Shc Chickasaw Gardens

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 33763 Based on policy review, medical record review, observation and interview, the facility failed to ensure staff utilized measures to decrease the spread of infection by failing to perform hand hygiene between glove changes prior to patient care; when moving from dirty tasks to clean tasks; failing to ensure aseptic technique was maintained when preparing and administering IV medications, failing to adhere to aseptic technique when caring for patients with CVCs and failing to ensure physician’s orders to prevent CVC related infections were followed. The findings included: 1. Review of the facility’s “HAND HYGIENE” policy (2/10/2019) revealed, “...Staff must disinfect their hands either by washing them with a disinfectant, hand soap or by disinfecting them with an alcohol based hand rub: Before donning and after doffing gloves. Between patient contacts. Prior to performing invasive procedures or manipulating an invasive device. After touching blood, body fluids, secretions, excretions, and contaminated items...” The facility failed to ensure hand hygiene and other measures to prevent the spread of infectious bacteria were performed per facility policy by 3 of 9 (RN #2, RN #3, CCHT #1) staff observed during 1 of 3 (11/13/2023-11/15/2023) observation days on the dialysis treatment floor. Observations on the treatment floor on 11/13/2023, revealed RN #2, RN #3, and CCHT #1 failed to remove gloves and perform hand hygiene when moving from dirty task areas to clean tasks and failed to perform hand hygiene between glove use. In an interview on 11/15/2023 at 10:30 AM, the CM verified hand hygiene should be performed anytime gloves are removed, and when moving from a dirty to clean area or task. Refer to V113. 2. Review of the facility’s “MEDICATION ADMINISTRATION” policy (4/5/2022) revealed, “...Vials (applies to both single and multi-dose vials)...Disinfect rubber stopper with alcohol if it is a multiple use vial, which has been opened. Discard alcohol pad and use a new pad after each puncture...” The facility failed to maintain aseptic technique during preparation of intravenous medication for 1 of 2 nurses (RN #1) observed during medication preparation. Observations on 11/13/2023 at 12:50 PM on the dialysis treatment floor revealed RN #1 punctured the rubber stopper of a vial of Heparin and withdrew medication into a syringe 6 times, using the same alcohol prep pad. RN #1 did not clean the rubber stopper with a new alcohol pad after each puncture of the rubber stopper. In an interview on 11/15/2023 at 9:45 AM, the CM verified a new alcohol prep pad should be used after every entry into a medication vial. Refer to V143. 3. Review of the facility’s “Medication Administration” policy (4/5/2022) revealed, “...In the event that a medication is missed, the registered nurse must notify the nephrologist...log an incident and submit to the Center Manager for any adverse event or missed medication...” The facility failed to ensure medications to prevent CVC related infections were administered for 1 of 5 (Patient #1) sampled patients with a CVC; and failed to ensure measures to prevent CVC infections were followed by 1 of 2 (RN #1) RNs observed performing CVC site care. Medical record review for Patient #1 revealed an admission date of 9/17/2021 with diagnoses which included ESRD, HIV and Hypertensive Chronic Kidney Disease. Review of the 2/8/2023 physician’s order revealed “...Gentamicin 320 mcg/ml...3 times per week /Cath Lock Art...Ven...” Review of the treatment flow sheets revealed no documentation Gentamicin was administered on 8/31/2023, 9/14/2023, 9/19/2023, 9/28/2023, 10/5/2023, 10/17/2023 and 11/7/2023. In an interview on 11/15/2023 at 9:55 AM, the CM verified the Gentamicin was not administered as ordered. Observations on the treatment floor on 11/13/2023 beginning at 1:22 PM, revealed RN #1 donned gloves without performing hand hygiene then removed the old CVC dressing from the patient’s chest and discarded the dressing and gloves. RN #1 performed hand hygiene, donned new gloves and performed CVC site care and applied a new dressing. After the dressing was applied, the RN reached under her gown and obtained a pen from her uniform, dated and initialed the patient’s CVC dressing, then placed the pen back in her uniform. In an interview on 11/15/2023 at 10:06 AM, the CM verified hand hygiene should have been performed before the nurse donned gloves and started the procedure. The CM further verified it was unacceptable for the nurse to use the pen from her pocket to write on the patient’s CVC dressing. Refer to V147.”

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 33763 Based on policy review, medical record review and interview, the facility failed to ensure plans of care were updated and individualized when they failed to ensure measures to address and treat hypertension were followed, failed to revise the plan of care to address shortened treatment times, failed to follow the prescribed BFRs, failed to administer nutritional supplements as ordered, and failed to administer heparin as ordered. The findings included: 1 Review of the facility’s “HYPERTENSION” policy (5/8/2020) revealed, “...Hypertension may be an adverse event of hemodialysis treatment... Document the situation including patient symptoms, all interventions and response to these interventions in the medical record... Hypertension Management... BP>/=180/100... Is the patient symptomatic?... No... Intervention... Notify physician if BP>/=180/100. Is NOT resolved with ultrafiltration... Document ALL Communication attempts and interactions with physician. Interdialytic interventions. Nursing assessments...” Review of the facility’s “COMPREHENSIVE ASSESSMENT AND PLAN OF CARE” policy (5/21/2020) revealed, “... PURPOSE... To perform assessments and develop a plan of care that considers every aspect of a patient’s wellbeing... The IDT members are expected to interact and share information from the comprehensive assessment to facilitate the development of the plan of care... The IDT if responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care...” The facility failed to accurately document administration of antihypertensives for 3 of 10 (Patient #2, #3 and #4) sampled patients, and failed to ensure the IDT revised, updated, and implemented individualized interventions to address shortened treatments for 2 of 10 (Patients #5, #10) sampled patients. A. Medical record review for Patient #2 revealed an admission date of 8/21/2023 with diagnoses that included Hypertension and ESRD. Review of a 10/18/2023 order revealed the following medication: Clonidine HCL. Dosage/Strength- 1mg/0.1mg [sic]. Frequency- as needed. Route- oral. Review of the treatment flowsheets dated 10/18/2023 through 11/10/2023 revealed the nursing assessment documentation and medication administration record failed to accurately document interventions provided for Hypertension on 10/18/2023, 10/20/2023, 10/23/2023, and 10/25/2023. B. Medical record review for Patient #3 revealed an admission date of 2/4/2022 with diagnoses that included Acute Kidney Failure. Review of the 4/4/2023 order revealed the following medication: Clonidine HCL. Dosage/Strength- 0.1mg/0.1mg. Frequency- as needed. Route- oral and Clonidine HCL 3 mg/.1mg [sic]. Frequency - as needed. Route - oral. Review of the treatment flowsheets dated 8/5/2023 through 9/12/2023 revealed the nursing assessment documentation and medication administration record failed to accurately document interventions provided for Hypertension on 8/5/2023, 8/8/2023, 8/10/2023, 8/12/2023, 8/15/2023, 9/1/2023, 9/5/2023, 9/7/2023, 9/9/2023 and 9/12/2023. C. Medical record review for Patient #4 revealed an admission date of 2/26/2021 with diagnoses that included Hypertensive Chronic Kidney Disease and ESRD. Review of the 4/5/2023 order revealed the following medication: Clonidine HCL. Dosage/Strength- 0.1mg/0.1mg. Frequency- as needed. Route- oral, and Clonidine HCL 1 tab/0.3 mg Frequency as needed. Route oral. Review of the treatment flowsheets dated 9/6/2023 through 10/30/2023 revealed the nursing assessment documentation and medication administration record failed to accurately document interventions provided for Hypertension on 9/6/2023, 9/8/2023, 9/13/2023, 9/15/2023, 9/20/2023, 9/21/2023, 9/29/2023, 10/2/2023, 10/9/2023, 10/13/2023, 10/16/2023, 10/18/2023, 10/20/2023 and 10/30/2023. D. Medical record review for Patient #5 revealed an admission date of 12/20/2020 with diagnoses that included HTN and ESRD. Review of 3/10/2023 dialysis orders revealed treatment length of 240 minutes (4 hours). Review of 15 Hemo Treatment Log Detail sheets beginning 10/4/2023 through 11/13/2023 revealed Patient #5 shortened 6 of the 15 treatments. Review of Patient #5’s Patient Conference Report (plan of care) revealed a “problem” of “Non-adherence to dialysis treatment prescription/schedule” started 4/25/2022 with a target date of 10/31/2023. Review of IDT notes beginning 6/1/2023 through 11/1/2023 revealed no updated, revised or individualized interventions to address Patient #5’s continued non-compliance with treatment time. E. Medical record review for Patient #10 revealed an admission date of 3/6/2023 with diagnoses that included ESRD. Review of 3/6/2023 dialysis orders revealed treatment length of 210 minutes (3.5 hours). Review of 15 Hemo Treatment Log Detail sheets beginning 10/4/2023 through 11/10/2023 revealed Patient #10 shortened 8 of the 15 treatments. Review of a 5/1/2023-11/13/2023 Plan of Care revealed no documentation of problems with non-adherence to treatment times or prescription. Review of IDT notes beginning 5/1/2023 through 11/13/2023 revealed on 8/7/2023 Patient #10’s nurse practitioner documented, “...long discussion on need for strict adherence with scheduled HD treatments and risks associated with missing treatments...” There were no revised or individualized interventions implemented after 8/7/2023 to address Patient #10’s continued non-compliance with treatment times. In an interview on 11/15/2023 at 10:00 AM the CM verified there were no new or individualized interventions to address Patient #5 and #10’s continued non-compliance with treatment times. Refer to V543. 2. Review of the facility’s “Adequacy for In-Center hemodialysis Protocol” policy reviewed 1/9/2020 revealed, “...To ensure that treatment orders enable all patients to receive an adequate delivered dialysis dose...Procedure...If prescribed blood flow rate is not achieved within 50ml/min, notify physician of actual delivered BFR and request orders to decrease BFR or increase time to achieve prescribed adequacy...Note: Documentation should accompany when prescribe [prescribed] flow is not met...” Review of the facility’s “Initiation of Hemodialysis Treatment...” policy reviewed 6/2/2023 revealed, “...When there is a variance between the actual blood flow rate (BFR) and the prescribed BFR, document the reason for the variance in the treatment record...” The facility failed to ensure physician’s orders for prescribed BFR and DFR were followed for 10 of 10 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) sampled hemodialysis patients. A. Medical record review for Patient #1 revealed an admission date of 9/17/2021 with diagnoses that included ESRD, HIV, and Hypertensive Chronic Kidney Disease. Review of the 2/8/2023 physician’s order revealed a BFR of 400 cc/min. Review of the treatment flowsheets revealed the prescribed BFR was not followed on 9/5/2023, 9/23/2023, 9/28/2023, 10/5/2023, 10/17/2023, 11/7/2023 and 11/9/2023. There was no documentation why the prescribed BFR was not followed for 7 of 15 treatment days reviewed. B. Medical record review for Patient #2 revealed an admission date of 8/21/2023 with diagnoses that included Hypertension and ESRD. Review of the 8/21/2023 physician’s order revealed a BFR of 350 cc/min. Review of the treatment flowsheets revealed the prescribed BFR was not followed on 10/4/2023, 10/13/2023, 10/16/2023, 10/18/2023 and 11/3/2023. There was no documentation why the prescribed BFR was not followed for 5 of 15 treatment days reviewed. C. Medical record review for Patient #3 revealed an admission date of 2/4/2022 with diagnoses that included ESRD and Acute Kidney Failure. Review of the 4/4/2023 physician’s order revealed a BFR of 350 cc/min. Review of the treatment flow sheets revealed the prescribed BFR was not followed on 8/5/2023. There was no documentation why the prescribed BFR was not followed. D. Medical record review for Patient #4 revealed an admission date of 2/26/2021 with diagnoses that included ESRD and Hypertensive Chronic Kidney Disease. Review of the 4/5/2023 physician’s order revealed a BFR of 400 cc/min. Review of the treatment flow sheets revealed the prescribed BFR was not followed on 9/13/2023. There was no documentation why the prescribed BFR was not followed. E. Medical record review for Patient #5 revealed an admission date of 12/30/2020 with diagnoses that included HTN and ESRD. Review of the 3/10/2023 physician’s order revealed a BFR of 450 cc/min. Review of the treatment flow sheets revealed the prescribed BFR was not followed on 10/25/2023 and 11/13/2023. There was no documentation why the prescribed BFR was not followed for 2 of 15 treatment days reviewed. F. Medical record review for Patient #6 revealed an admission date of 2/4/2022 with diagnoses that included ESRD, Type 1 Diabetes Mellitus and HTN. Review of the 4/5/2023 physician’s order revealed a BFR of 300 cc/min. Review of the treatment flow sheets revealed the prescribed BFR was not followed on 8/30/2023. There was no documentation why the prescribed BFR was not followed. G. Medical record review for Patient #7 revealed an admission date of 8/17/2023 with diagnoses that included HTN, DM and ESRD. Review of the 8/17/2023 physician’s order revealed a BFR of 350 cc/min. Review of the treatment flow sheets revealed the prescribed BFR was not followed on 10/12/2023 and 10/24/2023. There was no documentation why the prescribed BFR was not followed for 2 of 15 treatment days reviewed. H. Medical record review for Patient #8 revealed an admission date of 4/14/2023 with diagnoses that included HTN and ESRD. Review of the 4/14/2023 physician’s order revealed a BFR of 350 cc/min. Review of the treatment flow sheets revealed the prescribed BFR was not followed on 10/9/2023, 10/18/2023 and 11/3/2023. There was no documentation why the prescribed BFR was not followed for 3 of 15 treatment days reviewed. I. Medical record review for Patient #9 revealed an admission date of 12/3/2021 with diagnoses which included ESRD and HTN. Review of the 4/5/2023 physician’s order revealed a BFR of 400 cc/min. Review of the treatment flow sheets revealed the prescribed BFR was not followed on 10/23/2023, 10/30/2023, 11/6/2023 and 11/10/2023. There was no documentation why the prescribed BFR was not followed for 4 of 15 treatment days reviewed. J. Medical record review for Patient #10 revealed an admission date of 3/6/2023 with diagnoses which included ESRD. Review of the 3/6/2023 physician’s order revealed a BFR of 400 cc/min. Review of the treatment flow sheets revealed the prescribed BFR was not followed on 10/9/2023, 10/16/2023, 10/18/2023, 10/20/2023 and 11/3/2023. There was no documentation why the prescribed BFR was not followed for 5 of 15 treatment days reviewed. In an interview on 11/15/2023 at 9:25 AM, the CM verified staff are expected to document the reason when the prescribed BFR is not followed. Refer to V544. 3. Review of the facility’s “Comprehensive Assessment and Plan of Care” policy (5/21/2020) revealed, “...The IDT members are expected to interact and share information from the comprehensive assessment to facilitate the development of the plan of care...The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care...” Review of the facility’s “Medication Administration” policy (4/5/2022) revealed, “...In the event that a medication is missed, the registered nurse must notify the nephrologist...log an incident and submit to the Center Manager for any adverse event or missed medication. The event and intervention must also be documented on the treatment log of the patient...” The facility failed to ensure nutritional supplements were administered as ordered for 1 of 9 (Patient #6) sampled patients with ordered nutritional supplements. Medical record review for Patient #6 revealed an admission date of 1/27/2021 with diagnoses that included ESRD, Type 1 Diabetes Mellitus and HTN. Review of the 3/3/2023 physician’s order revealed IDPN 433 ml via IV 3 times a week. Review of the treatment flow sheets revealed IDPN was not administered as ordered on 6/21/2023, 6/23/2023, 6/26/2023, 8/2/2023, 8/7/20203, 8/9/2023, 8/28/2023, 8/30/2023, 9/6/2023, 9/8/2023, 9/11/2023, 10/30/2023, 11/1/2023, 11/3/2023 and 11/8/2023. There was no documentation Patient #6 refused the IDPN on the treatment flow sheets. There was no documentation to indicate the IDPN was discontinued by the physician. In an interview on 11/15/2023 at 9:45 AM, the RD stated IDPN was recommended for patients whose nutritional status was “really bad,” because it can be absorbed more readily than oral nutritional supplements. The RD stated Patient #6’s IDPN had been on hold, but then stated, “I’m not sure if he’s getting it now or not...” In an interview on 11/15/2023 at 9:55 AM, the CM verified the IDPN was not given. Refer to V545. 4. Review of the facility’s “MEDICATION ADMINISTRATION” policy (4/5/2022) revealed, “...Medications will be administered in a safe manner following infection control policies and the recommendations of federal and state regulatory agencies... Documentation... Document electronically to indicate the date, time, route and location if indicated...” The facility failed to ensure physician orders for Heparin administration were followed for 2 of 9 (Patient #7 and 8) sampled patients receiving Heparin. A. Medical record review for Patient #7 revealed an admission date of 8/17/2023 with diagnoses that included HTN, DM and ESRD. Review of 8/17/2023 physician orders revealed, “...Heparin Load: 2000 units. Hourly Dose: 1500...Total Heparin 7250 units...” Review of treatment flow sheets dated 10/7/2023 through 11/11/2023 revealed no documentation Patient #7 received the ordered hourly dosage of Heparin on 10/10/2023 and 10/28/2023. B. Medical record review for Patient #8 revealed an admission date of 4/14/2023 with diagnoses that included HTN and ESRD. Review of 4/14/2023 physician orders revealed, “...Heparin Load: 5000 units. Hourly Dose: 1000 units...Total Heparin: 9000 units...” Review of treatment flow sheets dated 10/9/2023 through 11/10/2023 revealed no documentation Patient #8 received the ordered hourly dosage of Heparin on 10/9/2023, 10/18/2023 and 11/3/2023. In an interview on 11/15/2023 at 10:00 AM, the CM verified the Heparin orders for Patient #7 and Patient #8 were not followed for all treatment days reviewed. Refer to V547.”

“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 and other measures to prevent the spread of potentially infectious bacteria were performed per facility policy by 3 of 9 (RN #2, RN #3, and CCHT #1) staff observed during 1 of 3 (11/13/2023-11/15/2023) observation days on the dialysis treatment floor. The findings included: 1. Review of the facility’s “HAND HYGIENE” policy (2/10/2019) revealed, “...Staff must disinfect their hands either by washing them with a disinfectant, hand soap or by disinfecting them with an alcohol based hand rub: Before donning and after doffing gloves. Between patient contacts. Prior to performing invasive procedures or manipulating an invasive device. After touching blood, body fluids, secretions, excretions, and contaminated items...” 2. Observations on the treatment floor on 11/13/2023 beginning at 10:10 AM, revealed RN #2 performed CVC site care at station #19. RN #2 removed and discarded the old CVC dressing, then began performing CVC site care. RN #2 failed to remove gloves, perform hand hygiene and don a new pair of gloves after removing the old dressing. Observations continued at station #19 with RN #2 initiating dialysis. After initiation was complete, RN #2 removed her left glove, rubbed hand sanitizer on the left hand, then donned a new glove. RN #1 did not remove the right glove, perform hand hygiene, or don a new glove before moving to a new task. 3. Observations on the treatment floor on 11/13/2023 beginning at 12:35 PM, revealed CCHT #1 performing initiation of dialysis via an AV Fistula. CCHT #1 typed on the computer, set up supplies, then began to clean the AV Fistula sites without first removing gloves, performing hand hygiene and donning a new pair of gloves. 4. Observations on the treatment floor on 11/13/2023 beginning at 1:10 PM revealed RN #2 performed discontinuation of dialysis with a CVC. At the end of the procedure, RN #2 removed gloves and put on a new pair of gloves without performing hand hygiene. In an interview on 11/15/2023 at 10:30 AM, the CM verified hand hygiene should be performed anytime gloves are removed, and when moving from a dirty to clean area or task.”

“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 intravenous medication by 1 of 2 nurses (RN #1) observed during medication preparation. The findings included: Review of the facility’s “MEDICATION ADMINISTRATION” policy (4/5/2022) revealed, “...Medications will be administered in a safe manner following infection control policies and the recommendations of federal and state regulatory agencies...Vials (applies to both single and multi-dose vials)...Disinfect rubber stopper with alcohol if it is a multiple use vial, which has been opened. Discard alcohol pad and use a new pad after each puncture...” Observations on the treatment floor on 11/13/2023 at 12:50 PM, revealed RN #1 punctured the rubber stopper of a vial of Heparin and withdrew medication into a syringe 6 times, using the same alcohol prep pad. In an interview on 11/15/2023 at 9:45 AM, the CM verified a new alcohol prep pad should be used after every entry into a medication vial.”

“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, medical record review, and interview, the facility failed to ensure medications to prevent CVC related infections were administered for 1 of 5 (Patient #1) sampled patients with a CVC; and failed to ensure measures to prevent CVC infections were followed by 1 of 2 (RN #1) RNs observed performing CVC site care. The findings included: 1. Review of the facility’s “Medication Administration” policy (4/5/2022) revealed, “...Medications will be administered in a safe manner...In the event that a medication is missed, the registered nurse must notify the nephrologist...log an incident and submit to the Center Manager for any adverse event or missed medication...” 2. Medical record review for Patient #1 revealed an admission date of 9/17/2021 with diagnoses which included ESRD, HIV and Hypertensive Chronic Kidney Disease. Review of the 2/8/2023 physician’s order revealed the patient was to received hemodialysis treatments 3 times a week via a CVC. The order further revealed “Gentamicin 320 mcg/ml...3 times per week /Cath Lock Art...Ven...” Review of the 8/31/2023 treatment flow sheet revealed no documentation Patient #1 received Gentamicin as ordered. There was no documentation of the reason the patient did not receive gentamicin as ordered. Review of the 9/14/2023 treatment flow sheet revealed no documentation Patient #1 received Gentamicin as ordered. There was no documentation of the reason the patient did not receive gentamicin as ordered. Review of the 9/19/2023 treatment flow sheet revealed no documentation Patient #1 received Gentamicin as ordered. There was no documentation of the reason the patientdid not receive gentamicin as ordered. Review of the 9/28/2023 treatment flow sheet revealed no documentation Patient #1 received Gentamicin as ordered. There was no documentation of the reason the patient did not receive gentamicin as ordered. Review of the 10/5/2023 treatment flow sheet revealed no documentation Patient #1 received Gentamicin as ordered. There was no documentation of the reason the patient did not receive gentamicin as ordered. Review of the 10/17/2023 treatment flow sheet revealed no documentation Patient #1 received Gentamicin as ordered. There was no documentation of the reason the patient did not receive gentamicin as ordered. Review of the 11/7/2023 treatment flow sheet revealed no documentation Patient #1 received Gentamicin as ordered. There was no documentation of the reason the patient did not receive gentamicin as ordered. In an interview on 11/15/2023 at 9:55 AM, the CM verified Gentamicin was not administered 3 times per week as ordered. 3. Observations on the treatment floor on 11/13/2023 beginning at 1:22 PM, revealed RN #1 donned gloves without performing hand hygiene then removed the old CVC dressing from the patient’s chest and discarded the dressing and gloves. RN #1 performed hand hygiene, donned new gloves and performed CVC site care and applied a new dressing. After the dressing was applied, the RN reached under her gown and obtained a pen from her uniform, dated and initialed the patient’s CVC dressing, then placed the pen back in her uniform. In an interview on 11/15/2023 at 10:06 AM, the CM verified hand hygiene should have been performed before the nurse donned gloves and started the procedure. The CM further verified it was unacceptable for the nurse to use the pen from her pocket to write on the patient’s CVC dressing.”

“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 review and interview the facility failed to accurately document administration of antihypertensives and failed to address hypertension for 3 of 10 (Patient #2, #3, and #4) sampled patients and failed to ensure the IDT revised, updated, and implemented individualized interventions to address shortened treatments for 2 of 10 (Patients #5 and #10) sampled patients. The findings included: 1 Review of the facility’s “HYPERTENSION” policy (5/8/2020) revealed, “...Hypertension may be an adverse event of hemodialysis treatment. Staff and patients are taught how to respond to this side effect including...In-center: Re-check blood pressure every 30 minutes; notify physician if hypertension not resolved with ultrafiltration at the end of dialysis...Document the situation including patient symptoms, all interventions and response to these interventions in the medical record...Hypertension Management...BP>/=180/100...Is the patient symptomatic?...No...Intervention...Notify physician if BP>/=180/100. Is NOT resolved with ultrafiltration...Document ALL Communication attempts and interactions with physician. Interdialytic interventions. Nursing assessments...” Review of the facility’s “COMPREHENSIVE ASSESSMENT AND PLAN OF CARE” policy (5/21/2020) revealed, “...PURPOSE...To perform assessments and develop a plan of care that considers every aspect of a patient’s wellbeing...The IDT members are expected to interact and share information from the comprehensive assessment to facilitate the development of the plan of care...The IDT if responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care...” 2 Medical record review for Patient #2 revealed an admission date of 8/21/2023 with diagnoses that included Hypertension and ESRD. Review of a 10/18/2023 order revealed the following medication: Clonidine HCL. Dosage/Strength- 1mg/0.1mg [sic]. Frequency- as needed. Route- oral. Review of Hemo Treatment Log Detail sheets beginning 10/18/2023 through 11/10/2023 revealed the following: 10/18/2023- 6:48 PM Dialysis treatment began. 7:32 PM bp 180/117. Clonidine was administered to Patient #2 for increased bp. There was no documentation of the dosage of Clonidine administered for increased bp. 8:32 PM - 170/111. Clonidine was administered to Patient #2. There was no documentation of the dosage of Clonidine administered. 10:20 PM - 174/115. Treatment ended. The notes documented Patient #2’s blood pressure remained elevated. There was no documentation of additional interventions provided by the nurse. 10:20 PM Dialysis treatment ended. 10:25 PM - The MAR documented Clonidine HCL 1mg was administered. Review of Patient #2’s post-dialysis vital signs revealed a blood pressure of 181/117. There was no documentation the nurse notified the physician of Patient #2’s continued elevated blood pressure post dialysis. 10/25/2023 - 6:23 PM Dialysis treatment began. 6:31 PM bp 155/103. The nurse documented DBP elevated, asymptomatic, administered Clonidine as ordered. 6:33 PM - The MAR documented Clonidine HCL 1mg PO was administered. 8:31 PM - bp 155/105. The nurse documented bp elevated, asymptomatic, and administered Clonidine. There was no documentation of the dosage of Clonidine administered. 9:57 PM Dialysis treatment ended. There was no documentation of Patient #2’s response to Clonidine. There was no documentation the physician was notified of the increased blood pressures during treatment. 3. Medical record review for Patient #3 revealed an admission date of 2/4/2022 with diagnoses that included Acute Kidney Failure. Review of the 2/16/2023 order revealed the following medication: Clonidine HCL. Dosage/Strength- 0.1mg/0.1mg. Frequency- as needed. Route- oral. An order dated 6/13/2023 revealed Clonodine HCL 3mg/0.1mg [sic]. Frequency - as needed. Route - oral. Review of Hemo Treatment Log Detail sheets beginning 8/5/2023 through 9/12/2023 revealed the following: 8/5/2023 - 1:05 PM bp 171/108. Dialysis treatment began. 1:31 PM - 163/106. 2:01 PM - 161/98. 2:31 PM - 168/117. 3:01 PM - 156/106. 3:51 PM - The MAR documented both Clonidine HCL 3 mg and Clonidine 0.1 mg were administered. There was no documentation of the patient’s response to the administration of Clonidine. 3:54 PM Dialysis treatment ended. There was no documentation the physician was notified of the increased bp during treatment. There was no documentation Clonidine was administered during treatment for the elevated blood pressures. 8/8/2023 - 11:01 AM bp 163/108. Dialysis treatment began. 11:02 AM - 179/126. The nurse documented DBP was elevated and will monitor. 11:32 AM - 184/124. The notes documented “medicated with clondine [clonidine] 0.1 mg po will monitor...” 12:02 PM - 187/126. The notes documented, “...remain hypertensive medicated with clondine [clonidine] 0.3 mg po per order...” 12:32 PM - 189/123. The notes documented, “hypertension/diastolic b/p noted...medicated with clondine [clonidine]...” There was no documentation of the dose of Clonidine administered. 1:02 PM - 213/134. 1:06 PM - 189/120. The notes documented, “...hypertensive/diastolic b/p noted...” 1:32 PM - 187/133. 2:02 PM - 190/132. 2:05 PM 190/125. The notes documented, “...hypertension/diastolic b/p noted patient alert denies chestpain or discomfort...” 2:32 PM - 206/129. 3:06 PM - The notes documented treatment ended and the patient’s blood was returned. 3:26 PM - The MAR documented Clonidine HCL 3 mg PO was given at 3:25 PM and Clonidine 0.1 mg PO was administered at 3:26 PM. There was no documentation of Patient #3’s response to Clonidine. There was no documentation the physician was notified of increased blood pressures during treatment. 8/10/2023 - 8:49 AM - The MAR documented both Clonidine HCL 3 mg PO and Clonidine 0.1 mg PO as needed were administered. 9:05 AM Dialysis treatment began. 9:06 AM The nurse documented BP elevated, asymptomatic gave Clonidine as ordered...” There was no documentation of the dose of Clonidine administered. 9:08 AM - bp 176/111. 9:32 AM - 183/116. The notes documented, “...BP remains elevated continuing to monitor...” 10:02 AM - 167/111. The notes documented, “...DBP elevated asymptomatic will monitor...” 10:32 AM - 160/110. The notes documented, “...DBP elevated asymptomatic will monitor...” 11:02 AM - 166/110. The notes documented, “...DBP elevated asymptomatic will monitor...” 11:32 AM - 163/108. The notes documented, “...DBP elevated asymptomatic will monitor...” 12:02 PM - 162/107. The notes documented, “...DBP elevated asymptomatic will monitor...” 12:32 PM - 135/102. The notes documented, “...DBP elevated asymptomatic will monitor...” 1:02 PM - 126/89. 1:08 PM - Dialysis treatment ended. There was no documetnation of the Patient’s response to Clonidine. There was no documentation the physician was notified of increased blood pressures during treatment. 8/12/2023 - 11:01 AM bp 177/112. Dialysis treatment began. 12:01 PM - 196/126. The notes documented, “...monitoring BP, pt remains asymptomatic, clonidine given...” There was no documentation of the dose of Clonidine administered. 12:31PM - 186/108. The notes documented, “...Monitoring BP...” 12:46 PM - 159/96. The notes documented, “...rechecking b/p.” 1:01 PM - 195/110. 1:36 PM - 183/114. 2:01 PM - 141/100. 3:01 PM 167/104. 3:17 PM The MAR documented Clonidine HCL 0.1 mg was given. 3:19 PM 142/99. 3:52 PM - The notes documented, “BP erratic, pt. asymptomatic post-tx, no overt s/sx noted...” There was no documentation of the Patient #3’s response to Clonidine. There was no documentation the physician was notified of increased blood pressures during treatment. 8/15/2023 - 11:01 AM bp 196/131. Dialysis treatment began. 11:11 AM - 192/121 The notes documented, “...bp rechecked... bp remains elevated, pt asymptomatic, feet down, monitoring.” 12:01 PM - 195/128. 12:31 PM - 189/123. The notes documented, “...BP elevated but trending down. UF goal increased to 4200. monitoring...” 12:51 PM - The MAR documented both Clonidine HCL 3 mg PO and Clonidine 0.1 mg PO were administered. 1:01 PM - 152/107. The notes documented, “...bp trending don [down]. pt asymptomatic. monitoring...” 1:31 PM - 124/89. 3:01 PM - Dialysis treatment ended. There was no documentation the physician was notified of elevated blood pressures during treatment. 9/1/2023 - 7:05 PM The MAR documented both Clonidine HCL 3 mg PO and Clonidine 0.1 mg PO were administered. 7:12 PM bp 186/127. Dialysis treatment began. 7:31 PM - 201/132. 8:01 PM - 217/139. The notes documented, “...BP elevated asymptomatic will monitor...” 8:31 PM - 206/138. The notes documented, “...BP elevated asymptomatic will monitor...” 9:01 PM - 172/131. The notes documented DBP elevated increased UF goal to 4300 will monitor.” 9:27 PM - 172/116. The notes documented,, “...DBP elevated asymptomatic.” 10:01 PM - The notes documented,”Hypertension BP elevated asymptomatic patient received clonidine as ordered and shortened tx...” Dialysis treatment ended. There was no documentation of the dose of Clonidine administered. There was no documetnation of the patient #3’s response to clonidine. There was no documentation the physician was notified of the increased blood pressures. 9/5/2023 - 11:39 AM The MAR documented both Clonidine HCL 3 mg PO and Clonidine 0.1 mg PO were administered. 11:41 AM - Dialysis treatment began. 11:49 AM - 190/133. The notes documented, “...BP and HR elevated apical pulse 100 asymptomatic gave clonidine as ordered will monitor.” There was no documentation of the dose of Clonidine administered. 12:01 PM - 187/125. 12:31 PM - 202/132. The notes documented, “...notified of hypertension/diastolic/sinus tachycardia, received clonidine earlier will monitor...” 1:01 PM - 198/129. 1:32 PM - 159/118. 2:01 PM - 138/104. The notes documented, “...Patient alert, B/p trending down diastolic noted asymptomatic will monitor...” 2:32 PM - 146/118. 2:53 PM The notes documented, “...BP and HR elevated asymptomatic tx ended blood returned.” Dialysis treatment ended. 5:40 PM The notes documented, “Diastolic post b/p 114 with sinus tachycardia pulse @ 114 denies chest pain or shortness of breath, discharge via stretcher home stable without complaints...” There was no documentation of the patient’s response to clonidine. There was no documentation the physician was notified of the elevated blood pressures during treatment. 9/7/2023 - 11:04 AM bp 161/112. Dialysis treatment began. The notes documented, “...Elevated bp noted, clonidine given...” There was no documentation of the dose of Clonidine administered. 11:32 PM - 174/123. 12:02 PM - 195/135. The notes documented, , “..hypertension/diastolic/pulse noted medicated with clonidine 0.1 mg po will monitor...” 12:09 PM - The MAR documented Clonidine HCL 3 mg PO was given. 12:32 PM - 189/130. The notes documented, “...blood pressure trend dow [down] slightly, monitoring...” 1:02 PM - 165/118. 1:32 PM - 146/111. The notes documented, “...Diastolic b/p noted asymptomatic will monitor...” 2:02 PM - 154/111. The notes documented, “...diastolic b/p noted patient stable will monitor...” 2:32 PM - 155/113. The notes documented, “...dbp remains elevated, feet down, monitoring...” 2:34 PM 157/112. 2:57 PM - 140/109. 2:58 PM - Dialysis treatment ended. 3:50 PM - The MAR documented Clonidine .1 mg was administered 5:22 PM The notes documented, “...Post Dialysis Nursing Assessment...Diastolic /pulse noted feet down will continue to monitor...” There was no documentation of the patient’s response to clonidine. There was no documentation the physician was notified of the elevated blood pressures during treatment. 9/9/2023 - 12:01 PM bp 146/100. Dialysis treatment began. 12:03 PM - 152/105. 12:33 PM - 147/101. 1:03 PM - 156/104. 1:33 PM - 149/94. 2:03 PM - 171/123. 2:07 PM - 167/120. 2:10 PM - 171/118. 2:45 PM - 162/114. 2:47 PM - 180/117. The notes documented, “...hypertension/diastolic/pulse noted received clonidine 0.1 mg b/p trending down will monitor...” 3:03 PM - 161/113. 3:34 PM - 143/110. 3:55 PM - Dialysis treatment ended. There was no documentation the physician was notified of the eleveated blood pressures during treatment. 9/12/2023 - 11:07 AM 188/128. Dialysis treatment began. The notes documented, “...hypertension/diastolic/sinus tachycardia noted patient states she just took home b/p meds will monitor...” 11:32 AM - 187/135. 12:02 PM - 187/127. The notes documented, “...patient b/p remains elevates [elevated] denies headache or dizziness at this time will continue to monitor...” 12:32 PM - 174/124. 1:02 PM - 178/130. 1:32 PM - 181/123. 1:43 PM - 186/116. 2:06 PM 187/134. The notes documented”...patient returned from restroom hypertension/diastolic/pulse noted medicated with clondine [clonidine].” There was no documentation of the dose of Clonidine administered. 2:32 PM - 166/127 2:33 PM - The MAR documented Clonidine HCL 3 mg PO was administered. . 3:02 PM - 183/126. 3:07 PM - 158/122. 4:08 PM - The notes documented, “...Post Dialysis Nursing Assessment...blood pressure elevated but trended down. pt asymptomatic, MD aware...” Dialysis treatment ended. There was no documenation to address the patient’s elevated blood pressures from 11:07 AM to 2:06 PM. 4. Medical record review for Patient #4 revealed an admission date of 2/26/2021 with diagnoses that included Hypertensive Chronic Kidney Disease and ESRD. Review of the 3/8/2023 order revealed the following medication: Clonidine HCL. Dosage/Strength- .1mg/.1mg.[sic] Frequency- as needed. Route- oral. Review of a 4/8/2022 order revealed Clonidine HCL 1 tab/.3 mg [sic] Frequency as needed. Route oral. Review of the Treatment Log Detail sheets beginning 9/6/2023 through 10/30/2023 revealed the following: 9/8/2023 2:22 PM The MAR documented Clonidine HCL 0.1 mg PO and Clonidine PO as1 tab were administered. There was no documentation of the dosage of the clonidine administered as ‘1 tablet’ to the patient. 2:36 PM 183/115. The notes documented, “...bp elevate; asymptomatic; medicated with clonidine.” There was no documentation of the dose of Clonidine administered. 3:01 PM _ 187/116. 3:31 PM - 155/110. The notes documented, “...bp remains elevated; asymptomatic; monitoring...” 4:01 PM - 180/102. The notes documented, “...bp remains elevated; asymptomatic; cuff adjusted; pt medicated with additional dose of clonidine...” There was no documentation of the dose of Clonidine administered. 4:31 PM - 164/110. 5:01 PM - 138/79. The notes documented, “...bp improved...” The patient’s blood pressure remained within normal limits the remainder of the treatment. 6:09 PM - Dialysis treatment ended. There was no documentation the physician was notified of the elevated blood pressures during treatment. 9/13/2023 10:15 AM 199/152. The notes documented”...Pt arrive w/elevated bp fluid overload [named physician] made rounds aware of condition...able to run tx...” Dialysis treatment began. 10:30 AM - 213/143. 10:41 AM The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as1 tab as needed were administered. There was no documentation to indicate the dosage of the Clonidine administered as ‘1 tablet.’ 11:00 AM - 200/136. 11:30 AM - 114/24. 11:41 PM - 103/25. 12:00 PM - 137/23. 12:06 PM - 154/99. 12:16 PM - 154/99. 12:31 PM - 126/20. 1:00 PM - 78/54. 1:10 PM - 120/66. 1:14 PM - 106/28. 1:16 PM - 104/63. 1:29 PM - 119/79. Dialysis treatment ended. 9/15/2023 2:02 PM The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as1 tab were administered. There was no documentation of the strength of clonidine administered as ‘1 tablet.’ Dialysis treatment began. 2:06 PM 232/144. The notes documented, “...bp elevated; medicated with clonidine...monitoring...” 2:32 PM - 154/105. The notes documented, “...bp improved...” 3:01 PM - 115/72. 3:36 PM - 43/27. The notes documented, “...bp low; asymptomatic; uf off...monitoring.” 3:59 PM - 109/72. The notes documented, “...bp improved; awake and alert; not feeling well; uf off; 100 ml saline given...” 4:02 PM - 145/100. 4:32 PM - 127/78. The patient’s blood pressure remained within normal limits the remainder of the treatment. 5:38 PM - Dialysis treatment ended. 9/20/2023 2:06 PM The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as1 tab were administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet. Dialysis treatment began. 2:10 PM 224/148. The notes documented, “...bp elevated; medicated with clonidine po...” 2:32 PM - 223/158. 3:02 PM - 218/139. The notes documented,, “...additional dose of clonidine given; pt remains asymptomatic...” There was no documentation of the dose of Clonidine administered. 3:32PM - 178/115. The notes documented,, “...bp improved...” 4:02 PM - 209/142. 4:32 PM - 207/118. The notes documented,, “...bp remains elevated; medicated with additional dose of clonidine...” There was no documentation of the dose of Clonidine administered. 5:02 PM - 210/135. 5:32 PM - 211/139. 6:02 PM - 165/114. The notes documented,”...bp improved; apical hr 68; no complaints...” 6:34 PM - 101/70. 6:38 PM - 211/151. 7:02 PM - 240/161. The notes documented,, “...bp remains elevated...” 7:07 PM - 224/139. 7:09 PM - Dialysis treatment ended. 7:17 PM - The notes documented, “htn Events-Symptoms...bp remains elevated; encouraged pt to go to ed due to sustained htn; pt remains asymptomatic; state that she will go the ed; provider aware..” There was no documentation to indicate the amount of the Clonidine administered ‘as 1 tablet’. 9/21/2023 12:02 PM bp 217/138. Dialysis treatment began, 12:07 PM - 207/141 The notes documented, “...Hypertension/diastolic b/p noted patient states she took home med will monitor...” 12:32 PM - 219/148. The notes documented, “...hypertension/diastolic b/p noted nurse practitioner making rounds aware, patient medicated with clonidine...” There was no documentation of the dose of Clonidine administered. 1:03 PM - 209/147. The notes documented, “...remains hypertensive/diastolic b/p noted feet down...” 1:20 PM - The MAR documented Clonidine PO as1 tab was administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet.’ 1:32 PM - 147/105. The notes documented, “...b/p trended down diastolic notes patient stable...” 2:18 PM - Dialysis treatment ended. There was no documentation the physician was notified of elevated blood pressures during treatment. 9/29/2023 2:39 PM The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as1 tab as needed were administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet.’ 2:43 PM 220/135. The notes documented, “...bp elevated...medicated with clonidine po- MD aware of pt elevated bp...” Dialysis treatment began. 3:02 PM - 204/116. The notes documented, “...bp elevated; asymptomatic...medicated with clonidine po.” There was no documentation of the dose of Clonidine administered. 3:32 PM - 178/119. The notes documented,”...bp improved...” 4:02 PM - 201/120. The notes documented,”...bp elevated; asymptomatic; additional dose of clonidine given...” There was no documentation of the dose of Clonidine administered. 4:32 PM - 190/118. 5:02 PM - 159/98. The notes documented, “...bp wnl...” 5:32 PM - 159/90. 5:55 PM - 175/114. The notes documented,, “...tx terminated. will reassess bp prior to pt leaving clinic floor. 6:04 PM “Post-Dialysis” 175/107. 10/2/2023 3:42 PM The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as1 tab were administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet.’ Dialysis treatment began. 3:50 PM 207/150. The notes documented, “...bp elevated...medicated with clonidine...” 4:01 PM - 199/140. 4:31 PM - 144/108. The notes documented, “...bp improved but remains high...” 5:01 PM - 161/110. 5:31 PM 178/86. The notes documented, “...bp wnl...” 6:01 PM - 163/107. 6:02 PM - Dialysis treatment ended. 6:10 PM “Post-Dialysis” 166/109. There was no documentation the physician was notified of the increased blood pressures during the treatment. 10/9/2023 2:38 PM The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as1 tab were administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet.’ 2:44 PM 174/123. The notes documented, “...bp elevated...medicated with clonidine; provider aware of htn...” 2:45 PM - 185/108. 3:00 PM - 177/103. 3:01 PM - 192/116. 3:30 PM - 187/120. The notes documented, “...bp elevated; asymptomatic; medicated with clonidine po.” There was no documentation of the dose of Clonidine administered. 4:01 PM - 179/112. 4:30 PM - 151/103. The notes documented, “...bp remains elevated; asymptomatic...” 5:00 PM - 181/119. 5:21 PM - 117/113. The notes documented, “...bp remains elevated; cuff adjusted...pt states ‘i [I] feel great’...” 5:30 PM - 168/111. 6:00 PM - 180/117. The notes documented, “...bp remains elevated; provider aware of htn...” 6:28 PM - 187/138. Dialysis treatment ended. There was no documentation to indicate the amount of Clonidine administered as ‘1 tablet.’ 10/13/2023 2:23 PM bp 161/120. Dialysis treatment began. 2:24 PM - 188/108. 2:30 PM - 157/102. 3:00 PM - 162/109. 3:31 PM - 143/102. 4:00 PM - 151/105. 4:30 PM - 133/98. 4:50 PM - The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as ‘1 tablet’ were administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet.’ 5:00 PM - 160/107. 5:30 PM - 177/103. 6:00 PM - 156/98. 6:13 PM - 170/110. 6:14 PM - 152/113. Dialysis treatment ended. There was no documentation in the treatment notes to indicate the RN was aware of the patient’s hypertension. There was no documentation the patient’s provider was aware of the elevated bps during the treatment. 10/16/2023 3:12 PM The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as1 tab as needed were administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet.’ 3:17 PM 223/141. The notes documented, “...bp elevated...medicated with clonidine po.” Dialysis treatment began. 3:32 PM - 161/120. 4:02 PM - 152/96. The notes documented, “...bp improved...” 4:31 PM - 166/91. 5:02 PM - 200/162. The notes documented, “...cuff adjusted will reassess...bp low uf off...” 5:32 PM - 92/54. 6:03 PM - 87/77. The notes documented, “...Patient alert.” 6:06 PM - 111/63. The notes documented, “...bp improved- monitoring...” 6:33 PM - 123/78. Patient #4’s blood pressure remained wnl the remainder of the treatment. 7:28 PM - Dialysis treatment ended. 10/18/2023 2:30 PM The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as ‘1 tablet’ were administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet.’ Dialysis treatment began. 2:33 PM- 160/103. The notes documented, “...bp elevated; asymptomatic; monitoring...” 3:00 PM - 141/97. The notes documented, “...bp improved...” 3:30 PM - 143/93. 4:00 PM - 127/79. 4:30 PM 129/75. 5:00 PM 93/74. The notes documented, “...bp low; cuff adjusted; will reassess...” 5:30 PM - 124/83. The notes documented, “...bp wnl...” Patient #4’s blood pressure remained wnl the remainder of the treatment. 6:32 PM - Dialysis treatment ended. 10/20/2023 2:18 PM The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as ‘1 tablet’ were administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet.’ 2:22 PM - 215/144. Dialysis treatment began. 2:32 PM 199/136. 3:02 PM 208/143. 3:33 PM 221/136. The notes documented, “...bp remains elevated; pt complains of cramping; uf off...” 4:03 PM - 200/126. 4:33 PM - 215/100. The notes documented, “...bp slightly improved; still complaints of cramping on and off...” 5:02 PM - 210/138. 5:32 PM - 215/140. The notes documented, “...bp elevated; additional dose of clonidine given...” There was no documentation of the dose of Clonidine administered. 5:51 PM - 224/141. The notes documented, “...pt c/o feeling light headed and cramping; adjusted UFG and turned UF of [off]...” 6:03 PM - 221/135. 6:21 PM - 208/140. The notes documented, “...tx terminated...pt encouraged to go to ed for sustained elevated bp...” There was no documentation the physician was notified of elevated blood pressures during the treatment. 10/30/2023 2:54 PM. The MAR documented both Clonidine HCL 0.1 mg PO and Clonidine PO as ‘1 tablet’ were administered. There was no documentation of the dosage of clonidine administered as ‘1 tablet.’ 2:55 PM - 103/75. 3:01 PM - 235/128. The notes documented, “...bp elevated; asymptomatic; monitoring...” 3:31 PM - 169/138. 4:01 PM - 177/90. The notes documented, “...bp improved...” 4:33 PM 146/95. 5:01 PM - 157/101. The notes documented, “...bp elevated...” 5:41 PM - 170/117. 6:00 PM 178/117. The notes documented, “...bp remains elevated; asymptomatic...” 6:23 PM - 175/102. 6:30 PM - Dialysis treatment ended. 6:32 PM “Post-Dialysis” 177/104. There was no documentation the physician was notified of the elevated blood pressures during treatment. 5. Medical record review for Patient #5 revealed an admission date of 12/20/2020 with diagnoses that included HTN and ESRD. Review of 3/10/2023 dialysis orders revealed treatment length of 240 minutes (4 hours). Review of 15 Hemo Treatment Log Detail sheets beginning 10/4/2023 through 11/13/2023 revealed Patient #5 shortened 6 of the 15 treatments. Review of Patient #5’s Patient Conference Report (plan of care) revealed a “problem” of “Non-adherence to dialysis treatment prescription/schedule” started 4/25/22 with a target date of 10/31/2023. Review of IDT notes beginning 6/1/2023 through 11/1/2023 revealed no documentation of updated, revised or individualized interventions to address Patient #5’s continued non-compliance with treatment time. 6. Medical record review for Patient #10 revealed an admission date of 3/6/2023 with diagnoses that included ESRD. Review of 3/6/2023 dialysis orders revealed treatment length of 210 minutes (3.5 hours). Review of 15 Hemo Treatment Log Detail sheets beginning 10/4/2023 through 11/10/2023 revealed Patient #10 shortened 8 of the 15 treatments. Review of a 5/1/2023-11/13/2023 Plan of Care revealed no documentation of problems with non-adherence to treatment times or prescription. Review of IDT notes beginning 5/1/2023 through 11/13/2023 revealed on 8/7/2023 Patient #10’s nurse practitioner documented, “...long discussion on need for strict adherence with scheduled HD treatments and risks associated with missing treatments...” There were no documentation to revise or individualize interventions implemented after 8/7/2023 to address Patient #10’s continued non-compliance with treatment times. In an interview on 11/15/2023 at 10:00 AM the CM verified there were no new or individualized interventions to address Patient #5 and #10’s continued non-compliance with treatment times.”

“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 and interview, the facility failed to ensure physician’s orders for prescribed BFR and DFR were followed for 10 of 10 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) sampled hemodialysis patients. The findings included: 1. Review of the facility’s “Adequacy for In-Center hemodialysis Protocol” policy (1/9/2020) revealed, “...To ensure that treatment orders enable all patients to receive an adequate delivered dialysis dose...Procedure...If prescribed blood flow rate is not achieved within 50ml/min, notify physician of actual delivered BFR and request orders to decrease BFR or increase time to achieve prescribed adequacy...Note: Documentation should accompany when prescribe [prescribed] flow is not met...” Review of the facility’s “Initiation of Hemodialysis Treatment...” policy reviewed 6/2/2023 revealed, “...When there is a variance between the actual blood flow rate (BFR) and the prescirbed BFR, document the reason for the variance in the treatment record...” 2. Medical record review for Patient #1 revealed an admission date of 9/17/2021 with diagnoses which included ESRD, HIV, and Hypertensive Chronic Kidney Disease. Review of the 2/8/2023 physician’s order revealed a BFR of 400 cc/min. Review of the 9/5/2023 treatment flow sheet revealed the BFR was 350 from 12:01 PM until 2:12 PM. There was no documentation why the BFR was not delivered as ordered at 400 cc/min. Review of the 9/23/2023 treatment flow sheet revealed the BFR was 350 from 11:03 AM until 2:03 PM. There was no documentation why the BFR was not delivered as ordered at 400 cc/min. Review of the 9/28/2023 treatment flow sheet revealed the BFR was 350 from 11:01 AM until 3:02 PM. There was no documentation why the BFR was not delivered as ordered at 400 cc/min. Review of the 10/5/2023 treatment flow sheet revealed the BFR was 350 at 2:01 PM, “0” at 2:31 PM and 300 from 3:01 PM through 3:31 PM. There was no documentation why the BFR was not delivered as ordered at 400 cc/min. Review of the 10/17/2023 treatment flow sheet revealed the BFR was 350 from 10:31 AM until 2:02 PM. There was no documentation why the BFR was not delivered as ordered at 400 cc/min. Review of the 11/7/2023 treatment flow sheet revealed the BFR was 350 from 11:32 AM until 2:02 PM. There was no documentation why the BFR was not delivered as ordered at 400 cc/min. Review of the 11/9/2023 treatment flow sheet revealed the BFR was 200 from 12:02 PM until 12:32 PM, 300 from 1:02 PM until 1:32 PM, 250 at 2:02 PM, “0” at 2:32 PM and 250 at 3:03 PM.There was no documentation why the BFR was not delivered as ordered at 400 cc/min. 3. Medical record review for Patient #2 revealed an admission date of 8/21/2023 with diagnoses which included Hypertension and ESRD. Review of the 8/21/2023 physician’s order revealed a BFR of 350 cc/min. Review of the 10/4/2023 treatment flow sheet revealed the BFR was 300 from 5:35 PM until 8:52 PM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. Review of the 10/13/23 treatment flow sheet revealed the BFR was 300 from 6:31 PM until 8:38 PM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. Review of the 10/16/23 treatment flow sheet revealed the BFR was 400 from 4:58 PM until 8:30 PM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. Review of the 10/18/23 treatment flow sheet revealed the BFR was 400 from 6:48 PM until 10:20 PM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. Review of the 11/3/23 treatment flow sheet revealed the BFR was 300 from 5:51 PM until 8:59 PM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. 4. Medical record review for Patient #3 revealed an admission date of 2/4/2022 with diagnoses which included ESRD and Acute Kidney Failure. Review of the 4/4/2023 physician’s order revealed a BFR of 350 cc/min. Review of the 8/5/2023 treatment flow sheet revealed the BFR was 305 from 1:05 PM until 3:31 PM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. 5. Medical record review for Patient #4 revealed an admission date of 2/26/2021 with diagnoses which included ESRD and Hypertensive Chronic Kidney Disease. Review of the 4/5/2023 physician’s order revealed a BFR of 400 cc/min. Review of the 9/13/2023 treatment flow sheet revealed the BFR was 350 from 10:30 AM until 1:29 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. 6. Medical record review for Patient #5 revealed an admission date of 12/30/2020 with diagnoses which included HTN and ESRD. Review of the 3/10/2023 physician’s order revealed a BFR of 450 cc/min. Review of the 10/25/2023 treatment flow sheet revealed the BFR was 400 from 4:10 PM until 8:02 PM. There was no documenation why the BFR was not delivered as ordered at 450 cc/min. Review of the 11/13/23 treatment flow sheet revealed the BFR was 400 from 4:32 PM until 6:03 PM. There was no documenation why the BFR was not delivered as ordered at 450 cc/min. 7. Medical record review for Patient #6 revealed an admission date of 2/4/2022 with diagnoses which included ESRD, Type 1 Diabetes Mellitus and HTN. Review of the 4/5/2023 physician’s order revealed a BFR of 300 cc/min. Review of the 8/30/2023 treatment flow sheet revealed the BFR was 350 from 6:29 AM until 8:35 AM. There was no documenation why the BFR was not delivered as ordered at 300 cc/min. 8. Medical record review for Patient #7 revealed an admission date of 8/17/2023 with diagnoses which included HTN, DM and ESRD. Review of the 8/17/2023 physician’s order revealed a BFR of 350 cc/min. Review of the 10/12/2023 treatment flow sheet revealed the BFR was 290 from 6:05 AM until 9:33 AM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. Review of the 10/24/2023 treatment flow sheet revealed the BFR was 250 from 6:02 AM until 8:01 AM, then 275 from 8:01 AM until 9:31 AM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. 9. Medical record review for Patient #8 revealed an admission date of 4/14/2023 with diagnoses which included HTN and ESRD. Review of the 4/14/2023 physician’s order revealed a BFR of 350 cc/min. Review of the 10/9/2023 treatment flow sheet revealed the BFR was 250 from 9:47 AM until 1:44 PM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. Review of the 10/18/2023 treatment flow sheet revealed the BFR was 300 from 9:59 AM until 1:51 PM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. Review of the 11/3/2023 treatment flow sheet revealed the BFR was 250 from 9:50 AM until 1:01 PM, then 300 from 1:01 PM until 1:49 PM. There was no documenation why the BFR was not delivered as ordered at 350 cc/min. 5. Medical record review for Patient #9 revealed an admission date of 12/3/2021 with diagnoses which included ESRD and HTN. Review of the 4/5/2023 physician’s order revealed a BFR of 400 cc/min. Review of the 10/23/2023 treatment flow sheet revealed the BFR was 300 from 2:02 PM until 4:32 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. Review of the 10/30/2023 treatment flow sheet revealed the BFR was 300 from 1:32 PM until 2:32 PM and 200 from 3:02 PM until 4:42 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. Review of the 11/6/2023 treatment flow sheet revealed the BFR was 350 from 2:02 PM until 4:25 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. Review of the 11/10/2023 treatment flow sheet revealed the BFR was 350 from 2:33 PM until 4:30 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. 11. Medical record review for Patient #10 revealed an admission date of 3/6/2023 with diagnoses which included ESRD. Review of the 3/6/2023 physician’s order revealed a BFR of 400 cc/min. Review of the 10/9/2023 treatment flow sheet revealed the BFR was 350 from 2:01 PM until 5:01 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. Review of the 10/16/2023 treatment flow sheet revealed the BFR was 305 from 3:01 PM until 4:31 PM, and 260 from 4:31 PM until 5:18 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. Review of the 10/18/2023 treatment flow sheet revealed the BFR was 300 from 2:31 PM until 2:38 PM, and 330 from 2:38 PM until 4:02 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. Review of the 10/20/2023 treatment flow sheet revealed the BFR was 300 from 2:01 PM until 4:31 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. Review of the 11/3/2023 treatment flow sheet revealed the BFR was 300 from 3:01 PM until 5:06 PM. There was no documenation why the BFR was not delivered as ordered at 400 cc/min. In an interview on 11/15/2023 at 9:25 AM, the CM verified staff were expected to document the reason when the prescribed BFR was not followed.”

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 33763 Based on policy review, medical record review and interview, the facility failed to provide nutritional supplements for 1 of 9 (Patient #6) sampled patients with ordered nutritional supplements. The findings included: 1. Review of the facility’s “Comprehensive Assessment and Plan of Care” policy (5/21/2020) revealed, “...The IDT members are expected to interact and share information from the comprehensive assessment to facilitate the development of the plan of care... The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care...” Review of the facility’s “Medication Administration” policy (4/5/2022) revealed, “...In the event that a medication if missed, the registered nurse must notify the nephrologist...log an incident and submit to the Center Manager for any adverse event or missed medication. The event and intervention must also be documented on the treatment log of the patient...” 2. Medical record review for Patient #6 revealed an admission date of 1/27/2021 with diagnoses which included ESRD, Type 1 Diabetes Mellitus and HTN. Review of the 3/3/2023 physician’s order revealed IDPN 433 ml via IV 3 times a week. Review of the Patient Conference Report dated 6/1/2023 to 11/13/2023 revealed, “...Nutrition Support albumin 3.3 g/dL collected 08/12/2022... Progress Note NP in clinic today and notified RD that pt is not tolerating IDPN. NP states pt is having diarrhea... RD called...and spoke with pharmacist. Pharmacist recommend that pt be placed on hold for one week to allow for the gut to rest and f/u with RD in the next couple of weeks to re-evaluate IDPN use for pt 05/04/2023...” Review of a physician’s progress note dated 6/14/2023 revealed, “...Nutrition: Albumin 2.8 g/dl (05/01/2023) On target: [No]... Protein supplementation [Yes] IDPN...” Review of the Patient Conference Report dated 6/1/2023 to 11/13/2023 revealed, “...Nutrition Support “...Progress Note Patient says that anything he is provided in the center gives him diarrhea and he will refuses [refuse] to take. Spoke with doctor and doctor stated he will speak with him and inform him that his diarrhea is not caused by any medicine he received in clinic...6/27/2023...” Review of the Patient Conference Report dated 6/1/2023 to 11/13/2023 revealed, “... Doctor... Monthly Comprehensive... Nutrition: Albumin 3.1 g/dl (08/02/2023)... Protein supplementation [Yes] IDPN...8/28/23...” Review of a physician’s progress note dated 8/28/2023 revealed, “... Nutrition: Albumin 3.1 g/dl (08/02/2023) On target: [No]... Protein supplementation [Yes] IDPN...” Review of a physician’s progress note dated 9/12/2023 revealed, “... Nutrition: Albumin 3.1 g/dl (08/02/2023)... Protein supplementation [Yes] IDPN...” Review of the Patient Conference Report dated 6/1/2023 to 11/13/2023 revealed, “... Doctor... Monthly Comprehensive... Nutrition: Albumin 3.1 g/dl (08/02/2023)... Protein supplementation [Yes] IDPN...10/10/23...” Review of the 6/21/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 6/23/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 6/26/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 8/2/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 8/7/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 8/9/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 8/28/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 8/30/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 9/6/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 9/8/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 9/11/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 10/30/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 11/1/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 11/3/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. Review of the 11/8/2023 treatment flow sheet revealed no documentation IDPN was administered as ordered. There was no documentation on the treatment flow sheets why IDPN was not administered. 3. In an interview on 11/15/2023 at 9:45 AM, the RD stated IDPN was recommended for patients whose nutritional status was “really bad,” because it can be absorbed more readily than oral nutritional supplements. The RD stated Patient #6’s IDPN had been on hold, but then stated, “I’m not sure if he’s getting it now or not...” In an interview on 11/15/2023 at 9:55 AM, the CM stated Patient #6 “...It [IDPN] hasn’t been ordered since May, the order should have been discontinued.””

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 33763 Based on policy review, medical record review and interview, the facility failed to ensure physician orders for Heparin administration were followed for 2 of 9 (Patient #7 and 8) sampled patients receiving Heparin. The findings include: 1. Review of the facility’s “MEDICATION ADMINISTRATION” policy (4/5/2022) revealed, “...Medications will be administered in a safe manner following infection control policies and the recommendations of federal and state regulatory agencies... Documentation... Document electronically to indicate the date, time, route and location if indicated...” 2. Medical record review for Patient #7 revealed an admission date of 8/17/2023 with diagnoses that included HTN, DM and ESRD. Review of 8/17/2023 physician orders revealed, “...Heparin Load: 2000 units. Hourly Dose: 1500... Total Heparin 7250 units...” Review of Hemo Treatment Log Detail sheets from 10/7/2023 through 11/11/2023 revealed no documentation Patient #7 received the ordered hourly dosage of Heparin on 10/10/2023 and 10/28/2023. 3. Medical record review for Patient #8 revealed an admission date of 4/14/2023 with diagnoses that included HTN and ESRD. Review of 4/14/2023 physician orders revealed, “... Heparin Load: 5000 units. Hourly Dose: 1000 units...Total Heparin: 9000 units...” Review of Hemo Treatment Log Detail sheets from 10/9/2023 through 11/10/2023 revealed no documentation Patient #8 received the ordered hourly dosage of Heparin on 10/9/2023, 10/18/2023 and 11/3/2023. 4. In an interview on 11/15/2023 at 10:00 AM, the CM verified the Heparin orders for Patient #7 and Patient #8 were not followed for all treatment days reviewed.”