Bay Area Dialysis Services at Aransas Pass

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 34839 Based on record review and interview, the facility’s direct care staff failed to ensure that all patients’ vascular access was in view during the dialysis treatment. One (Patient # 1) was not assessed or visible to the staff during their dialysis treatments. Failure to ensure the patient’s dialysis access was visible throughout treatment had the likelihood to result in the patient’s needle becoming dislodged. A dislodged needle could result in the patient bleeding out without the facility staff recognizing it. Findings include: During record review with the facility Clinical Manager on 12/11/2024 at 11:35 AM, the surveyor noted that P#1 did have an incident of blood loss. Records indicated that on October 31/2024, the technician noted there was dried blood on the patients arm, side of the chair and the floor. Interview with the Clinical manager confirmed the incident did occur, and the staff were presented with “ on the spot education “ on 11/01/2024 regarding review of policies and to assess patients access and surrounding area while obtaining vital signs.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 30177 Based on document review, interview, and policy review, the facility failed to update the list of staffs’ contacts to ensure the facility had a way to communicate with staff and the patient’s physician during an emergency. The failed practice had the potential to hinder the facility’s response time during an emergency and had the potential to negatively affect all 67 in-center hemodialysis patients receiving care at this facility. Findings include: Review of an untitled and undated facility document dated, which the clinical Manager retrieved from the facility’s “Emergency Plan” described as the emergency contact list failed to include the Social Worker, Dietitian, Biomedical Technician, and the nine physician who care for patients in this facility. During document review and interview with the Clinical Manager on 10/18/24 at 9:45 AM, the Clinical Manager was asked if the contact information for the Social Worker, Dietitian, Biomedical Technician, and the nine physicians who care for patients in this facility were included. The Clinical Manager confirmed that the emergency disaster contact list had not been updated and failed to include the Social Worker, Dietitian, Biomedical Technician, and the nine physician who care for patients in this facility. The Clinical Manager stated that the list should include all staff and physicians. Review of the facility’s undated emergency plan, revealed, “A current copy of the emergency lists must be kept locked in the emergency supply boxes or cart.””

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 30177 Based on the document review and interview, the facility failed to ensure that the emergency contacts included an alternate means of communicating with facility staff during an emergency. Failure to ensure the facility had more than one means for contacting facility staff had the potential to hinder the facility’s ability to respond promptly to an emergency and had the potential to negatively affect the 67 in-center hemodialysis patients receiving care at this facility. Findings include: Review of the undated document titled “Emergency Contacts” located in the Emergency Preparedness Plan revealed that it failed to include an alternate means for communicating with Certified Care Hemodialysis Technician (CCHT)3, CCHT 4, the Area Team Lead, and the Licensed Vocational Nurse. In an interview with the Clinical Manager on 10/18/24 at 9:45 AM, he/she confirmed that the list of emergency contacts failed to include an alternate means of communicating with CCHT3, CCHT4, the Area Team Lead, and the Licensed Vocational Nurse.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 30177 Based on observation, interview, and review of the facility’s policies, the facility failed to ensure 17 of 17 hemodialysis stations ( Stations 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and the Biomedical technical station) wall boxes (recessed plumbing box to supply water, concentrate, and dispose of waste) were clean and free of spatters of a white crystalized substance. The failure to clean the dialysis wall boxes and remove any build-up could lead to contamination and risk of infections. This deficient practice could potentially affect the 67 patients receiving treatment in the dialysis unit. Findings include: Observation on 10/16/24 at 9:13 AM with the Clinical Manager revealed that the wall boxes at Stations 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and the Biomedical Technical Station contained splatters and an accumulation of a white crystalized substance. In an interview on 10/16/24 at 9:30 AM, the Clinical Manager confirmed that splatters and a build-up of a white crystalized substance were on the wall boxes of Stations 1- 16 and the Biomedical Technical Station. When asked if the wall boxes were cleaned on a routine basis, the Clinical Manager responded, “I am not sure.” The Clinical Manager was then asked if the wall boxes were part of the patient’s station and were considered contaminated or dirty. He/she replied, “Yes.” A review of the facility’s policy titled “Cleaning and Disinfecting the Dialysis Station,” dated 09/05/23, indicated, “Dialysis wall boxes and the area/wall around the wall box must be routinely cleaned at the end of each treatment day or immediately if splattered with blood. All surfaces shall be disinfected with 1:100 bleach solution. Special attention should be given to removing build-up and/or cleaning splatter and spray of concentrate solution.””

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 30177 Based on observation, staff interview, and policy review, the facility failed to ensure the salt level in the brine tank (a plastic container that holds salt pellets) was “at least “half full. The failed practice did not ensure the facility followed policy to prevent scaling to the reverse osmosis membranes. This failed practice had the potential to negatively impact the safety and well-being of the 67 in-center hemodialysis patients receiving treatments at this facility. Findings include: Observation of the water treatment area on 10/16/24 at 9:30 AM with the Clinical Manager revealed the salt level in the brine tank was not maintained at a minimum of half full. The salt pellets were below the water level. During an interview on 10/16/24 at 9:40 AM, the Clinical Manager confirmed that the brine tank’s salt level were not maintained at the recommended half-full mark and that the salt pellets were submerged in the water. When asked about the expectations for the salt level, the Clinical Manager stated that it should be at least half full and above water. The Clinical Manager was then asked who was responsible for monitoring and maintaining the salt level in the brine tank. The Clinical Manager responded, “the Patient Care Technicians (PCTs) and the Biomedical Technician.” A review of the facility’s policy titled, “Water Softener,” with a published date of 05/03/23, revealed, “For all softeners, at a minimum, facility staff will monitor and document water softener each operational day by checking brine tank daily to be sure the tank is at least half filled with salt, adding salt pellets if necessary. . . Salt levels inside brine tanks will be maintained at a minimum of half full.””

“MIX SYS-DFU/MONITOR/PM/LOG/SANITIZE CFR(s): 494.40(a) 5.4.4.1 Mixing systems: follow DFU/monitor/PM/log/sanitization If a concentrate mixing system is used, the preparer should follow the manufacturer’s instructions for mixing the powder with the correct amount of water. If a concentrate mixing system is used, the number of bags or the weight of powder added should be determined and recorded. Manufacturer’s recommendations should be followed regarding any preventive maintenance and sanitization procedures. Records should be maintained indicating the date, time, person performing the procedure, and results (if applicable). 6.4.1 Mixing systems: Systems for preparing either bicarbonate or acid concentrate from powder should be monitored according to the manufacturer’s instructions. This Standard is not met as evidenced by: 30177 Based on observation, staff interview, policy review, and manufacturer’s instructions for use (IFU), the facility failed to ensure staff assigned responsibility for acid concentrate preparation followed facility policy and manufacturer’s IFU in that Certified Care Hemodialysis Technician (CCHT) 2 failed to flush 3.5 gallons of acid concentrate prior to sample testing, and failed to rinse the hydrometer (a tool used to measures the density) and hydrometer cylinder (container used to hold a liquid sample) before checking the specific gravity (measures the density of a substance). The failure to follow policy and IFU had the potential to skew sample results and may result in an incorrect specific gravity reading. The failed practice had the potential to adversely affect the 67 in-center hemodialysis patients receiving care at this facility. Findings Include: Observation of acid concentrate preparation and testing were observed on 10/17/24 at 8:48 AM with CCHTT2, who confirmed their responsibility for mixing and testing the acid concentrate. After completing the mixing process, CCHT2 collected a sample by filling a hydrometer cylinder and inserting the hydrometer to measure the specific gravity. CCHT2 failed to flush 3.5 gallons of solution to the “Residual Solution Bucket” and neglected to rinse both the hydrometer cylinder and the hydrometer before use. In an interview with CCHT2 and the Clinical Manager on 10/17/24 at 1:45 PM, CCHT2 confirmed that 3.5 gallons of acid solution should have been flushed to obtain a pure sample.CCHT2 also stated that the hydrometer and hydrometer cylinder should have been rinsed before use. A review of the facility’s policy titled “Acid Concentrate Mixing and Handling: Dry Acid Dissolution Unit,” published on 09/05/23, revealed that “Specific Gravity testing will be performed according to the Dry Acid Specific Gravity Test procedure located in the manufacturers’ IFU ... A review of the facility’s policy titled “Acid Concentrate Specific Gravity Testing Procedure,” published on 07/05/22, revealed, “Rinse the hydrometer and hydrometer cylinder with purified water before checking solution specific gravity ... Slightly open the transfer nozzle valve and flush 3.5 gallons of solution in the Residual Solution Bucket...” Review of the manufacturer’s IFU, “Obtain the clean hydrometer and measure the specific gravity of the solution in the hydrometer cylinder. If the hydrometer or the surface of the solution is not clean, discard the contents of the hydrometer cylinder into the residual solution bucket. Clean the hydrometer and the hydrometer cylinder and restart. Warning! Failure to flush the transfer hose with 3.5 gallons prior to measuring specific gravity may result in an incorrect specific gravity reading, and/or supply of an incorrect concentrate formulation to the hemodialysis machines, which may result in patient injury or death.””

“ACID CONC DIST-CONC LABELED & COLOR-CODED RED CFR(s): 494.40(a) 5.5.3 Acid concentrate distribution systems: labeled & color-coded red Acid concentrate delivery piping should be labeled and color-coded red at the point of use (at the jug filling station or the dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. If the acid system remains intact, no rinsing or disinfection is necessary. More than one type of acid concentrate may be delivered, and each line should clearly indicate the type of acid concentrate it contains. This Standard is not met as evidenced by: 30177 Based on observations and staff interview, the facility failed to label each outlet indicating the specific types of acid concentrates delivered to the treatment stations. The inability to identify each type of acid concentrate at the treatment stations creates potential risks for staff in recognizing the contents at each station and increases the chances of patients receiving the incorrect acid. The failed practice had the potential to negatively affect the 67 in-center hemodialysis patients at this facility. Findings Include: During a tour of the Treatment Area with the Clinical Manager and Area Team on 10/17/24 at 2:55 PM, the dialysis stations were equipped with two outlets for centrally delivering two types of acid concentrate: 2 potassium(k)/2.5 calcium (ca) and 3K/3.5 ca. There was no label indicating which outlet provided 2K/2.5 ca and which one supplied 3K/2.5 ca. In an interview with the Clinical Manager and Area Team on 10/17/24 at 3:05 PM, the Clinical Manager revealed that the facility dispensed two types of acid: 2K/2.5 and 3K/2.5ca. The Area Team Lead confirmed the outlets were not labeled to identify their contents. When asked how to identify the contents of various outlets, the Clinical Manager responded, “Yes, I can see how that might cause a mix-up.” A policy indicating that outlets must be clearly labeled with the acid type if more than one acid is centrally delivered to treatment stations was requested. The facility failed to provide a policy by the survey’s exit date.”

“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: 30177 Based on interview, document review, policy review, and review of the manufacturer’s prescribed preventative maintenance procedures, the facility failed to ensure 18 of 18 (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) 2008 T hemodialysis machines underwent two-year preventative maintenance per manufacturer’s instruction for use (IFU). Additionally, the facility failed to ensure the arterial drip chamber fluid levels were maintained at 90% full per manufacturer’s IFU for one of one observation days. Failure to follow the manufacturer’s IFU had the potential to negatively impact the safety and well-being of the 67 patients receiving in-center hemodialysis treatments at this facility. Findings include: 1. Interview with the Biomedical Technician (BMT) and the Area Technical Operations Manager (ATOM) on 10/16/24 at 2:24 PM, during the review of the “Machine/Equipment/Maintenance Worksheet,” the BMT confirmed that the facility uses 2008T Bluestar Premium hemodialysis machines. When asked if the hemodialysis machines were equipped with extended life pump components, the BMT replied, “Yes.” The ATOM was asked if the hemodialysis machines required two-year maintenance, which included rebuilding the concentrate (acid), bicarbonate, and ultrafiltration (UF) pumps with extended life components every two years or after 8000 hours of operation. He/she replied, “Yes.” The BMT confirmed that all 18 hemodialysis machines had more than 8000 hours of operation and had been operational for over two years. Review of the hemodialysis machines’ preventative maintenance documents revealed that 18 of 18 (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) hemodialysis machines did not have the two-year/8,000-hour required preventative maintenance completed. In a follow-up interview on 10/16/24 at 3:15 PM, the BMT was asked to provide documentation of the hemodialysis machine’s two-year or 8,000 hours of preventative maintenance. The BMT confirmed hemodialysis machines 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18 had not received the two-year or after 8000 hours preventative maintenance. Review of the facility’s policy titled, “Equipment Installation- Operation- Maintenance- Repair- and Disposal,” revision date 07/06/21, indicated, “Unless otherwise directed by company policy and procedures, all equipment will be installed, operated, maintained, and repaired in accordance with manufacturer’s IFU. Review of the manufacturer’s preventative maintenance procedures recommendations revealed, “Preventive maintenance for the 2008T hemodialysis system is simple and straightforward. Schedule maintenance is performed based on time intervals or the number of hours a machine is operated, whichever comes first. The time and hour intervals are as follows ...2008T Bluestar Premium machines concentrate (acid), bicarbonate, and ultrafiltration (UF) pumps with extended-life components are rebuilt every two years or after 8000 hours of operation. 2. During observation and interview on 10/16/24 at 8:15 AM, the Clinical Manager confirmed the arterial drip chamber fluid levels were less than 90% full in nine of 18 Stations (2, 3, 4, 5, 6, 7, 9, 14, and 16) in use. Review of the manufacturer’s DFU indicated, “Maintain fluid level in arterial chamber at approximately 90% full. Levels may rise or drop during the treatment due to changes in pressure or flow rate. Readjust levels as needed. Air leaks will also cause the chamber levels to fluctuate.” Review of the facility’s policy titled, “Initiation of Treatment Using an Arteriovenous Graft or Fistula and Optiflux Single Use Ebeam Dialyzer,” revision date 05/06/24, indicated, “Prior to starting the blood pump, verify the following ... The arterial chamber is 85-95% full ...” Review of the facility’s policy titled, “Initiation of Treatment Using a Centra Venous Catheter and Optiflux Single Use Ebeam Dialyzer,” revision date 05/06/24, indicated, “Prior to starting the blood pump, verify the following ... The arterial chamber is 85-95% full ...””

“PE-COMFORTABLE TEMPERATURE CFR(s): 494.60(c)(2) The dialysis facility must: (i) Maintain a comfortable temperature within the facility; and (ii) Make reasonable accommodations for the patients who are not comfortable at this temperature. This Standard is not met as evidenced by: 30177 Based on observation, document review, staff interview, and policy review, The facility failed to maintain a comfortable temperature for its patients. Additionally, no accommodations were in place to address the needs of those who expressed discomfort due to the temperature fluctuations, resulting in an uncomfortable experience for many patients. This failed practice had the potential to detract from the overall comfort of the patients who were cold and negatively impact the well-being of the 67 in-center hemodialysis patients receiving treatments at this facility. Findings included: On 10/16/24, at 8:30 AM, it was noted that the temperature was uncomfortably low, creating an uncomfortable environment. In an interview with the Clinical Manager on 10/16/24 at 8:40 AM, Surveyor 1 asked if the cold environmental temperature created patient concerns. The Clinical Manager responded, “Yes, it is cold in here, and patients do comment on being too cold. The Clinical Manager was asked if the facility’s heating system was functioning effectively. He/she replied, “We have been having problems with the temperature for a while. We only have three settings, 70, 71, or 72 degrees.” The Clinical Manager was asked if the low temperature raised concerns for staff. He/she stated that staff use of personal protective equipment influences their perceptions of what feels like a “comfortable” temperature. Most staff members feel hot, while patients feel cold because they are sitting for hours. When asked if the staff could raise and lower the thermostat, the Clinical Manager stated, “Yes.” The Clinical Manager was then asked if it is acceptable to allow the temperature to be randomly raised or lowered, depending on one person’s comfort level. He/she replied, “No.” The Clinical Manager was asked if there was a plan to determine a comfortable temperature in the patient treatment area for patients and staff. He/she responded, “No.” The Clinical Manager shared that a single thermostat serves the treatment area and the facility. During an interview with Patient (P)5 on 10/17/24 at 9:09 AM, he/she was asked if the temperature in the waiting area and treatment floor was” Too cold?” P5 replied, “Yes.” During an interview with P6 on 10/18/24 at 9:12 AM, he/she was asked if the temperature in the waiting area and treatment floor was” Too cold?” P6 replied, “Yes.” During an interview with P11 on 10/18/24 at 9:14 AM, he/she was asked if the temperature in the waiting area and treatment floor was” Too cold?” P11 replied, “Yes.” During an interview with P12 on 10/18/24 at 9:18 AM, he/she was asked if the temperature in the waiting area and treatment floor was” Too cold?” P12 replied, “Yes.” During an interview with Patient Care Technician (PCT) 2 on 10/18/24 at 9:21 AM, he/she was asked if the temperature in the waiting area and treatment floor was” Too cold?” PCT2 replied, “No, we get hot during change over and lower the temperature.” When asked if he/she considered the patient’s experience with the cold temperature, he/she responded, “No.” During an interview with a Licensed Vocational Nurse (LVN) on 10/18/24 at 9:30 AM, he/she was asked if the temperature in the waiting area and treatment floor was” too cold?” The LVN replied, “It’s always cold in here.” The LVN was then asked if patients expressed discomfort with the temperature. He/she stated, “Yes.” A review of a patient’s written grievance on 05/20/24 revealed that the patient reported that the facility was too cold. The “Resolution/Corrective Actions” revealed, “Our air conditioning thermometer is very limited; we can only adjust it between 70 and 72 degrees. We discussed that during turnaround, we would have the air set at 70 and, after turnaround put it at 72.” A policy indicating the need to maintain a comfortable temperature for patients and staff was requested. The facility failed to provide a policy by the survey’s exit date.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 18750 Based on interview, record review, and facility policy review, the facility failed to ensure that a physician ordered devise was in placed during treatment for one of 12 (Patient (P) P5) sampled patients. The Crit-Line Monitor (CLM) device was used to measure the patients’ blood during dialysis to help the staff determine the best fluid removal rate and ordered by the physician. This deficient practice had the potential to allow physician ordered devices to not be used to monitor patients. Findings include: Review of P5’s “medical record” revealed an admission date of 11/11/19 with diagnoses of end stage renal disease, type 2 diabetes mellitus, and fluid overload. Review of P5’s “physician orders” revealed, “04/22/22, In Center Hemodialysis, Monday/Wednesday/ Friday for 3 hours and 45 minutes. . .” Further review revealed, “12/09/22, Crit-line Monitor (CLM) Every Treatment. . .” Review of P5’s “Treatment Sheet for Facility” dated 02/13/23, 02/15/23, 02/17/23, 02/20/23, and 02/27/23 noted the CLM was broken and not working on each treatment day. During an interview on 10/17/24 at 4:40 PM, Registered Nurse (RN)1 was asked about the CLM. RN1 stated the Crit-Line was a great tool that could be used to monitor the fluid through the blood of a patient to see how much could be removed and at what rate. RN1 stated it was a great toll that had to be ordered by the physician. RN1 stated P5 would come into the facility overloaded and the monitor would have been beneficial in monitoring P5 if it had been working. RN1 was asked since a physician ordered it was the order being followed. RN1 stated, “No.” During an interview on 10/18/24 at 9:00 AM, the Clinical Manager was asked about the CLM not functioning when ordered by the physician. The Clinical Manager stated the CLM did not work on several machines at one time. The Clinical Manager stated she did not know if it was difficult to get parts or whether it was a warranty issue. During an interview on 10/18/24 at 10:40 AM, the Biomedical Technician was asked about the delay in fixing the CLM’s. The Biomedical Technician stated he would find out about the issues at end of day. The Biomedical Technician stated sometimes he would check the machine, and it worked fine for one shift and stopped working for the next shift. Sometimes the monitored had to just be verified because it had been turned off. Sometimes it was having to wait for parts to come in, but most of the time just verification was needed. During an interview on 10/18/24 at 11:00 AM, the Area Team Lead stated there was a time when several monitors were not working and she told staff this was not acceptable. The Area Team Lead confirmed that when the CLM is not working, physician orders are not followed. Review of the facility policy titled, “Use of the Crit-Line Monitor Devices” with a publish date of 06/28/24 revealed, “Policy: CLM devices may only be used with a written Physician (MD) order. . .””