Davita Pinecrest Dialysis Center

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 48653 Based on observation and record review, the facility staff failed to maintain and provide a sanitary environment in the laboratory area. The facility staff failed to follow the “Infection Control for Dialysis Facilities” policy. Findings include: During a tour of the facility’s in-center treatment area with Staff # 1 on 08/04/2025 at 9:45 AM, the surveyor observed laboratory refrigerator # 1 to have a build-up of dust and dirt inside of it. There was a brown and red colored substance on the bottom of the refrigerator shelf that appeared to be blood. A review of the facility’s “Infection Control for Dialysis Facilities” policy dated of April 2023 revealed, PURPOSE: To minimize the spread of infections or blood borne pathogens in the dialysis facility environment. POLICY: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients...DISINFECTION: 12. Cleaning and/or disinfection of equipment and surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials...Prior to routine disinfection, remove all visible blood...Cleaning of visible blood should be performed when first observed....” An interview was conducted with Staff # 1 on 08/04/2025 at 9:50 AM which confirmed the presence of dirt, dust, and blood-appearing substance on the bottom of laboratory refrigerator # 1.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interviews, the facility’s nursing staff failed to ensure that medications stored in the facility were properly secured and safeguarded from unauthorized access. The facility’s nursing staff failed to follow the “Medication Policy”. Findings include: During a tour of the facility’s in-center treatment area with Staff # 1 on 08/04/2025 at 9:45 AM, the surveyor observed the following, There was no licensed nurse in the medication preparation and storage area at the time of the observations. The medication cabinets in the medication preparation area were unlocked, allowing the surveyor to access the medications. The following medications were stored in a white bin on the counter of the medication preparation area: Promethazine, 2 bottles of Calcitriol, 2 bottles of Cinacalcet, Tylenol, Clonidine, and Loperamide. A review of the facility’s “Medication Policy” with a date of November 2023 revealed, “PURPOSE: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of all medications ...POLICY: 1. The Facility Administrator/designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications and performs a monthly audit and inventory ...11. All refrigerated medications, for example, erythropoietin-stimulating agents (ESA) and vaccines, are to be locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations. Non-refrigerated medications are to be stored in cabinet(s) and locked at the close of each business day if not under the direct supervision of the licensed teammate or per state regulations ...” An interview was conducted with Staff # 1 on 08/04/2025 at 9:50 AM, which confirmed the medications in the facility were unsecured and the facility’s nursing staff failed to follow the facility’s “Medication Policy”.”

“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: 48749 Based on record review and interview, the facility failed to ensure direct care staff were reporting patient vital signs that fell outside of the facility’s set parameters to the Charge Nurse (CN) for further assessment and intervention on 1 (# 4) of 1 patient charts reviewed. Also, the facility’s Charge Nurse failed to report patient vital signs that fell outside the facility’s set parameters to the Physician. The facility staff failed to follow the facility’s “Pre-Intra-Post Data Collection, Monitoring and Nursing Assessment” policy. Findings include: Patient #4 A review of the treatment sheet dated 04/05/2025 for Patient #4 revealed the following; At 5:25 AM, during the nursing pre-treatment assessment, Staff #12 documented Patient #4’s vital signs as BP (blood pressure): 153/103; HR (heart rate): 133. There was no documentation found to support that Staff #12 notified the Physician of the abnormal vital signs before initiating treatment. Further review of the treatment sheet for 04/05/2025 revealed, Staff #19 and Staff #20 documented the following vital signs during Patient #4’s treatment; “5:32 AM: BP: 149/99; HR: 115 6:02 AM: BP: 120/82; HR: 131 6:30 AM: BP 148/98; HR: 120 7:02 AM: BP 157/95; HR: 119 7:32 AM: BP 142/111; HR: 122 8:02 AM: BP 185/124; HR: 121 8:32 AM: BP 170/119; HR: 127 9:32 AM: BP 169/130; HR: 124” There was no documentation found to support that Staff #19 and Staff #20 reported the abnormal vital signs to the Charge Nurse. There was no documentation found to support that the abnormal vital signs were reported to the Physician during Patient #4’s treatment on 04/05/2025. A review of the treatment sheet dated 04/08/2025 for Patient #4 revealed the following; At 5:03 AM, during the nursing pre-treatment assessment, Staff #12 documented Patient #4’s vital signs as BP: 149/92; HR: 125. There was no documentation found to support that Staff #12 notified the Physician of the abnormal vital signs before initiating treatment. Further review of the treatment sheet for 04/08/2025 revealed, Staff #12 and Staff #21 documented the following vital signs during Patient #4’s treatment; “5:16 AM: BP: 133/93; HR: 119 5:31 AM: BP: 158/99; HR: 131 6:01 AM: BP 169/108; HR: 116 6:31 AM: BP 163/109; HR: 116 7:01 AM: BP 121/93; HR: 121 7:31 AM: BP 135/59; HR: 117” There was no documentation found to support that the abnormal vital signs were reported to the Physician during Patient #4’s treatment on 04/08/2025. Also, Staff #12 documented that Patient #4 finished treatment at 1.1 kilograms over the target weight. There was no documentation found to support that the Physician was notified of Patient #4 finishing treatment over the patient’s target weight. A review of the facility’s policy titled, “Pre-Intra-Post Data Collection, Monitoring and Nursing Assessment” dated April 2024 revealed the following: “POLICY: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: i. Measurement of patient temperature. ii. Measurement of Blood Pressure (BP). 1. Sitting and standing BP measurement required pre- and post-treatment (if patient is unable to stand, document the reason in the patient’s electronic record or flow sheet). 2. Intradialytic BP in the sitting/reclined or supine position. iii. Heart or pulse rate, noting also if the beat is regular or irregular. iv. Patient weight. v. Patient’s report of well-being, level of pain or discomfort, complaints, hospitalization. vi. Vascular access status. PRE-TREATMENT DATA COLLECTION/ASSESSMENT 4. Any abnormal findings or findings outside of any patient-specific physician-ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. 7. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated. INTRADIALYTIC DATA COLLECTION/ASSESSMENT 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law. 9. Intradialytic treatment monitoring and data collection, which may be performed by the PCT or licensed nurse, includes: 11. Abnormal findings or findings outside of any patient-specific physician-ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions, and patient responses will be documented in the patient’s medical record. POST TREATMENT DATA COLLECTION/ASSESSMENT 15. The PCT or licensed nurse will obtain and document basic data on each patient post-dialysis and compare to pre-dialysis findings. If the patient has received Korsuva (difelikefalin) during the treatment, the licensed nurse will assess the patient prior to discharge. 16. If an abnormal finding(s) or concern is identified post-treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. ABNORMAL FINDINGS Unless other abnormal parameters are established by the facility’s Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. Within each category, definitions may be adjusted by a patient-specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. Blood pressure: Pre-dialysis: * Systolic greater than 180 mm/Hg or less than 90 mm/Hg * Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg Blood Pressure-Intradialytic: * Systolic greater than 180 mm/Hg or less than 90 mm/Hg * Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg * Signs/symptoms of hypotension may include: * Nausea and vomiting * Cold and clammy skin * Restlessness * Rapid, shallow respirations * Excessive yawning * Diaphoretic Blood Pressure Post Treatment: * If the patient can stand: * Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg * Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg * If the patient is not able to stand, document the reason and the sitting BP * Sitting BP for patients that cannot stand: * Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg *Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg * Signs/symptoms of hypotension may include: * Nausea and vomiting * Cold and clammy skin * Restlessness * Rapid, shallow respirations * Excessive yawning * Diaphoretic * Dizziness * Feeling faint Heart or Pulse Rate Pre/Intra/Post: * Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heartbeat” An Interview was conducted with Staff #3 on 05/28/2025 at 2:20 PM. Staff #3 stated, “Patient #4 had been non-compliant with scheduled treatments and medications”. Staff #3 reported that staff should be taking an apical pulse if abnormal or fast and compare pulse with the machine. Staff should be reporting all abnormal vital signs to the charge nurse and the Physician.”

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility’s charge nurse failed to ensure: A. a post-treatment nursing assessment was completed before 2 (Patient # 6 and Patient # 7) of 2 patients’ discharge from the facility. (Cross Refer to Tag V0502) B. vital signs that fell outside of the facility’s set parameters were reported to the provider for further assessment and intervention on 1 (Patient # 4) of 1 patient chart reviewed. The facility staff failed to follow the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. (Cross Refer to Tag V0504)”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to change gloves and perform hand hygiene between patient encounters and before touching dialysis equipment in 2 (Patient # 5 and # 6) of 2 patient encounters. The facility staff failed to follow the “INFECTION CONTROL FOR DIALYSIS FACILITIES” policy. Findings include: During a tour of the facility’s in-center treatment area on 04/02/2025 at 9:30 AM with Staff # 12 (Charge Nurse), the surveyor observed Staff # 5 (CCHT) assist Patient # 6 to the weigh station after completing treatment. Staff # 5 was observed assisting the patient in putting his shoes on. Staff # 5 touched the patient’s shoes with gloves on and proceeded to assist the patient out into the lobby with the same pair of gloves on. Staff # 5 came back into the in-center treatment area and went to Patient # 5’s dialysis station to assist the patient in lowering the footrest of the recliner. Staff # 5 never changed gloves or performed hand hygiene in between the two patient interactions. A review of the facility’s policy, “INFECTON CONTROL FOR DIALYSIS FACILITIES” with a date of April 2024 revealed, “PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. POLICY: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients ... HAND HYGEINE 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area. PPE (i.e., gown, gloves, eye protection, face shield) 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. PPE is to be: a. Removed prior to leaving the treatment area. b. Removed as soon as possible if overtly contaminated and i. Disposable, deposit in a biohazard waste container ii. Non-disposable, properly disinfect and place in designated area c. PPE is not to be worn in non-treatment areas, for example, teammate lounge, teammate offices.” An interview was conducted with Staff # 4 on 04/02/2025 at 10:40 AM. Staff # 4 confirmed the facility policy requires staff members to change gloves and perform hand hygiene in between patient encounters and dialysis equipment.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to ensure 4 (IV antibiotic # 1, and # 2, Heparin Syringe # 1 and # 2) of 4 pre-prepared intravenous (IV) medications were properly labeled with the date, time, and initials of the staff member preparing the medications. Also, the facility staff failed to ensure that 2 (Heparin Syringe # 3 and # 4) of 2 medications were properly safeguarded and not accessible to unauthorized persons. The facility staff failed to follow the “Medication Policy”. Findings include: During a tour of the facility’s in-center treatment area with Staff # 12 on 04/02/2025 at 9:30 AM, the surveyor observed 2 intravenous (IV) antibiotic bags that were prepared in the medication room. The IV bags were spiked with IV tubing and hanging on an IV pole. IV antibiotic # 1 was labeled, “Vancomycin 750 milligrams”. There was no date, time, or preparer identified on the label. IV antibiotic # 2 was labeled, “Cefepime 2 grams”. There was no date, time, or preparer identified on the label. Heparin syringes # 1 and # 2 were found predawn and stored in the locked medication cabinet in the medication room. There was no date, time, or preparer identified on the labels of the Heparin syringes. Heparin syringe # 3 was found sitting out on the chairside table at Station # 16. There was no patient at the machine receiving treatment at the time of the observation. The medication was unsecured and there were no staff members in the area to ensure the medication was safeguarded. Heparin Syringe # 4 was found connected to the machine’s tubing and was loaded into the heparin infusion pump located at Station # 16. There was no patient receiving treatment at the time of the observation. This deficient practice had the likelihood to result in a patient receiving heparin doses that were not prescribed to them. A review of the facility’s policy, “Medication Policy” with a date of October 2024 revealed, “PURPOSE: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of all medications .... 11. All refrigerated medications, for example erythropoietin stimulating agents (ESA) and vaccines are to be locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations. Non-refrigerated medications are to be stored in cabinet(s) and locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations ... 20. If medications are prepared and administered immediately, by the same licensed nurse teammate, the medications do not need to be labeled. If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient’s name, name of medication, date, time prepared, dose, and initials of teammate preparing the medication ...” An interview was conducted with Staff # 4 on 04/02/2025 at 11:30 AM which confirmed the facility’s staff failed to follow the “Medication Policy” and failed to ensure medications were properly stored and safeguarded from unauthorized persons.”

“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: 48653 Based on observation, record review, and staff interview, the facility’s direct care staff failed to ensure that all patients’ vascular access was in view during the dialysis treatment. Three (Patient # 5, # 7, and #8) of 6 patient vascular accesses were covered with a blanket and were not visible to the staff during their dialysis treatments. The facility staff failed to follow the “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy. 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 a tour of the facility’s in-center treatment area with Staff # 12 on 04/02/2025 at 9:30 AM, the surveyor observed three patients’ hemodialysis access covered with blankets during treatment. Patient # 5 was receiving hemodialysis treatment at Station # 11. The patient’s access was not visible to the surveyor and was covered with a blanket. The access was covered for more than 15 minutes. Patient # 7 was receiving hemodialysis treatment at Station # 1. The patient’s access was not visible to the surveyor and was covered with a blanket. The access was covered for more than 15 minutes. Patient # 8 was receiving hemodialysis treatment at Station # 2. The patient’s access was not visible to the surveyor and was covered with a blanket. The access was covered for more than 15 minutes. A review of the facility’s policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” with a date of April 2024 revealed, “PURPOSE: To obtain and document baseline and ongoing information about the patient before, during, and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. POLICY: Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: i. Measurement of patient temperature ii. Measurement of Blood Pressure (BP) 1. Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet) 2. Intradialytic BP in the sitting/reclined or supine position iii. Heart or pulse rate, noting also if the beat is regular or irregular iv. Patient weight v. Patient’s report of well-being, level of pain or discomfort, complaints, hospitalization vi. Vascular access status. 2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). a. The assessment includes the following components: i. Review of patient reports, data collection, complaints and response to treatment ii. Verification that machine safety checks have been completed and documented iii. Verification of prescription including machine parameters iv. Verification that the patient access is visible and face is not covered ...” An interview was conducted with Staff # 4 on 04/02/2025 at 11:30 AM which confirmed the patients’ access sites were covered and not visible for greater than 15 minutes. Staff # 4 confirmed this practice was unsafe for the patients and could result in a needle dislodgement and/or bleeding.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility’s charge nurse failed to ensure a post-treatment nursing assessment was completed before 2 (Patient # 6 and Patient # 7) of 2 patients’ discharge from the facility. During a tour of the facility’s in-center treatment area on 04/02/2025 at 10:00 AM, the surveyor observed that Patient # 6 and # 7 had finished hemodialysis treatment. The surveyor observed to ensure the Charge Nurse assessed them prior to discharge. The patients proceeded to the weight station for a post-treatment weight and were not assessed by the charge nurse prior to discharge. A review of the facility’s policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” with a date of April 2024 revealed, “POLICY: Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: i. Measurement of patient temperature ii. Measurement of Blood Pressure (BP) 1. Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet) 2. Intradialytic BP in the sitting/reclined or supine position iii. Heart or pulse rate, noting also if the beat is regular or irregular iv. Patient weight v. Patient’s report of well-being, level of pain or discomfort, complaints, hospitalization vi. Vascular access status. 2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). a. The assessment includes the following components: i. Review of patient reports, data collection, complaints and response to treatment ii. Verification that machine safety checks have been completed and documented iii. Verification of prescription including machine parameters iv. Verification that the patient access is visible and face is not covered ... POST TREATMENT DATA COLLECTION/ASSESSMENT 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings. a. If the patient has received Korsuva (difelikefalin) during the treatment, the licensed nurse will assess the patient prior to discharge. 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility ...” An interview was conducted with Staff # 12 on 04/02/2025 at 10:30 AM. Staff # 12 was asked if a post-treatment assessment was completed. Staff # 12 stated, “I listened to the patient before treatment but I did not assess him after treatment finished”. Staff # 4 was present during the interview and confirmed that there was no post-treatment assessment completed on the patients. Staff # 4 stated, “I asked her where her stethoscope was and she had to go get it”.”

“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: 48653 Based on record review and interview, the charge nurse failed to ensure vital signs that fell outside of the facility’s set parameters were reported to the provider for further assessment and intervention on 1 (Patient # 4) of 1 patient chart reviewed. The facility staff failed to follow the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. Findings include: Patient # 4 A review of the hemodialysis treatment sheet dated 01/22/2025 for Patient # 4 revealed the patient arrived at treatment with a sitting blood pressure of 232/145. The patient was started on treatment by Staff # 16 (LVN) with a blood pressure of 217/145 at 1:37 PM. The charge nurse did not assess the patient prior to treatment initiation. The nurses pre-treatment assessment was docuemtned at 4:36 PM. The patient’s blood pressure remained elevated throughout treatment, with the systolic pressure never going below 200 mmHg (millimeters of mercury) and the diastolic pressure never going below 124 mmHg. The patient was discharged from the facility with a blood pressure of 213/124. There was no documentation that the doctor was made aware of the patient’s blood pressure. A review of the hemodialysis treatment sheet dated 01/24/2025 for Patient # 4 revealed the patient arrived at treatment with a sitting blood pressure of 226/156. The patient was started on treatment at 1:14 PM with a blood pressure of 226/165 by Staff # 7. The nurse did not assess the patient prior to treatment initiation. The pre-treatment assessment was documented at 1:25 PM. The following was documented throughout the patient’s treatment by Staff # 7, “1:24 PM: Blood Pressure 220/142 1:32 PM: Blood Pressure 225/156, patient complained of chest pain rated #2 on the pain scale, he states its like muscle spasm, O2 was started. 1:42 PM: Clonidine given, no blood pressure reading documented. 2:02 PM: Blood pressure: 236/142, patient states chest pain increased to # 4 on pain scale ...” The charge nurse did not call the doctor prior to starting the patient on hemodialysis treatment with an extremely elevated, symptomatic blood pressure. A review of the facility’s policy, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” with a date of April 2024 revealed, “”POLICY: Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: i. Measurement of patient temperature ii. Measurement of Blood Pressure (BP) 1. Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet) 2. Intradialytic BP in the sitting/reclined or supine position iii. Heart or pulse rate, noting also if the beat is regular or irregular iv. Patient weight v. Patient’s report of well-being, level of pain or discomfort, complaints, hospitalization vi. Vascular access status. 2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). a. The assessment includes the following components: i. Review of patient reports, data collection, complaints and response to treatment ii. Verification that machine safety checks have been completed and documented iii. Verification of prescription including machine parameters iv. Verification that the patient access is visible and face is not covered ... PRE-TREATMENT DATA COLLECTION/ASSESSMENT 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. 7. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated ....” An interview was conducted with Staff # 6 on 04/02/2025 at 11:40 AM which confirmed the facility’s nursing staff did not contact the doctor for further evaluation and interventions on symptomatic vital signs. Staff # 6 confirmed the patient was discharged with a blood pressure that was extremely elevated and unsafe.”