Westminster Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 10802 Based on observation, review of labels on facility’s evacuation supplies, and interview, facility’s governing body fail to ensure evacuation emergency supplies which were expired were not available for use and that the emergency evacuation cart supplies are readily available for use in an emergency. Findings: Observation and review on 03/11/2024 at 10:55 a.m of the facility’s evacuation cart revealed the following expired supplies: 50 AMD non- woven 4X4 sponges Lot 3 84037-3 expired 2/2024. 1 Cardiopulmonary resuscitator; Lot # 19100056; expired 6/18/2022 7 Luer Lock caps Lot 3 H 203006 expired 1/21/2024 The top of the cart also had accumulation of dirt and dust. The Surveyor immediately notified Facility’s Charge Nurse (H) who looked at the expired supplies. Facility’s Charge Nurse (H) confirmed that the above supplies in the emergency emergency evacuation cart were expired.”

“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: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to clean and disinfect the prime bucket, Hanson connectors, wall box, and chase cabinet behind the dialysis stations in 2 of 5 observed staff: Patient Care Technician (A) and (C) Findings: Review of facility’s current policy and procedure on cleaning and disinfecting the dialysis station published 09/05/2023, reference number 47806 version 14 directs staff as follows: “The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day, and it is critical that these items be thoroughly cleaned and disinfected between uses.” Review of the Center for Disease Control (CDC) Dialysis Safety: Dialysis Wall Boxes and Drains states: “ wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections. Wall boxes are part of the immediate patient care environment and are considered contaminated or dirty.” Patient Care Technician (A) Station #18 Observation on 03/11/2024 at 10:18 a.m. revealed Patient Care Technician (A) terminally cleaning station #18 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #18 at station #18, Patient Care Technician (A) failed to clean the prime bucket, Hanson connectors, wall box and chase cabinet. During an interview at 10:33 a.m., the Surveyor notified Patient Care Technician (A) that the prime bucket, Hanson connectors, wall box, and chase cabinet were not cleaned during station disinfection. Patient Care Technician (A) stated “Okay.” Patient Care Technician (C) Station #24 Observation on 03/12/2024 at 10:43 a.m. revealed Patient Care Technician (C) terminally cleaning station #24 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #24 at station #24, Patient Care Technician (C) failed to clean the wall box and chase cabinet. During an interview at 11:06 a.m., the Surveyor notified Patient Care Technician (C) that the wall box and chase cabinet were not cleaned during station disinfection. Patient Care Technician (C) stated “Okay, these are part of the station. I will clean them each time.””

“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, record review and interview, the facility’s licensed nurses and direct care staff failed to administer patients’ hemodialysis treatments based on physicians’ orders in 2 of 12 sampled patients: Patient #s 1 and 5 Findings: Review of the facility’s current Policy and Procedure on Nursing Supervision and Delegation; Policy #45265, published 11/06/2023 directs staff as follows: Policy The registered nurse must evaluate each patient preferably within an hour or according to state requirements to: ... “ Review accuracy and completeness of treatment and patient data “ Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. Patient #1 On 03/11/2024 at 7:34 a.m., Patient #1 was seated at station #17 machine #40 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and a dialysate flow rate of 500 mL/min via left lower upper arm vascular access. The patient was utilizing an Optiflux 180 non reuse dialyzer. The dialysate settings were: 2 potassium, 2.5 calcium, 34 bicarbonate, 137 sodium. Observation of the patient’s physician’s order located in the chairside computer revealed an order for bicarbonate 35.0 Review of the patient’s clinical record revealed a physician’s order dated 02/07/2024 for Bicarbonate setting: 35 (mEq/L). Interview with Patient Care Technician (A) at 7:41 a.m.: the Surveyor informed her that the dialysate bicarbonate setting was not set on the hemodialysis machine as prescribed by the physician. Patient Care Technician (A) said, “I should have made sure the order is right.” 10802 Patient #5 On 03/11/2024 at 7:10 a.m. Patient #5 was observed on the hemodialysis unit at station # 10. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. Review of the patient’s clinical record revealed a physician’s order dated 5/5/2023 - 5/3/2024 for “ Special attention: 50 mls saline flush q 30 minutes during tx, every treatment.” “Heparin has not been used.” Subsequent observation on 03/11/2024 at 9:00 a.m. revealed no indication that the patient was administered Normal Saline flush every 50 minutes as ordered by the physician. On 03/13/2024 the Surveyor notified Registered Nurse (H ) that the patient was not administered Normal Saline flushes as prescribed by the physician. She confirmed that it was “missed.” Review of the patient’s treatment sheets for the following days revealed no documentation that Normal Saline flushes were administered as prescribed by the physician every treatment on the following days: 03/11/2024, 03/08/2024, 03/06/2024, 03/04/2024, 03/01/2024”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 10802 Based on observation, record review and interview, the facility’s registered nurses failed to conduct intradialytic assessment and post treatment assessment when patients present with unusual findings during pre-treatment intradialytic hemodialysis treatment and post assessment in 4 of 12 sampled patients: Patient #s 5, 8, 3 and 10 Findings: Texas Board of Nursing RN Scope of practice. Rule 15.28. Assessment The comprehensive assessment is the first step and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis, and interpretation of data. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence- based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed. Patient Diagnosis/Problem Identification/Planning The second step in the nursing process is analyzing data gathered during the assessment and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary health care team, as appropriate for their educational background and scope. The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, participate in the patient diagnoses, and to formulate goals, teaching plans and outcomes. A nursing plan of care for patients is developed by the RN, who has the overall responsibility to coordinate nursing care for patients. Teaching plans address health promotion, maintenance, restoration, and prevention of risk factors. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary health care team during the planning process. Implementation Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate certain nursing tasks within the plan of care for patients within legal, ethical, and regulatory parameters and in consideration of health restoration, disease prevention, patient independence, wellness, and promotion of healthy lifestyles. The RN’s duty to patient safety when making assignments to other nurses or when delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN scope of practice may include the supervision of LVNs or other RNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual’s performance and activity. 5 The RN may have to directly observe and evaluate the nursing care provided depending on the LVN’s skills and competence, patient conditions, and level of urgency in emergent situations. The RN may determine when it is appropriate to delegate tasks to unlicensed personnel and maintains accountability for how the unlicensed personnel perform the tasks. The RN is responsible for supervising the unlicensed personnel when tasks are delegated. The proximity of supervision is dependent upon patient conditions and skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process. Evaluation and Evaluation and Re-assessment A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary. 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 ... It the PCT/LVN 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. “ The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional information. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment needed.” Patient #5 On 03/11/2024 at 7:10 a.m. Patient #5 was observed on the hemodialysis unit at station # 10. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. Review of the patient’s treatment sheet revealed the following findings: The patient’s hemodialysis treatment was initiated by the Patient Care Technician assigned to the patient on 3/8/2024 at 06.30 a.m. with documented blood pressure of 138/71 and pulse rate of 78 beats per minute, at a blood flow rate of 350 mls /per minute and dialysate flow rate of 500 mls/ minute. Patient’s documented parameters during hemodialysis treatment were as follows: 07:03 a.m.: blood pressure 123/61, pulse rate 73 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 07:32 a.m.: blood pressure 114/63, pulse rate 70 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 8:00 a.m.: blood pressure 122/75, pulse rate 73 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 8:32 a.m.: blood pressure 97/61, pulse rate 68 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 8:33 a.m.: The patient Care Technician assigned to the patient documented “ BP trending, adjusted uf goal to 2.0. RN notified.” 9:00 a.m.: blood pressure 109/58, pulse rate 70 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 9:46 a.m.: blood pressure 101/60, pulse rate 68 beats per minute, blood flow rate of 200 mls/ minute and dialysate flow rate of 500 mls/ minute. Patient’s treatment discontinued by the patient care technician assigned to the patient. Review of the patient’s clinical record revealed no documentation of intradialytic assessment by the registered nurse when the patient’s blood pressure dropped. Patient #8 Review of patient #8’s clinical record (demographic data) dated 03/01/2024 revealed, the patient was admitted to the facility on 4/09/2021 with diagnosis of end stage renal disease, on in center hemodialysis treatment three times weekly. Review of the patient’s treatment sheet revealed the following findings: The patient’s hemodialysis treatment was initiated by the patient care technician assigned to the patient on 3/1/2024 at 11.45 a.m. with documented blood pressure of 146/90 and pulse rate of 81 beats per minute, at a blood flow rate of 350 mls /per minute and dialysate flow rate of 500 mls/ minute. Patient’s documented parameters during hemodialysis treatment were as follows: 12:01 p.m.: blood pressure 155/92, pulse rate 88 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 12:31 p.m.: blood pressure 146/97, pulse rate 83 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 13:03 p.m.: blood pressure 105/75, pulse rate 82 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 13:34 p.m.: blood pressure 87/58, pulse rate 62 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. The patient care technician assigned to the patient documented “BP low, RN informed, pt verbal ok. UF on MINIUM.” 14:01 p.m.: blood pressure 86/59, pulse rate 85 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 14:32 p.m.: blood pressure 99/70, pulse rate 88 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 15:01 p.m.: blood pressure 125/83, pulse rate 88 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. 15:17 p.m.: blood pressure 115/75, pulse rate 96 beats per minute, blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. Patient’s hemodialysis treatment terminated by the patient care technician. Review of the patient’s clinical record revealed no documentation that the registered nurse assessed the patient intradialytic after the patient experienced a fall in blood pressure. Post treatment assessment by the registered nurse indicated the patient tolerated hemodialysis treatment. Interview on 03/13/2024 at 9:35 a.m. with Registered Nurse (H) revealed she said patient care technicians notify her of patients’ drop or increase in blood pressure but sometimes she gets busy and forgets.” 48020 Patient #3 Observation on 03/11/2024 at 7:42 a.m., Patient #3 was observed at station #20, hemodialysis machine #1 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Vital signs were as follows: blood pressure 182/82 pulse rate of 76 beats per minute. Treatment sheet dated 03/11/2024: Review of the patient’s clinical record (treatment sheet) dated 03/11/2024 revealed the following documentation: 07:38 a.m.: documented blood pressure of 181/82 and pulse rate of 76 beats per minute 07:50 a.m.: documented blood pressure of 181/82 and pulse rate of 76 beats per minute - RN documented “Denies Complaints; RN rounds completed, TX RX verified, bp elevated took medicine 30 minutes ago” 06:00 a.m.: documented blood pressure of 167/64 and pulse rate of 75 beats per minute 08:00 a.m.: documented blood pressure of 104/51 and pulse rate of 72 beats per minute 08:30 a.m.: documented blood pressure of 97/62 and pulse rate of 71 beats per minute - PCT documented “pt BP low, UFR decreased, pt on minimum, RN notified” 09:00 a.m.: documented blood pressure of 104/65 and pulse rate of 73 beats per minute - PCT documented “pt Bp improved, RN Notified, goal set to 2.5kg” 09:33 a.m.: documented blood pressure of 128/64 and pulse rate of 72 beats per minute 10:00 a.m.: documented blood pressure of 145/78 and pulse rate of 74 beats per minute 10:30 a.m.: documented blood pressure of 143/76 and pulse rate of 88 beats per minute 11:00 a.m.: documented blood pressure of 146/96 and pulse rate of 76 beats per minute 11:44 a.m.: documented blood pressure of 136/75 and pulse rate of 74 beats per minute - treatment ended 12:23 Post treatment assessment - RN documented “Treatment time completed. UF go not met due to low bp. Left 4.2kg above edw, Denies complaints. No distress noted ...” There was no documentation of an intradialytic assessment performed by the registered nurse to determine the patient’s response to taking her blood pressure medication pre-treatment nor after report by the PCT of the UF being decreased to minimum UF. Patient #10 Observation on 03/12/2024 at 7:51 a.m., Patient #10 was observed at station #20, hemodialysis machine #1 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min via a left upper arm vascular access. Vital signs were as follows: blood pressure 176/107 pulse rate of 72 beats per minute. Review of the patient’s clinical record located in the chairside computer reveal a physician’s order dated 02/22/2024 for blood flow rate of 400 mL/min and a dialysate flow rate of 800 mL/min.. Treatment sheet dated 03/05/2024: Review of the patient’s clinical record (treatment sheet) dated 03/05/2024 revealed the following documentation: 07:14 a.m.: Pre-treatment vital signs: blood pressure of 161/111 sitting, 175/102 standing, pulse of 80 beats per minute. 07:15 a.m.: Pre-treatment assessment: RN did not document any notes about the elevated reportable diastolic blood pressure 07:22 a.m.: documented blood pressure of 170/107 and pulse rate of 80 beats per minute, blood flow rate 300 mL/min, dialysate flow rate 800 mL/min - PCT documented “Treatment initiated ... bp diastolic elevated, pt already took her meds before tx” 08:00 a.m.: documented blood pressure of 154/98 and pulse rate of 90 beats per minute, blood flow rate 300 mL/min, dialysate flow rate 800 mL/min 08:38 a.m.: documented blood pressure of 143/95 and pulse rate of 82beats per minute, blood flow rate 300 mL/min, dialysate flow rate 800 mL/min 09:05 a.m.: documented blood pressure of 160/93 and pulse rate of 81 beats per minute, blood flow rate 400 mL/min, dialysate flow rate 800 mL/min 09:38 a.m.: documented blood pressure of 160/96 and pulse rate of 87 beats per minute, blood flow rate 400 mL/min, dialysate flow rate 800 mL/min 10:00 a.m.: documented blood pressure of 172/100 and pulse rate of 87 beats per minute, blood flow rate 400 mL/min, dialysate flow rate 800 mL/min 10:30 a.m.: documented blood pressure of 182/101 and pulse rate of 89 beats per minute, blood flow rate 400 mL/min, dialysate flow rate 800 mL/min - PCT documented “rechecked bp” 10:40 a.m.: documented blood pressure of 161/97 and pulse rate of 95 beats per minute, blood flow rate 400 mL/min, dialysate flow rate 800 mL/min - PCT documented “bp improved” 11:11 a.m.: documented blood pressure of 164/100 and pulse rate of 94 beats per minute, blood flow rate 400 mL/min, dialysate flow rate 800 mL/min 11:30 a.m.: documented blood pressure of 154/101 and pulse rate of 96 beats per minute, blood flow rate 200 mL/min, dialysate flow rate 800 mL/min - Treatment Discontinued 12:01 Post treatment assessment - RN documented “ ... reinforced limit oral fluid intake and importance of BP control, pt expressed understanding.” There was no documentation of an intradialytic assessment performed by the registered nurse to determine the patient’s response to taking her blood pressure medication pre-treatment. There was no justification for the blood flow rate (BFR) of 300 mL/min from 07:22 a.m. - 8:38 a.m. (prescribed BFR = 400 mL/min) documented by the PCT or RN. Interview with Patient Care Technician (D) on 03/12/2024 at 12:10 p.m.: the Surveyor notified Patient Care Technician (D) the patient’s machine was not set to the prescribed blood from rate of 400 mL/min from 07:22 a.m. - 8:38 a.m. Patient Care Technician (D) said, the patient requested to start the blood flow rate off slowly and then move up to prescribed blood flow rate. The Surveyor notified her that there was not documentation the patient requested a lowered BFR. Patient Care Technician (D) said, “I didn’t document it.” Interview with Clinical Manager (I) on 03/13/2024 at 12:30 p.m.: the Surveyor notified Clinical Manager (I) the registered nurses are not performing intradialytic assessments: to determine the patients’ response to taking blood pressure medications pre-treatment, after the PCT reports decreasing the UF to minimum mL/min, and when the blood flow rate is not set to prescription by the PCT during the hemodialysis treatment. Clinical Manager (I) confirmed the Surveyor’s findings.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review facility’s registered nurse failed to offer/administer/verify pneumococcal vaccinations of patients in 4 of 12 sampled patients: Patient #s 2, 1, 4 and 8 Findings: Review of the MAB Recommended Evaluation and Immunization Against Pneumococcal Infection 3.0 directs the nurses as follows: Goal: The purpose of this algorithm is to reduce the incidence of pneumococcal disease by providing immunization to eligible patients. 1. Establish Patient Pneumococcal Vaccination Status 3. Identify vaccine(s) given, Prevnar 13 (PCV13), Pneumovax 23 (PPSV23), Prevnar 20 (PCV20) or Vaxneuvance (PCV15) and date(s) of vaccination “ Prior history of vaccination with Prevnar 13 (PCV13), or Pneumovax 23 (PPSV23), or Vaxneuvance (PCV15) - Go to 3. Patient Previously Vaccinated 3. Patient Previously Vaccinated IF: Patient vaccinated with Prevnar 13 and Pneumovax 23 (PPSV23) with one or two does prior to age 65 THEN: “ Schedule administration of Prevnar 20 (PCV20) 5 years following administration of Pneumovax 23 (PPSV23) or Prevnar 13 (PCV13) o Discontinue Algorithm Patient #2 Observation on 03/11/2024 at 7:08 a.m., Patient #2 was observed at station #4, hemodialysis machine #7 receiving hemodialysis treatment at a blood flow rate of 500 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record (Patient Transfer) revealed a physician’s order dated 01/25/2021 for “CMAB recommended Algorithm for Pneumococcal Immunization- Eval and immunization against Pneumococcal infection V2.0. Every treatment clinic” with a stop date of 01/24/2022. Review of the patient’s clinical record (Pneumonia Immunization Tracking Assessment Form) revealed the patient received the Pneumovax 23 (PPSV23) pneumococcal vaccination on 11/01/2017. The “Suggested Action” on the report directs the nurses to “Admin PCV20 as ordered on or after 11/01/2018.” The “Current Pneumococcal Vaccination Status” revealed “Series In-Progress for ages 19-64” for Patient #2. There was no documentation the patient was administered the Prevnar 20 (PCV20) pneumococcal vaccination. Patient #1 Observation on 03/11/2024 at 7:34 a.m., Patient #1 was observed at station #17, hemodialysis machine #15 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record (Patient Transfer) revealed no physicians order for “CMAB recommended Algorithm for Pneumococcal Immunization- Eval and immunization against Pneumococcal infection V2.0. Every treatment clinic.” Review of the patient’s clinical record (Pneumonia Immunization Tracking Assessment Form) revealed the patient received the Pneumovax 23 (PPSV23) pneumococcal vaccination on 12/04/2017 and 12/31/2017. The “Suggested Action” on the report directs the nurses to “Admin PCV20 as ordered on or after 12/31/2018.” The patient also received “pneumococcal vaccination” (brand name not documented) on 01/08/2007 and 12/01/2012. The “Current Pneumococcal Vaccination Status” revealed “Series In-Progress for ages 19-64” for Patient #1. There was no documentation the patient was administered the Prevnar 20 (PCV20) pneumococcal vaccination. On 03/12/2024 at 12:15 p.m., the Surveyor requested documentation from Clinical Manager (I) of Patient #1 and #2 receiving the Prevnar 20 (PCV20) pneumococcal vaccination. No evidence was provided. 10802 Patient 4 Review of patient #4’s clinical record revealed the patient was admitted to the facility on 6/25/ 2019 with diagnosis of hypertension anemia in chronic kidney disease, on in center hemodialysis three times weekly. Review of the patient’s clinical record ( vaccination record) revealed documentation which indicated the patient had pneumococcal vaccination 12/19/2018 and 12/12/2018 from outside the facility. There was no documentation the facility obtained verification that the patient was offered or administered the pneumococcal vaccination. On 03/13/2024 at 11:05 a.m, The Surveyor reviewed the patient’s clinical record with the Facility’s Charge Nurse. The Charge nurse confirmed that documentation was not obtained which confirmed that the patient received the pneumoccal vaccination series. Patient #8 On 03/11/2024 at 13:32 p.m. Patient #8 was observed on the hemodialysis unit at station # 11. The patient was utilizing hemodialysis machine #3 for hemodialysis treatment. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. Review on 03/12/2024 of Patient # 8’s clinical record revealed the patient was admitted to the facility on 4/09/2021 with admitting diagnosis of hypertension and end stage renal disease on in- center hemodialysis three times weekly. Review of the patient’s hospitalization record revealed documentation dated 4/24/2023 which indicated the patient had a diagnosis of pneumonia and acute hypoxic respiratory failure requiring intubation. Review of the patient’s clinical record revealed documentation of pneumococcal vaccination administered to the patient on 10/24/2018. There is no documentation the patient was administered the series of pneumococcal vaccination. On 03/13/ 2024 at 11:00 a.m The Surveyor reviewed the patient’s clinical record with the Facility’s Charge Nurse who confirmed that the patient did not receive the full series of pneumoccal vaccination.”

“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, interview, the facility’s governing body failed to ensure expired supplies are not stored, and in use in the facility for care and services of patients. Findings: Review of the facility’s current Policy and Procedure on Expiration Dates Sterile Supplies: published 07/04/2012 directs staff as follows: Policy “ Sterile items will be checked before use to ensure that they have not expired. Appropriately dispose of sterile items that have reached the expiration date. Documentation - Expiration dates of sterile supplies contained in emergency boxes or code carts should be noted and logged as per facility protocol. 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 on 03/11/2024 during tour of the facility revealed the following expired supplies were observed co-mingled with supplies in use for patient care: Treatment Floor Observation of the Treatment Floor on 03/11/2024 at 07:49 a.m. revealed the following: 1 bottle- Aniosgel 85 (Pod 1 below the gloves on the rolling IV pole): NPC Lot #D075155, expired 02/2024 1 bottle- Aniosgel 85 (Pod 5 across from stations 19 & 20): NPC Lot #D075155, expired 02/2024 Interview with Patient Care Technician (B) on 03/11/2024 at 10:09 a.m.: the Surveyor notified Patient Care Technician (B) that she used expired hand sanitizer to disinfect her hands. Patient Care Technician (B) said, “Were supposed to check it to make sure it’s not expired.” Emergency/Code Cart Observation of the Emergency/Code Cart on 03/11/2024 at 11:27 a.m. revealed the following: 1- Bemis Suction Canister 800 cc (attached to suction machine): Catalog # 424410, Serial # 844-871, expiration date 11/2016 6- Nipro Safe Touch vascular access needles (3rd drawer): Lot # 18L01, expiration date 11/30/2023 3- Cardinal Health Transparent Dressing (3rd drawer): Lot # 18080185SNSH, expiration date 07/31/2023 7- Luer Lock Cap Set (3rd drawer): Lot # 20300b, expiration date 01/21/2024 1- Bemis Suction Canister 1200 cc (6th drawer): Reference # 484410, expiration date 02/01/2023. On 03/11/2024 at 11:44 a.m., the Surveyor notified Registered Nurse (H) of the expired suction canisters on the crash cart. Registered Nurse (H) stated, “We didn’t know that these canisters expire. We usually check the supplies at the beginning of the month and put it in the computer.” Med Prep Room Observation of the Med Prep Room floor on 03/11/2024 at 11:56 a.m. revealed the following: 1 box- 10% Calcium Chloride Injection 1gm/10 mL (cabinet above the “Hand Wash Sink”): Lot # 22018NOCO, expiration date 01/2024 Multiple- BD PrecisionGlide needles 18g x 1½ (cabinet above the “Med Sink”): Lot # 8144938, expiration date 07/31/2023 Supply Room (rolling shelves) Observation of the Supply Room on 03/11/2024 at 12:27 p.m. revealed the following: 1 box- Tempa Dot ®: Lot # 07096, expiration date 01/06/2023 1 case plus 3 boxes- BD PrecisionGlide needles 18g x 1½ (cabinet above the “Med Sink”): Lot # 8144938, expiration date 07/31/2023 1 blue container with multiple needles - BD Filter Needle: Lot # 814871, expiration date 05/31/2023 Interview with Clinical Manager (I) on 03/11/2024 at 12:38 p.m.: the Surveyor notified Clinical Manager (I) of the expired medication and supplies found during the clinic tour. Clinical Manager (I) said, “Okay, let me take a look at it.””

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 10802 Based on observation, record review and interview the facility failed to ensure information in patients’ clinical records are accurate and reflect patients’ conditions and prescribed treatments in 9 of 12 sampled patients: Patient #s 5, 4, 9, 8, 1, 2, 3, 10 and 12 Findings: Interview on 03/11/2024 with the Facility’s Regional Operations Director when asked by the Surveyor about the capability of using a Crit-Line to monitor the patients. She said the facility did not have the use of Crit-Lines and that the orders should have been discontinued. Patient #5 On 03/11/2024 at 7:10 a.m. Patient #5 was observed on the hemodialysis unit at station # 10. The patient was utilizing hemodialysis machine #27 for hemodialysis treatment. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. Review of the patient’s clinical record revealed a physician’s order dated 7/14/2023 - 7/12/2023 for Ancillary order “Crit-Line monitor ( CLM) for outpatient dialysis version 2.1 every treatment. Observation of the patient’s hemodialysis machine revealed no indication of a Crit- Line monitor in place. Review of the patient’s clinical record (treatment sheets) revealed documentation by the patient care technician assigned to the patient with the following entry: 03/11/2024 09:51. “ Crit-Line Monitor.” 03/08/2024 07:24. “ Crit-Line Monitor.” 03/06/2024 06:13. “ Crit-Line Monitor.” 03/04/2024 06:38. “ Crit-Line Monitor.” 03/01/2024 10:05. “ Crit-Line Monitor.” Patient #4 On 03/11/2024 at 7:15 a.m. Patient #4 was observed on the hemodialysis unit at station # 14. The patient was utilizing hemodialysis machine #20 for hemodialysis treatment. The patient was receiving hemodialysis treatment at a blood flow rate of 450 mls/ minute and dialysate flow rate of 800 mls/ minute via a right upper arm vascular access. Review of the patient’s clinical record revealed a physician’s order dated 11/1/2023 - 10/30/2024 for Ancillary order “Crit-Line monitor ( CLM) for outpatient dialysis version 3.2 every treatment. Observation of the patient’s hemodialysis machine revealed no indication of a Crit- line monitor in place. Review of the patient’s clinical record (treatment sheets) revealed no documentation on the treatment sheet as to the status of the order. There were no documentation as to the use of Crit-Line or not. 03/11/2024, 03/08/2024, 03/06/2024 , 03/04/2024 , 03/01/2024 Patient #9 On 03/11/2024 at 10:34 a.m. Patient #9 was observed on the hemodialysis unit at station # 15, hemodialysis machine #2. The patient was receiving hemodialysis treatment at a blood flow rate of 450 mls/ minute and dialysate flow rate of 800 mls/ minute via a double lumen central venous catheter. Review of the patient’s clinical record revealed a physician’s order dated 8/28/2023 - 8/26/2024 for Ancillary order “Crit-Line monitor ( CLM) for outpatient dialysis version 3.2 every treatment.” Observation of the patient’s hemodialysis machine revealed no indication of a Crit- line monitor in place. Review of the patient’s clinical record (treatment sheets) revealed documentation by the patient care technician assigned to the patient with the following entry: 03/11/2024 08:28. “ Crit-Line Monitor.” 03/08/2024 07:57. “ Crit-Line Monitor.” 03/06/2024 08:01. “ Crit-Line Monitor.” 03/04/2024 07:59. “ Crit-Line Monitor.” 03/01/2024 08:53. “ Crit-Line Monitor.” Review of a standing order ( algorithm) on the patient’s clinical record with only the patient’s name, not signed by the physician or the registered nurse and not dated, revealed the following directive: “use Crit-Line monitor for every outpatient dialysis treatment.” “ Nurse to consult with physician when nurse believes that, based on assessment of the patient’s condition, it may not be appropriate to follow the standing order.” #5 Checking target weight” Use Crit-Line Monitor Measurements of percentage blood volume change and plasma refill to evaluate target weight on the following patients: New to clinic New to Crit-Line Monitor Post- hospitalization Established Crit-Line Monitor patients, weekly.” Patient #8 On 03/11/2024 at 13:32 p.m. Patient #8 was observed on the hemodialysis unit at station # 11. The patient was utilizing hemodialysis machine #3 for hemodialysis treatment. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute. Review of the patient’s clinical record revealed a physician’s order dated 1/22/2024 - 1/20/2025 for Ancillary order “Crit-Line monitor ( CLM) for outpatient dialysis version 3.2 every treatment. Observation of the patient’s hemodialysis machine revealed no indication of a Crit- Line monitor in place. Review of the patient’s clinical record (treatment sheets) revealed documentation by the patient care technician and registered nurse assigned to the patient with the following entry: 03/11/2024 12:43 p.m. “ Crit-Line Monitor.” 03/08/2024 15:40 p.m. “ Crit-Line Monitor.” 03/06/2024 11:35 a.m. “ Crit-Line Monitor.” 03/04/2024 15:27 p.m. “ Crit-Line Monitor.” 03/01/2024 16:27 p.m. “ Crit-Line Monitor.” 48020 Patient #2 Observation on 03/11/2024 at 7:08 a.m., Patient #2 was observed at station #4, hemodialysis machine #7 receiving hemodialysis treatment at a blood flow rate of 500 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record (Patient Transfer) revealed a physician’s Standing Order for “Crit-Line Monitor (CLM) for Outpatients Dialysis- CLM Standing Order Version 3.2, Every Treatment” dated and Ancillary Orders “Crit-Line Monitor (CLM) Every Treatment” both dated 01/25/2021 - 01/24/2022. Observation of the patient’s hemodialysis machine revealed no indication of a Crit-Line Monitor in place. Review of the patient’s clinical record (treatment sheets) revealed documentation by the registered nurse or patient care technician assigned to the patient with the following entry: 03/11/2024 05:51 - “Crit-Line Monitor” 03/08/2024 05:55 - “Crit-Line Monitor” 03/06/2024 05:58 - “Crit-Line Monitor” 03/04/2024 09:00 - “Crit-Line Monitor” 03/01/2024 05:49 - “Crit-Line Monitor” 02/28/2024 05:52 - “Crit-Line Monitor” Patient #1 Observation on 03/11/2024 at 7:34 a.m., Patient #1 was observed at station #17, hemodialysis machine #15 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record (Patient Transfer) revealed a physician’s Standing Order for “Crit-Line Monitor (CLM) for Outpatients Dialysis- CLM Standing Order Version 3.2, Every Treatment” dated and Ancillary Orders “Crit-Line Monitor (CLM) Every Treatment” both dated 12/27/2023 - 12/25/2024. Observation of the patient’s hemodialysis machine revealed no indication of a Crit-Line Monitor in place. Review of the patient’s clinical record (treatment sheets) revealed documentation by the registered nurse or patient care technician assigned to the patient with the following entry: 03/11/2024 06:30 - “Crit-Line Monitor” 03/08/2024 06:18 - “Crit-Line Monitor” 03/06/2024 09:20 - “Crit-Line Monitor” 03/04/2024 08:51 - “Crit-Line Monitor” 03/01/2024 06:16 - “Crit-Line Monitor” 02/28/2024 10:37 - “Crit-Line Monitor” Patient #3 Observation on 03/11/2024 at 7:42 a.m., Patient #3 was observed at station #20, hemodialysis machine #1 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record (Patient Transfer) revealed a physician’s Standing Order for “Crit-Line Monitor (CLM) for Outpatients Dialysis- CLM Standing Order Version 3.2, Every Treatment” dated and Ancillary Orders “Crit-Line Monitor (CLM) Every Treatment” both dated 11/01/2023 - 10/30/2024. Observation of the patient’s hemodialysis machine revealed no indication of a Crit-Line Monitor in place. Review of the patient’s clinical record (treatment sheets) revealed documentation by the registered nurse or patient care technician assigned to the patient with the following entry: 03/11/2024 13:12 - “Crit-Line Monitor” 03/08/2024 07:30 - “Crit-Line Monitor” 03/06/2024 09:19 - “Crit-Line Monitor” 03/04/2024 07:35 - “Crit-Line Monitor” 03/01/2024 07:38 - “Crit-Line Monitor” 02/28/2024 07:34 - “Crit-Line Monitor” Patient #10 Observation on 03/12/2024 at 7:51 a.m., Patient #10 was observed at station #20, hemodialysis machine #1 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 800 mL/min via a left upper arm vascular access. Review of the patient’s clinical record (Patient Transfer) revealed a physician’s Standing Order for “Crit-Line Monitor (CLM) for Outpatients Dialysis- CLM Standing Order Version 3.2, Every Treatment” dated and Ancillary Orders “Crit-Line Monitor (CLM) Every Treatment” both dated 07/19/2023 - 07/17/2024. Observation of the patient’s hemodialysis machine revealed no indication of a Crit-Line Monitor in place. Review of the patient’s clinical record (treatment sheets) revealed documentation by the registered nurse or patient care technician assigned to the patient with the following entry: 03/11/2024 08:00 - “Crit-Line Monitor” 03/09/2024 11:00 - “Crit-Line Monitor” 03/07/2024 13:28 - “Crit-Line Monitor” 03/05/2024 12:01 - “Crit-Line Monitor” 03/02/2024 11:33 - “Crit-Line Monitor” 02/29/2024 11:27 - “Crit-Line Monitor” Patient #12 Observation on 03/12/2024 at 7:54 a.m., Patient #12 was observed at station #22, hemodialysis machine #6 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 800 mL/min via a left double lumen central venous catheter. Review of the patient’s clinical record (Patient Transfer) revealed a physician’s Standing Order for “Crit-Line Monitor (CLM) for Outpatients Dialysis- CLM Standing Order Version 3.2, Every Treatment” dated and Ancillary Orders “Crit-Line Monitor (CLM) Every Treatment” both dated 02/29/2024 - 02/27/2025. Observation of the patient’s hemodialysis machine revealed no indication of a Crit-Line Monitor in place. Review of the patient’s clinical record (treatment sheets) revealed documentation by the registered nurse or patient care technician assigned to the patient with the following entry: 03/11/2024 07:34 - “Crit-Line Monitor” 03/09/2024 07:15 - “Crit-Line Monitor” 03/07/2024 07:26 - “Crit-Line Monitor” 03/05/2024 11:06 - “Crit-Line Monitor” 03/02/2024 10:52 - “Crit-Line Monitor” 02/29/2024 07:52 - “Crit-Line Monitor” Interview with Registered Nurse (G) on 03/12/2024 at 2:15 p.m. revealed she said, “We do not have Crit-Lines, but we cannot close out the system without signing off for them.””