receive hemodialysis treatments 3 times a week via a CVC. The Treatment Details Report dated 11/16/2023 revealed the hemodialysis treatment was from 10:31 AM until 1:30 PM. The pre-treatment assessment was documented as completed at 2:06 PM, 3 hours and 35 minutes after the treatment was initiated. The Treatment Details Report dated 11/18/2023 revealed the hemodialysis treatment was from 10:50 AM until 1:39 PM. The pre-treatment assessment was documented as completed at 10:59 AM, 9 minutes after the treatment was initiated. The Treatment Details Report dated 11/20/2023 revealed the hemodialysis treatment was from 10:06 AM until 1:12 PM. The pre-treatment assessment was documented as completed at 3:15 PM, 5 hours and 9 minutes after the treatment was initiated. The post-treatment assessment was documented as completed at 3:13 PM, 2 hours and 1 minute after the treatment ended and 2 minutes before the pre-treatment assessment was completed. The Treatment Details Report dated 11/22/2023 revealed the hemodialysis treatment was from 10:27 AM until 1:38 PM. The pre-treatment assessment was documented as completed at 11:20 AM, 53 minutes after the treatment was initiated. The Treatment Details Report dated 11/25/2023 revealed the hemodialysis treatment was from 10:37 AM until 1:32 PM. The pre-treatment assessment was documented as completed at 11:04 AM, 27 minutes after the treatment was initiated. 5. Medical record review for Patient #3 revealed an admission date of 12/7/2023 with diagnoses which included Chronic Kidney Disease and ESRD. The physician’s orders dated 8/12/2023 and 11/15/2023 revealed the patient was to receive hemodialysis 3 times a week via an AV Fistula. The Treatment Details Report dated 11/1/2023 revealed the hemodialysis treatment was from 9:53 AM until 2:13 PM. The pre-treatment assessment was documented as completed at 10:25 AM, 32 minutes after the treatment was initiated. The Treatment Details Report dated 11/3/2023 revealed the hemodialysis treatment was from 10:03 AM until 2:22 PM. The pre-treatment assessment was documented as completed at 10:31 AM, 28 minutes after the treatment was initiated. The Treatment Details Report dated 11/6/2023 revealed the hemodialysis treatment was from 8:15 AM until 12:38 PM. The pre-treatment assessment was documented as completed at 1:47 AM, 5 hours and 32 minutes after the treatment was initiated. The Treatment Details Report dated 11/15/2023 revealed the hemodialysis treatment was from 9:41 AM until 1:27 PM. The pre-treatment assessment was documented as completed at 9:53 AM, 12 minutes after the treatment was initiated. The Treatment Details Report dated 11/17/2023 revealed the hemodialysis treatment was from 11:42 AM until 3:58 PM. The pre-treatment assessment was documented as completed at 12:18 PM, 36 minutes after the treatment was initiated. The Treatment Details Report dated 11/19/2023 revealed the hemodialysis treatment was from 5:57 AM until 9:01 AM. The pre-treatment assessment was documented as completed at 10:51 AM, 4 hours and 54 minutes after the treatment was initiated. The Treatment Details Report dated 11/22/2023 revealed the hemodialysis treatment was from 9:30 AM until 1:48 PM. The pre-treatment assessment was documented as completed at 9:46 AM, 16 minutes after the treatment was initiated. Further review revealed there was no documentation the patient’s physical status or vital signs were assessed from 9:35 AM until 11:33 AM, 1 hour and 52 minutes. The Treatment Details Report dated 11/27/2023 revealed the hemodialysis treatment was from 9:58 AM until 2:20 PM. The pre-treatment assessment was documented as completed at 10:22 AM, 24 minutes after the treatment was initiated. The Treatment Details Report dated 11/29/2023 revealed the hemodialysis treatment was from 9:37 AM until 1:55 PM. The pre-treatment assessment was documented as completed at 9:52 AM, 15 minutes after the treatment was initiated. 6. Medical record review for Patient #5 revealed an admission date of 9/16/2023 with diagnoses which included Diabetes Mellitus and ESRD. The physician’s orders dated 10/27/2023 revealed the patient was to receive hemodialysis treatments 3 times a week via a CVC. The Treatment Details Report dated 11/4/2023 revealed the hemodialysis treatment was from 5:50 AM until 9:41 AM. The pre-treatment assessment was documented as completed at 6:43 AM, 53 minutes after the treatment was initiated. The Treatment Details Report dated 11/16/2023 revealed the hemodialysis treatment was from 6:17 AM until 10:16 AM. The pre-treatment assessment was documented as completed at 7:00 AM, 43 minutes after the treatment was initiated. The post-treatment assessment was documented as completed at 11:38 AM, 1 hour and 22 minutes after the treatment ended. The Treatment Details Report dated 11/18/2023 revealed the hemodialysis treatment was from 6:02 AM until 10:23 AM. The pre-treatment assessment was documented as completed at 6:39 AM, 37 minutes after the treatment was initiated. The post-treatment assessment was documented as completed at 11:34 AM, 1 hour and 11 minutes after the treatment ended. The Treatment Details Report dated 11/22/2023 revealed the hemodialysis treatment was from 5:54 AM until 9:05 AM. The pre-treatment assessment was documented as completed at 6:17 AM, 23 minutes after the treatment was initiated. The Treatment Details Report dated 11/25/2023 revealed the hemodialysis treatment was from 6:33 AM until 10:10 AM. The pre-treatment assessment was documented as completed at 10:40 AM, 47 minutes after the treatment was initiated. In an interview on 12/6/2023 at 10:38 AM, the FA verified patients should be assessed by an RN before treatment is initiated and vital signs 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 BFR and DFR were followed for 3 of 5 (Patient #1, #2 and #3) sampled hemodialysis patients. The findings included: 1. Review of the facility’s “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” policy revised 10/2023 revealed, “...Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment... Intradialytic Data Collection Assessment... If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed...” 2. Medical record review for Patient #1 revealed an admission date of 9/6/2023 with diagnoses which included Acute Kidney Failure and ESRD. The physician’s orders dated 11/8/2023 revealed a BFR of 350 mL/min and a DFR of 600 mL/min. Review of the Treatment Details Report dated 11/8/2023 revealed the DFR was 500 mL/min from 9:44 AM until 1:19 PM. There was no documentation why the prescribed DFR was not followed as ordered. Review of the Treatment Details Report dated 11/15/2023 revealed the BFR was 400 mL/min from 7:18 AM until 10:33 AM. There was no documentation why the prescribed BFR was not followed as ordered. Review of the Treatment Details Report dated 11/17/2023 revealed the BFR was 300 mL/min from 6:02 AM until 9:31 AM. There was no documentation why the prescribed BFR was not followed as ordered. 3. Medical record review for Patient #2 revealed an admission date of 7/6/2023 with diagnoses which included ESRD. The physician’s orders dated 11/10/2023 revealed a BFR of 400 mL/min and a DFR of 500 mL/min. Review of the Treatment Details Report dated 11/16/2023 revealed the BFR was 350 mL/min from 10:31 AM until 2:05 PM. There was no documentation why the prescribed BFR was not followed as ordered. 4. Medical record review for Patient #3 revealed an admission date of 12/7/2017 with diagnoses which included Chronic Kidney Disease and ESRD. The physician’s orders dated 8/12/2023 through 11/15/2023 revealed a BFR of 500 mL/min and a DFR of 800mL/min. Review of the Treatment Details Report dated 11/3/2023 revealed the BFR was 450 mL/min from 10:04 AM until 2:01 PM. There was no documentation why the prescribed BFR was not followed as ordered. 5. In an interview on 12/6/2023 at 10:00 AM, the FA verified staff are supposed to document why the BFR and/or DFR are not followed as prescribed.”