Baylor Scott & White Killeen Dialysis West

“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: 51738 Based on a review of facility documents, interviews, and medical record reviews, the facility’s medical director failed to ensure that facility staff adhered to policies and procedures relative to patient care when dialysis technicians did not notify registered nurses of patient #1’s hypotensive episodes and interventions performed, did not recheck patient #1’s blood pressure (BP) after each hypotensive episode, and did not monitor patient #1’s BP more frequently. Findings: A review of facility documents reveals in part: --Initial Skills Competency Checklist Intradialytic Monitoring - “Monitors patient ...during treatment every 30 minutes or more often if patient is unstable ...NOTIFIES BAY NURSE FOR IRREGULARITIES, CHANGE IN PATIENT CONDITION, BP [Blood Pressure] OR PULSE IN REPORTABLE PARAMENTERS [SIC] Intradialytic Complications ...Re-checks blood pressure frequently until hypotension resolved AND patient is stable” --Vital Signs in Dialysis Patients - PowerPoint Presentation “Reportable Parameters - Systolic Blood Pressure < 100 [less than 100] - Unless a patient has a specific order to run lower [Systolic BP refers to the top number in a BP reading.] Monitoring the Patient ...Notify Nurse immediately for abnormal changes” --Killeen West/East Dialysis Mandatory Monthly Meeting: 11/18/25 - “ ...if out of parameters notify the CN [Charge Nurse]” 10/9 and 10/10/25 - “ ...if out of parameters notify the CN” 9/4 and 9/5/2025 - “HD [hemodialysis] intervention: needs to give intervention first, notify BN [Bay Nurse] if no improvement after intervention.” Interviews: In an interview on 12/16/2025 at 10:30 AM, Staff #3, CN, RN [Registered Nurse] reported that “techs” [nursing assistants, dialysis technicians, and Certified Clinical Hemodialysis Technician (CCHTs)] are trained to document all interventions in the patient’s chart and to notify the BNs for any abnormal vital signs or other issues. In an interview on 12/16/2025 at 12:00 PM, Staff #2, RN, reported that “techs” can perform interventions for hypotensive patients, including giving up to 200 mL of fluid and placing patients in Trendelenburg [positioning a patient on their back with their legs elevated above their head at an angle of approximately 15 to 30 degrees used to manage hypotension]. Staff #2, RN, added that “techs” should notify the RN “right away”. A review of the medical record for patient #1 reveals in part: A review of the Outpatient Hemodialysis Record on 11/3/2025 for patient #1 revealed documentation of four hypotensive episodes. “Vital signs stable” was documented three times. Staff #12, Dialysis Tech, documents notifying the BN twice. Patient #1’s BP was rechecked after two hypotensive episodes, but staff did not monitor BP more frequently. 11:28 AM - Treatment Started 12:30pm - BP 66/45 - “Vital Signs stable; RECHECKED BP GAVE PT 200 OF SALINE AND NOTIFIED THE NURSE, B/P WAS A LOT BETTER” - Staff #12, Dialysis Tech 1:00 PM - BP 94/59 - “Vital Signs stable; NOTIFIED NURSE GAVE PT ANOTHER 100 OF SALINE WILL MONITOR PT THROUGHOUT TREATMENT” - Staff #12, Dialysis Tech 1:15 PM - BP 86/50 - “Hypotension Asymptomatic ...saline bolus 100 ml ...” - Staff #13, RN 1:21 PM - BP 115/64 - [Recheck] 2:01 PM - BP 92/55 - “vital signs stable ... hypotension ...Pt [patient] is asymptomatic; Saline bolus given 100 mL ...” - Staff #12, Dialysis Tech 2:03 PM - BP 113/64 [Recheck] - “BP stabilized with fluid bolus” - Staff #12, Dialysis Tech and Staff #13, RN 2:34 PM - Treatment Ended A review of the Outpatient Hemodialysis Record on 11/5/2025 for patient #1 revealed documentation of six hypotensive episodes, including when dialysis was started. “Vital signs stable” was documented for all 6 episodes. Staff #11, BN and staff #9, Dialysis Tech 1, both document three of these hypotensive episodes. Staff #9, Dialysis Tech 1, only documents notifying the BN once out of the remaining 3 episodes. No one rechecked the patient’s BP after any of these hypotensive episodes and staff did not begin monitoring patient#1’s BP more frequently. At 2:30 PM, Staff #9, Dialysis Tech 1, documents a BP of 75/21 but then documents “Hypertension > 200 systolic [Hypertension greater than 200 systolic]”. At 2:41 PM, staff #9, Dialysis Tech 1, documents that treatment ended early due to patient #1’s hypotension. 12:00 PM - Treatment Started - BP 97/62 - “vital signs stable” - Staff #9, Dialysis Tech 1 and staff #11, RN 12:30 PM - BP 97/33 - “Hypotension < 100 systolic, vital signs stable, 100 ml given” - Staff #9, Dialysis Tech 1 and staff #11, RN 1:01 PM - BP 90/53 - “Hypotension < 100 systolic ...vital signs stable” - Staff #9, Dialysis Tech 1 1:32 PM - BP 94/52 - “Hypotension < 100 systolic - bn notified, fluid given -will monitor - vital signs stable, 100 ml given” - Staff #9, Dialysis Tech 1 2:00 PM - BP 91/53 - “Hypotension < 100 systolic - vital signs stable, 100 ml given” - Staff #9, Dialysis Tech 1 2:30 PM - BP 75/28 - “Hypertension > 200 systolic - “vital signs stable, 100 ml given” - Staff #9, Dialysis Tech 1 2:41 PM - BP 122/71 - “tx [treatment] ended early due to low BP” - Staff #9, Dialysis Tech 1 A review of the Outpatient Hemodialysis Record on 11/7/2025 for patient #1 revealed documentation of five hypotensive episodes. Staff #8, CNA and Staff #9, Dialysis Tech 1, documented “Vital signs stable” for three episodes, only notified the BN of patient hypotension once, only rechecked the BP after 2 hypotensive episodes, and did not increase the monitoring frequency. Staff #9, CNA administered 200 mL of fluid twice, but did not notify the BN. 12:08 PM - Treatment Started 1:02 PM - BP 95/61 - “vital signs stable ...No complaints.” - Staff #8, CNA 1:33 PM -BP 80/47 - “200 mL fluid given” - Staff #9, Dialysis Tech 1 1:36 PM - BP 107/59 - Staff #9, Dialysis Tech 1 2:00 PM - BP 88/55 - “200 mL fluid given” - Staff #9, Dialysis Tech 1 2:02 PM - BP 98/58 -“vital signs stable ...Hypotension < 100 systolic” - Staff #9, Dialysis Tech 1 2:32 PM - BP 94/36 - vital signs stable ...Hypotension < 100 systolic ...bn [bay nurse] notofied [sic], pt [patient] asymptomatic, continue to monitor” - - Staff #9, Dialysis Tech 1 2:46 PM - Treatment Ended”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 43999 Based on observation and staff interview, the facility failed to provide to ensure that each patient is: treated with respect, dignity, and recognition of his or her individualty and personal needs. Findings: Policy titled: Patient Rights and Responsibilities partly stated: “The rights and responsibilities recognized at BSWH (Baylor Scott & White Hospital) are as follows: · Patients have the right to have a family member, surrogate decision-makers to promote representative and the patient’s physician promptly notified of their admission to a BSWH facility. · BSWH will collaborate with patients and their surrogate decision-makers to promote patient health and welfare by recommending treatments based on medical science and health care professional judgment - We will treat all with dignity, compassion, and respect for personal values, including spiritual beliefs.” Interview with Staff #1 and Staff #3, on 2/4/25, revealed an incident occurred and after investigation, the staff did not assist patient with needs when notified. Documentation of the facility grievance report identified staff did not provide patient care to provide respect, dignity with personal needs. Above findings confirmed on 02/04/25 in an interview with facility Director of Nurising and Nurse Manger during the survey process.”

“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: 28421 Based on observation and interview, it was determined that the facility failed to practice appropriate infection control. Findings : Facility policy entitled “Hand Hygiene” stated microorganism transmission could take place through direct or indirect contact. “Direct contact transmission involves skin to skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person. Indirect contact transmission involves contact of a susceptible host with a contaminated object, usually inanimate, in the patient’s environment.” The same policy goes on to state, “Patients and families are encouraged to decontaminate their hands prior to care activities.” * Tour of the patient treatment area on 7/15/24 revealed 4 patients discontinuing dialysis. None of these patients were observed washing their hands after treatment. 3 patients were observed entering the treatment area. None of these patients were prompted to wash their hands or access sites before initiating treatment. * Tour of the two water rooms on 7/15/24 revealed exposed insulation in half of Water Room A. The paint on the floor was cracked and peeling. Both water rooms had double doors leading outside that needed weather stripping. The empty space under the door could allow insects access into the building. * Baseboards at station 13 & at the clean sink at entrance to treatment room were cracked with water damage to sheet rock observed, decreasing ability to disinfect area. * One floor tile at the clean sink was broken, exposing the sheet rock. The above findings were confirmed by the Biomedical Technician and the Charge Nurse during the tour.”

“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: 43999 Based on observation and interview, the facility failed to ensure that appropriate infection control measures and/or practices to prevent infections were practiced and followed, 2 out of 6 facility staff failed to remove gloves and wash hands between each patient or station. This practice placed all patients at the facility at risk for infection. Findings: “ Infection Prevention and Control Document Number: BSWH.IPC.004.P, Last Review/Revision Date: 10/31/2023 states in part , Glove use is not a substitute for cleaning hands. -Hand hygiene is always performed after removal of gloves, as dirty gloves can soil hands. It is important to change gloves: - If gloves are damaged. - Moving from a contaminated body site to a clean body site. - If gloves look dirty or have blood or bodily fluids on them after completing a task...” Staff # 6 failed to deglove and sanitize hands prior to resetting an alarm, then returned to pervious patient machine with same gloves to complete machine setup. Staff # 9 failed to deglove and sanitize hands when going from setting up a machine for patient’s treatment to disconnecting another patient from treatment. The above findings were confirmed during the observation by the staff members.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 28421 Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its patients and staff. Findings: “OSHA/Bloodborne Pathogen Regulations Policy #138-030-060” stated in part “The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner.” Tour of the two water rooms on 7/15/24 revealed exposed insulation in half of Water Room A. The paint on the floor was cracked and peeling. Both water rooms had double doors leading outside that needed weather stripping. The empty space under the door could allow insects access into the building. The above findings were confirmed by the Biomedical Technician on 7/16/24.”