Fresenius Medical Care Baytown Dialysis

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to protect against bacterial and viral cross-contamination by not changing out wetted transducer protectors in a timely manner: Hemodialysis machine #26 Findings: Review of facility’s current policy and procedure on Maintenance of Transducer Protectors published 11/07/2022, reference number 47275 version 2 directs staff as follows: Background The transducer protectors must be dry to provide accurate venous and arterial pressures. Cross contamination can occur if the internal transducer becomes contaminated with blood and is not disinfected or changed before the machine is used on another patient. Policy The transducer protector must be changed immediately when contaminated with saline or blood. If the back of the transducer protector is contaminated with blood, the internal transducer must be checked by biomedical staff prior to use of the machine for another patient for contamination and changed or disinfected as necessary. The internal transducer will be examined on at least an annual basis in the home, semiannual basis, or 2000 hours, whichever comes first in the clinic, and any time maintenance is performed by the biomedical staff as part of routine maintenance. Patient #2: Station #21 Hemodialysis Machine #26 On 09/30/2024 at 8:59 a.m. Patient #2 was observed at station #21 hemodialysis machine #26 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of Autoflow 600 mL/min via a left lower arm vascular access. There was light red tinged fluid inside of the venous chamber transducer protector. Subsequent observation at 9:47 a.m. revealed the light red tinged fluid was still present inside of the transducer protector. The Surveyor immediately notified Patient Care Technician (D) who confirmed that the transducer protector was wetted and then she replaced it with a new one.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 48020 Based on observation, interview, and record review, the facility’s governing body failed to ensure that the light covers were cleaned and free of pests and the floor tiles were free of buildup and cracks in the hemodialysis treatment area. Findings: Observation of the hemodialysis treatment floor on 09/30/2024 at 9:17 a.m. revealed the following: Light covers with dust and dead pests in them: a single row of light covers near the wall, starting in POD 1 and moving across the treatment floor to POD 9 were dirty. Black buildup on the floor tiles by the handwashing sinks, starting in POD 1 and moving across the treatment floor to POD 9. White buildup on floor tiles underneath some of the hemodialysis machines in every POD. The floor tiles #s 21 & 22 has cracks in the seams in front of the hemodialysis machines. Interview on 09/30/2024 during a walk-through of the treatment floor, the Senior Regional Manager verified the findings up above. Review of the Facility’s Patient Grievance Report on 10/01/2024 revealed that the facility received the following grievances: 1. 08/27/2024- the patient complained, “Floors with this much wear and tear, need to be done more often.” 2. 08/28/2024- the patient complained, “The floors are dirty and need to be buffed and properly cleaned.” Interview with the Facility’s Clinical Manager on 10/01/2024 revealed the treatment floor was waxed two weeks prior to the survey.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s governing body failed to ensure expired supplies are not stored and ready for use on the emergency cart. Findings: Review of the Bemis “Expiration Information: Canisters & Liners” revealed: “All Bemis Canisters and Liners include an expiration date on the carton label and individual product. Expiration is three (3) years from the date of manufacture. Canisters and Liners should not be used past the labeled expiration date. Structural integrity can be compromised by factors such as, heat, time, and light exposure. Placing a negative vacuum on a compromised canister/liner can result in product failure.” Observation of the emergency cart on 09/30/2024 at 09:28 a.m. revealed a Bemis Suction Canister attached to the suction machine with the expiration date of 10/2013. In the 4th drawer revealed two Zoll CPR Stat-padz used for the automated external defibrillator (AED) , Lot 3722A, expiration date 2024-09-10. Interview on 09/30/2024 at 9:30 a.m. with Registered Nurse (B) confirmed the Bemis suction canister and the Zoll AED pads were expired.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 48020 Based on observation, interview and record review Facility’s Registered Nurses failed to ensure patients’ hemodialysis treatments were administered based on the physician’s order in 7 of 17 sampled patients: Patient #s 1, 8, 10, 6, 16, 11 and 13 Findings: Normal Saline Flushes Patient #1 On 09/30/2024 at 8:31 a.m., Patient #1 was observed at station #37 machine #31 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of Autoflow 1.5 mL/min via a left upper arm vascular access. Review of the hemodialysis orders pulled up in the chairside computer by the patient care technician and the physician’s order dated 01/05/2024 found in patient’s clinical record revealed: “Special Attention: NO HEPARIN d/t excessive bleeding while holding. Pt is taking Eliquis, 50mL NS flushes every 30 mins., Every Treatment” Current Treatment Sheets: Review of the patient’s treatment sheet dated 09/25/2024 revealed the patient received hemodialysis treatment from 7:52 a.m. to 11:45 a.m. and 50 mL of normal saline was administered at 8:42 a.m. and 100 mL normal saline was administered at 11:09 a.m. by the patient care technician. No other normal saline flushes were documented. Review of the patient’s treatment sheets dated 09/23/2024 and 09/27/2024, revealed no normal saline flushes were documented during the hemodialysis treatments. Treatment sheets prior to self-reported hospital transfer: Review of the patient’s treatment sheet dated 04/05/2024, revealed the patient received hemodialysis treatment from 7:30 a.m. to 11:32 a.m. and no normal saline flushes were documented during the hemodialysis treatment. Patient #8 On 09/30/2024 at 9:11 a.m., Patient #8 was observed at station #7 machine #7 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of Autoflow 800 mL/min via a left central venous catheter. The patient was not receiving Heparin. Review of the hemodialysis orders pulled up in the chairside computer by the patient care technician and the physician’s order dated 11/11/2024 found in patient’s clinical record revealed: “Special Attention: FLUSH LINES 50cc Q30 MIN, Every Treatment” Review of the patient’s treatment sheet dated 09/30/2024 revealed the patient received hemodialysis treatment from 8:11 a.m. to 12:07 p.m. and 100 mL of normal saline was administered at 9:10 a.m. by the licensed practical nurse and 100 mL of normal saline was administered at 9:16 a.m. by the registered nurse for blood pressure support. No other normal saline flushes were documented. Patient #10 On 10/01/2024 at 9:11 a.m., Patient #10 was observed at station #35 machine #25 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of a600 mL/min via a left upper arm vascular access. The patient was not receiving Heparin. Review of the hemodialysis orders pulled up in the chairside computer by the patient care technician and the physician’s order dated 10/26/2023 found in patient’s clinical record revealed: “Special Attention: NO HEPARIN **FLUSH Q30 MIN 50CC NA**, Every Treatment” Current Treatment Sheets: Review of the patient’s treatment sheet dated 09/17/2024, 09/19/2024, 09/21/2024, 09/24/2024, 09/26/2024, 09/28/2024, revealed no normal saline flushes were documented during the hemodialysis treatments. Treatment sheets prior to self-reported hospital transfer: Review of the patient’s treatment sheet dated 11/30/2023, 12/02/2023 and 12/05/2023, revealed the no normal saline flushes were documented during the hemodialysis treatments. During an interview on 10/01/2024 at 11:56 a.m., the clinical manager confirmed the Patient #s 1, 8 and 10 did not receive 50 mL normal saline flushes every 30 minutes as prescribed for the dates in question. Blood Flow Rates Patient #6 On 09/30/2024 at 8:56 a.m., Patient #8 was observed at station #20 machine #17 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of Autoflow 700 mL/min via a right upper arm vascular access. Review of the patient’s clinical record revealed a physician’s order dated 09/20/2024 with the prescribed blood flow rate of 350 mL/min. Treatment sheet dated 09/16/2024 Review of the patient’s treatment sheet dated 09/16/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 350 mL/min but received hemodialysis treatment at a blood flow rate of 400 mL/min from 8:09 a.m. - 10:00 a.m. There was no justification documented for the blood flow rate of 400 mL/min. Patient #16 Review of the patient’s clinical record (demographic data) on 09/30/2024 revealed the patient was admitted to the facility 03/17/2023. Review of the patient’s clinical record revealed a physician’s order with the prescribed blood flow rate of 350 mL/min. Treatment sheet dated 08/10/2023 Review of the patient’s treatment sheet dated 08/10/2023 revealed documentation which indicated the patient was prescribed a blood flow rate of 350 mL/min but received hemodialysis treatment at a blood flow rate of 300 mL/min from 11.30 a.m. - 15:53 p.m. There was no justification documented for the blood flow rate of 300 mL/min. Patient #11 Review of the patient’s clinical record (demographic data) on 10/01/2024 revealed the patient was admitted to the facility 08/08/2023. Review of the patient’s clinical record revealed a physician’s order dated 09/14/2024 with the prescribed blood flow rate of 400 mL/min. Treatment sheet dated 09/24/2024 Review of the patient’s treatment sheet dated 09/24/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min but received hemodialysis treatment at a blood flow rate of: 350 mL/min from 8:37 a.m. - 10:33 a.m. and 300 mL/min from 11:05 a.m. - 11:35 a.m. There was no justification documented for the blood flow rates of 350 mL/min and 350 mL/min. Patient #13 Review of the patient’s clinical record (demographic data) on 10/01/2024 revealed the patient was admitted to the facility 06/07/2022. Review of the patient’s clinical record revealed a physician’s order dated 07/25/2024 with the prescribed blood flow rate of 400 mL/min. Treatment sheet dated 09/21/2024 Review of the patient’s treatment sheet dated 09/21/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min but received hemodialysis treatment at a blood flow rate of: 500 mL/min from 10:59 a.m. - 13:51 p.m. There was no justification documented for the blood flow rates of 500 mL/min. During an interview on 10/01/2024 at 12:00 p.m., the clinical manager confirmed Patient #s 6, 16, 11 and 13 did not receive treatment at the prescribed blood flow rate for the dates in question.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 48020 Based on observation, record review and interview: the facility’s: registered nurses failed to conduct post treatment assessment on patients when patients experienced a change in condition pre or during hemodialysis treatment in 4 of 17 sampled and closed patients: Patient #s 1, 9, 3 and 16 B) patient care technicians failed to reposition the patient’s blood cuff or report the Systolic blood pressures greater than 180 mm/Hg to the nurse in 2 of 17 sampled and closed patients: Patient #s 5 and 16 Findings: Review of the facility’s current Policy and Procedure on Patient Assessment and Monitoring; Policy # 45284, published 05/01/2023 directs staff as follows: Data Collection Direct patient care staff may collect data such as weight, BP, pulse, respirations, temperature, general observations, access, and complaints reported by the patient. If the PCT/LPN note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. o The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. During Treatment o Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. o Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations. Follow the steps below for monitoring patient and machine parameters during treatment: Step Action/Rationale 1 Blood Pressure Record blood pressure. o Recheck blood pressures after a drop that requires interventions such as administering normal saline. o Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to the nurse: o Systolic blood pressures greater than 180 mm/Hg o Diastolic blood pressure greater than 100 mm/Hg o Blood Pressure less than or equal to 100 mm/Hg Patient #5 On 09/30/2024 at 8:27 a.m., Patient #5 was observed at station #32 machine #39 receiving hemodialysis treatment at a blood flow rate of 300 mL/min and dialysate flow rate of 500 mL/min via a left central venous catheter. Vital signs were as follows: blood pressure 168/42 pulse 52 beats per minute. Review of the patient’s clinical record on 09/30/2024 revealed the following: Treatment sheet dated 09/27/2024: Review of treatment sheet dated 09/27/2024 revealed the following documentation: 07:56 a.m.: documented blood pressure of 135/40 and pulse rate of 63 beats per minute - Treatment initiated 08:00 a.m.: documented blood pressure of 185/52 and pulse rate of 63 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 08:35 a.m.: documented blood pressure of 159/55 and pulse rate of 61 beats per minute 09:00 a.m.: documented blood pressure of 186/62 and pulse rate of 52 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 09:30 a.m.: documented blood pressure of 192/61 and pulse rate of 51 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 10:04 a.m.: documented blood pressure of 196/66 and pulse rate of 52 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 10:32 a.m.: documented blood pressure of 183/56 and pulse rate of 54 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 11:00 a.m.: documented blood pressure of 151/50 and pulse rate of 64 beats per minute - PCT documented, “Denies Complaints; Patient Alert; Treatment Discontinued” The Patient Care Technician (PCT) did not reposition the patient’s blood cuff or report the Systolic blood pressures greater than 180 mm/Hg to the nurse. Patient #1 On 09/30/2024 at 8:31 a.m., Patient #1 was observed at station #37 machine #31 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of Autoflow 1.5 mL/min via a left upper arm vascular access. Vital signs were as follows: blood pressure 122/50 pulse 62 beats per minute. Review of the patient’s clinical record on 09/30/2024 revealed the following: Treatment sheet dated 04/01/2024 (prior to self-reported incident): Review of treatment sheet dated 04/01/2024 revealed the following documentation: 08:29 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral” 11:45 a.m.: registered nurse documented the post treatment assessment which revealed “UF goal not met, treatment tolerated, advised pt to adhere to fluid restrictions between scheduled treatments, assessed EDW to ensure EDW is accurate. Pt refused extra tx. Will attempt to meet UF goal at next treatment. Pt left at 6.4kg>DW.” The registered nursed did not document a reassessment of edema found during the pretreatment assessment. Treatment sheet dated 04/05/2024 (prior to self-reported incident): Review of treatment sheet dated 04/05/2024 revealed the following documentation: 08:29 a.m.: registered nurse documented the pretreatment assessment which revealed: “Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Edema Ankle - Location: Bilateral” 11:45 a.m.: registered nurse documented the post treatment assessment which revealed “UF goal not met, treatment tolerated, advised patient to adhere to fluid restrictions between scheduled treatments, assessed EDW to ensure EDW is accurate. Will attempt to meet UF goal at next treatment. Pt. left at 2.6>DW. Patient left a/ox3.” The registered nursed did not document a reassessment of edema found during the pretreatment assessment. Patient #9 On 09/30/2024 at 8:51 a.m., Patient #9 was observed at station #23 machine #38 receiving hemodialysis treatment at a blood flow rate of 300 mL/min and dialysate flow rate of 500 mL/min via a left central venous catheter. Vital signs were as follows: blood pressure 153/58 pulse 54 beats per minute. Review of the patient’s clinical record on 09/30/2024 revealed the following: Treatment sheet dated 09/18/2024: Review of treatment sheet dated 09/18/2024 revealed the following documentation: 07:00 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral” 10:13 a.m.: registered nurse documented the post treatment assessment which revealed “Tx ended early per pt, pt tolerated tx well, left ambulating. BP >160, pt asymptomatic. 2.1kg>EDW. Pt educated on fluid, diet restrictions, signs and symptoms of fluid overload and medication, tx complication, pt verbalized understanding.” The registered nursed did not document a reassessment of edema found during the pretreatment assessment. Treatment sheet dated 09/23/2024: Review of treatment sheet dated 09/23/2024 revealed the following documentation: 07:02 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral” 10:49 a.m.: registered nurse documented the post treatment assessment which revealed “Tx completed, pt tolerated tx well, left ambulating. BP >140, pt asymptomatic. 2.4kg>EDW. Pt educated on fluid, diet restrictions, signs and symptoms of fluid overload, tx compliance, pt verbalized understanding.” The registered nursed did not document a reassessment of edema found during the pretreatment assessment. Treatment sheet dated 09/27/2024: Review of treatment sheet dated 09/27/2024 revealed the following documentation: 07:14 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral” 10:33 a.m.: registered nurse documented the post treatment assessment which revealed “Goal not met. BP hypertensive, ASX. Pt agreed to adhere to medications including taking BP meds as prescribed. VS otherwise WDL. No C/O. D/c aox3, ambulatory w/steady gait in NAD. “ The registered nursed did not document a reassessment of edema found during the pretreatment assessment. Patient #3 On 09/30/2024 at 9:05 a.m., Patient #3 was observed at station #11 machine #30 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of Autoflow 700 mL/min via a left upper arm vascular access. Vital signs were as follows: blood pressure 167/76 pulse 60 beats per minute. Review of the patient’s clinical record on 09/30/2024 revealed the following: Treatment sheet dated 09/27/2024: Review of treatment sheet dated 09/27/2024 revealed the following documentation: 07:17 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Dyspnea/Dyspnea on Exertion, Shortness of Breath Lungs - Decreased breath sounds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral Edema Lower Leg - Location: Bilateral” 11:21 a.m.: registered nurse documented the post treatment assessment which revealed “Unable to reach goal d/t MD order to set pt per gain. BP remains elevated. ASX. Voices improved SOB. No C/O. D/c aox3, ambulatory w/steady gait in NAD. Left above DW, reinforced education of fluid, diet, and Bp ctrl, pt verbalized understanding.” The registered nursed did not document a reassessment of edema found during the pretreatment assessment. Patient #16 Review of the patient’s clinical record (demographic data) on 09/30/2024 revealed the patient was admitted to the facility 03/17/2023. Treatment sheet dated 08/08/2023 (prior to self-reported incident): Review of treatment sheet dated 08/08/2023 revealed the following documentation: 14:33 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lungs - Decreased breath sounds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Left Lungs - Sound Location - Location: Bilateral Edema Lower Leg - Location: Left” 12:00 p.m.: documented blood pressure of 130/62 and pulse rate of 66 beats per minute - Treatment initiated 12:33 p.m.: documented blood pressure of 172/83 and pulse rate of 70 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 13:30 p.m.: documented blood pressure of 184/92 and pulse rate of 73 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 14:05 p.m.: documented blood pressure of 187/89 and pulse rate of 73 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 14:31 p.m.: documented blood pressure of 193/91 and pulse rate of 77 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 15:09 p.m.: documented blood pressure of 202/98 and pulse rate of 78 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 15:34 p.m.: documented blood pressure of 199/108 and pulse rate of 80 beats per minute - PCT documented, “Denies Complaints; Patient Alert” 15:48 a.m.: documented blood pressure of 196/101 and pulse rate of 81 beats per minute - PCT documented, “Denies Complaints; Patient Alert; Treatment Discontinued” The Patient Care Technician (PCT) did not reposition the patient’s blood cuff or report the Systolic blood pressures greater than 180 mm/Hg to the nurse. 15:52 p.m.: registered nurse documented the post treatment assessment which revealed “Tx completed w/o incident. A&Ox4, denies c/o. VSS. D/c via wheelchair. AVF intact, no S/S of infection. Fluid restriction & infection control education provided. Pt verbalized understanding.” The registered nursed did not document a reassessment of lung sounds and edema found during the pretreatment assessment. Treatment sheet dated 08/10/2023 (prior to self-reported incident): Review of treatment sheet dated 08/10/2023 revealed the following documentation: 12:20 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lungs - Decreased breath sounds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Right Lungs - Sound Location: Bilateral Edema Lower Leg - Location: Right” 15:52 p.m.: registered nurse documented the post treatment assessment which revealed “Tx completed w/o incident; goal met. A&Ox4, denies c/o. VSS. D/c via wheelchair. AVF intact, no S/S of infection. Fluid restriction & infection control education provided. Pt verbalized understanding.” The registered nursed did not document a reassessment of lung sounds and edema found during the pretreatment assessment. Treatment sheet dated 08/12/2023 (prior to self-reported incident): Review of treatment sheet dated 08/12/2023 revealed the following documentation: 12:50 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lungs - Decreased breath sounds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Left Edema Ankle - Location: Left Lungs - Sound Location: Bilateral” 15:47 p.m.: registered nurse documented the post treatment assessment which revealed “Pt bp improved during treatment. He stated he feels better post treatment. Nurse was able to pull 1.1 off patient after 2hours. BP noted 137/60, and he denies any complaints.” The registered nursed did not document a reassessment of lung sounds and edema found during the pretreatment assessment. Interview with the Clinical Manager on 10/01/2024 at 2:55 p.m. confirmed the patient care technicians did not reposition the patient’s blood cuff or report the Systolic blood pressures greater than 180 mm/Hg to the nurse. The reassessments of edema and lung sounds were not completed post treatment by the registered nurses.”