Fresenius Medical Care Museum District

“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: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to wash/sanitize their hands after touching their contaminated face shields: 2 of 6 staff observed Findings: Review of the facility’s current policy and procedure: Hand Hygiene: published 03/17/2023, reference number 47664, version 7 directs the staff as follows: “Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water “ Entering and leaving the treatment area ... “ Immediately after removing gloves ... “ After contact with inanimate objects near the patient “ After contact with other objects within the patient station or treatment space Patient Care Technician (F) Observation on 12/18/2024 at 9:21 a.m., revealed Patient Care Technician (F) tearing tape strips at the clean supply cart in the middle of the bay. Patient Care Technician (F) picked up the tape strips, touched her face shield to adjust it and with her contaminated hands, grabbed clean gloves from the box sitting on top of the clean supply cart. Patient Care Technician (F) then walked over to the patient sitting at station #13, placed the tape strips on the blue pad, and donned the gloves. Patient Care Technician (F) failed to wash/sanitize her hands after touching her contaminated face shield. Interview with Patient Care Technician (F) on 12/18/2024 at 9:36 a.m., the Surveyor notified Patient Care Technician (F) that she did not wash/sanitize her hands after touching her face shield. Patient Care Technician (F) said “Yes, ma’am. It’s a bad habit.” Patient Care Technician (G) Observation on 12/18/2024 at 9:29 a.m., revealed Patient Care Technician (G) standing at the clean supply cart in the middle of the bay. Patient Care Technician (G) touched his face shield to pull it down over his face and with his contaminated hands, grabbed clean gloves from the box sitting on top of the clean supply cart, donned the gloves and walked over touched the machine screen at station#17. Patient Care Technician (G) failed to wash/sanitize his hands after touching his contaminated face shield. The Surveyor immediately notified Patient Care Technician (G) that he did not wash/sanitize his hands after touching his face shield. Patient Care Technician (F) said “Okay.””

“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 9 of 17 sampled and closed patients: Patient #s 1, 6, 10, 14, 17, 3, 11, 16, 15 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. Dialysate Flow Rate: Patient #1 On 12/17/2024 at 1:41 p.m. Patient #1 was observed on the treatment floor of the facility at station #18 machine #9. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 600 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left upper arm vascular access. Review of the physician’s order dated 11/28/2024 revealed the prescribed dialysate flow rate of 800 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 12/07/2024 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 800 mL/min but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 11:01 a.m. - 12:00 p.m. and 12:22 p.m. - 13:41 p.m. There was no justification documented for the dialysate flow rate of 500 mL/min. Patient #6 On 12/17/2024 at 1:53 p.m. Patient #6 was observed on the treatment floor of the facility at station #1 machine #26. The patient was receiving hemodialysis treatment at a blood flow rate of 425 mL/min and dialysate flow rate of 500 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left upper arm vascular access. Review of the physician’s order dated 11/26/2024 revealed the prescribed dialysate flow rate of 500 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 12/14/2024 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 500 mL/min but received hemodialysis treatment at a dialysate flow rate of 800 mL/min from 11:05 a.m. - 15:26 p.m. There was no justification documented for the dialysate flow rate of 800 mL/min. Patient #10 Review of the patient’s clinical record on 12/17/2024 revealed the patient was admitted to the facility on 01/03/2022 with diagnoses of end stage renal disease, hypertension, diabetes mellitus on in-center hemodialysis three times weekly. Review of the physician’s order dated 12/02/2024 revealed the prescribed dialysate flow rate of 800 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 12/13/2024 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 800 mL/min but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 17:43 p.m. - 21:04 p.m. There was no justification documented for the dialysate flow rate of 500 mL/min. Patient #14 Review of the patient’s clinical record on 12/17/2024 revealed the patient was admitted to the facility on 03/03/2023 with diagnoses of end stage renal disease, congestive heart failure, hypertension, on in-center hemodialysis three times weekly. Treatment sheet review: Review of the patient’s treatment sheet dated 07/19/2023 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 800 mL/min but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 11:22 a.m. - 11:42 and 12:17 p.m. - 14:03 p.m. There was no justification documented for the dialysate flow rate of 500 mL/min. Review of the physician’s order on the treatment sheet revealed a blood flow rate of 800 mL/min. Patient #17 Review of the patient’s clinical record on 12/17/2024 revealed the patient was admitted to the facility on 05/04/2010 with diagnoses of end stage renal disease, hypertension, on in-center hemodialysis three times weekly. Review of the physician’s order dated 10/17/2020 revealed the prescribed dialysate flow rate of 800 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 12/12/2020 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 800 mL/min but received hemodialysis treatment at a dialysate flow rate of 600 mL/min from 11:59 a.m. - 15:27 p.m. There was no justification documented for the dialysate flow rate of 600 mL/min. Blood Flow Rate: Patient #3 On 12/17/2024 at 1:44 p.m. Patient #1 was observed on the treatment floor of the facility at station #9 machine #1. The patient was receiving hemodialysis treatment at a blood flow rate of 325 mL/min and dialysate flow rate of 500 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the physician’s order dated 10/24/2024 revealed the prescribed blood flow rate of 325 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 12/14/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 325 mL/min but received hemodialysis treatment at a blood flow rate of 300 mL/min from 12:04 p.m. - 13:21 p.m. and 250 mL/min from 13:21 p.m. - 14:39 p.m. There was no justification documented for the blood flow rates of 300 mL/min and 250 mL/min. Patient #11 Review of the patient’s clinical record on 12/17/2024 revealed the patient was admitted to the facility on 08/17/2022 with diagnoses of end stage renal disease, congestive heart failure, diabetes mellitus, on in-center hemodialysis three times weekly. Review of the physician’s order dated 10/17/2023 revealed the prescribed blood flow rate of 400 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 11/25/2023 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min but received hemodialysis treatment at a blood flow rate of 300 mL/min from 12:51 p.m. - 15:20 p.m. There was no justification documented for the blood flow rates of 300 mL/min. Review of the patient’s treatment sheet dated 11/28/2023 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min but received hemodialysis treatment at a blood flow rate of 350 mL/min from 11:40 a.m. - 15:43 p.m. There was no justification documented for the blood flow rates of 350 mL/min. Patient #14 Review of the patient’s clinical record on 12/17/2024 revealed the patient was admitted to the facility on 03/03/2023 with diagnoses of end stage renal disease, congestive heart failure, hypertension, on in-center hemodialysis three times weekly. Treatment sheet review: Review of the patient’s treatment sheet dated 07/14/2023 revealed documentation which indicated the patient was prescribed a blood flow rate of 250 mL/min but received hemodialysis treatment at a blood flow rate of 300 mL/min from 11:10 a.m. - 15:20 p.m. There was no justification documented for the blood flow rates of 300 mL/min. Review of the physician’s order on the treatment sheet revealed a blood flow rate of 250 mL/min. Patient #16 Review of the patient’s clinical record on 12/18/2024 revealed the patient was admitted to the facility on 09/16/2009 with diagnoses of end stage renal disease, congestive heart failure, hypertension, on in-center hemodialysis three times weekly. Treatment sheet review: Review of the patient’s treatment sheet dated 04/20/2022 revealed documentation which indicated the patient was prescribed a blood flow rate of 450 mL/min but received hemodialysis treatment at a blood flow rate of 500 mL/min from 10:56 a.m. - 14:56 p.m. There was no justification documented for the blood flow rates of 500 mL/min. Review of the patient’s treatment sheet dated 04/22/2022 and 04/25/2022 revealed documentation which indicated the patient was prescribed a blood flow rate of 450 mL/min but received hemodialysis treatment at a blood flow rate of 500 mL/min. There was no justification documented for the blood flow rates of 500 mL/min. Treatment Time: Patient #15 Review of the patient’s clinical record on 12/18/2024 revealed the patient was admitted to the facility on 09/16/2009 with diagnoses of end stage renal disease, diabetes mellitus, hypertension, aortic valve disease, on in-center hemodialysis three times weekly. Review of the physician’s order dated 12/18/2019 revealed the prescribed hemodialysis treatment time of four hours. Treatment sheet review: Review of the patient’s treatment sheet dated 07/17/2023 revealed documentation which indicated the “Hours On” the hemodialysis treatment was 3:00 instead of the prescribed 4:00 hours. There was no documented justification why the patient did not receive the hemodialysis treatment at the prescribed time nor whether the patient signed and early termination Against Medical Advice form. Record review and interview on 12/18/2024 at 12:51 p.m. with the facility’s Clinical Coordinator (B) confirmed Patient #s 1, 6, 10, 14, 17, 3, 11, 16, 15 did not receive their hemodialysis treatments as prescribed for the dates in question.”

“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 screen patients on admission for tuberculosis in 2 of 17 sampled patients. Patient #s 7, 8 Findings: Review of the facility’s current policy and procedure: Patient Tuberculosis Testing: published 02/05/2024, reference number 47628, version 5 directs the staff as follows: “Background: Patients with End Stage Renal Disease (ESRD) should have at least one test for Mycobacterium tuberculosis infection to screen for tuberculosis. New Admission Screening: The Mantoux Tuberculin Skin Test (TST) or the Interferon-Gamma Release Assay (IGRA) blood tests, can be used to test for Mycobacterium tuberculosis. Additional tests are required to confirm infectious TB disease. On admission, review the medical records of each patient to determine if they have received TB testing within the last year ... Patient who have no documented TB test within the last year will be tested using the TST. Physician order required.” Patient #7 On 12/17/2024 at 1:56 p.m. Patient #7 was observed on the treatment floor of the facility at station #24 machine #23. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 700 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record (demographic data) revealed she is a 77-year-old female who was admitted to the facility on 08/15/2024, with diagnosis of end stage renal disease, other cardiac disease, hypertension and diabetes mellitus. Review of the patient’s clinical record revealed no documentation that the patient was screened for tuberculosis. Patient #8 Review of the patient’s clinical record on 12/18/2024 revealed he is a 61-year-old male who was admitted to the facility on 08/16/2024, with diagnosis of end stage renal disease, hypertension and diabetes mellitus. Review of the patient’s clinical record revealed no documentation that the patient was screened for tuberculosis. Interview with Clinical Coordinator (B) on 12/18/2024 at 1:02 p.m. confirmed there was no record Patient #s 7 and 8 were screened for tuberculosis.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 48020 Based on observation and interview, the facility’s interdisciplinary team failed to ensure participation by the patient in the interdisciplinary care plan in 3 of 17 sampled patients: Patient #s 3, 5, 9 Findings: Review of the facility’s current Policy and Procedure on Comprehensive Interdisciplinary Assessment and Plan of Care; Policy #45283, published 07/03/2023 directs staff as follows: “Comprehensive Assessment Participation and Plan of Care Review “ The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record.” Patient #3 On 12/17/2024 at 1:44 p.m. Patient #1 was observed on the treatment floor of the facility at station #9 machine #1. The patient was receiving hemodialysis treatment at a blood flow rate of 325 mL/min and dialysate flow rate of 500 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record (demographic data) revealed the patient was admitted to the facility on 09/19/2022 with diagnoses of end stage renal disease, diabetes mellitus on in-center hemodialysis three times weekly. Review of the patient’s clinical record revealed an interdisciplinary Plan of Care (POC) signed by the patient dated 07/27/2023. The Surveyor requested from the Clinical Coordinator a current POC with documented participation by the patient. The POC was not provided. Patient #5 On 12/17/2024 at 1:49 p.m. Patient #5 was observed on the treatment floor of the facility at station #3 machine #4. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 500 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left central venous catheter. Review of the patient’s clinical record (demographic data) revealed the patient was admitted to the facility on 02/18/2023 with diagnoses of end stage renal disease, congestive heart failure, hypertension, diabetes mellitus on in-center hemodialysis three times weekly. Review of the patient’s clinical record revealed an interdisciplinary Plan of Care (POC) signed by the patient dated 06/30/2023. The Surveyor requested from the Clinical Coordinator a current POC with documented participation by the patient. The POC was not provided. Patient #9 Review of the patient’s clinical record on 12/18/2024 revealed the patient was admitted to the facility on 06/24/2022 with diagnoses end stage renal disease, hypertension, on in-center hemodialysis three times weekly. Review of the patient’s clinical record revealed an interdisciplinary Plan of Care (POC) signed by the patient dated 10/31/2022. The Surveyor requested from the Clinical Coordinator a current POC with documented participation by the patient. The POC was not provided. Interview with Facility Administrator (C) and Clinical Coordinator (B) on 12/18/2024 at 10:23 a.m. about Patient #s 3, 5 and 9 not participating in the POC. Clinical Coordinator (B) said, the participation in the POC by the patient “has fallen through the cracks.””

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 48020 Based on observation, record review and interview: the facility’s registered nurses failed to conduct assessments when patients experienced a change in condition before or during hemodialysis treatment in 5 of 17 sampled patients: Patient #s 2, 3, 5, 12, 6 B) the facility’s medical director failed to ensure the direct care staff replaced expired medications and supplies on the emergency cart and the emergency evacuation box per policy. Findings: Review of the facility’s current Policy and Procedure on Patient Assessment and Monitoring; Policy # 45284, published 05/01/2023 directs staff as follows: Data Collection Direct patient care staff may collect data such as weight, BP, pulse, respirations, temperature, general observations, access, and complaints reported by the patient. If the PCT/LPN note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. o The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. Review of the facility’s current policy and procedure: Emergency Medications, Equipment and Supplies: published 05/01/2023, reference number: 46865, version 6 directs the staff as follows: “Emergency Cart “ The emergency cart must be: o Checked monthly or after use for contents, expiration dates, cleanliness, and proper functioning of all equipment. “ An itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date. Emergency Evacuation Box “ An emergency evacuation box must: o Be checked monthly or after use for contents, expiration dates and cleanliness “ An itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date.” Reassessment of breath sounds, edema and pain: Patient #2 On 12/17/2024 at 1:43 p.m. Patient #2 was observed on the treatment floor of the facility at station #19 machine #5. The patient was receiving hemodialysis treatment at a blood flow rate of 250 mL/min and dialysate flow rate of 800 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 12/17/2024 revealed the following: Treatment sheet review: Review of treatment sheet dated 12/07/2024 revealed the following documentation: 09:31 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lungs: Decreased breath sounds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral 14:18 p.m.: registered nurse documented the post treatment assessment which revealed “Note: RN Evaluation - No Unusual findings noted Notes: d/c pt. home, amb alert, ox3, no sob/cp. Ufg met, tx tolerated well, left > edw, advised to watch intake closely, verbalized understanding. post v/s stable. b/t continuous, no prolonged bleeding nor infection noted. d/c stable.” The registered nurse did not document a reassessment of edema found during the pretreatment assessment. Patient #3 On 12/17/2024 at 1:44 p.m. Patient #1 was observed on the treatment floor of the facility at station #9 machine #1. The patient was receiving hemodialysis treatment at a blood flow rate of 325 mL/min and dialysate flow rate of 500 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 12/18/2024 revealed the following: Treatment sheet review: Review of treatment sheet dated 12/14/2024 revealed the following documentation: 11:17 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral” 14:48 p.m.: registered nurse documented the post treatment assessment which revealed “Notes: d/c pt. home, w/walker alert, ox3, no sob/cp. Ufg met, tx tolerated well, advised to watch intake closely, verbalized understanding. post v/s stable. b/t continuous, no prolonged bleeding nor infection noted. d/c stable.” The registered nurse did not document a reassessment of edema found during the pretreatment assessment. Review of the patient’s treatment sheets dated 12/07/2024 and 12/12/2024 revealed the registered nurse did not document a reassessment of edema found during the pretreatment assessment. Patient #5 On 12/17/2024 at 1:49 p.m. Patient #5 was observed on the treatment floor of the facility at station #3 machine #4. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 500 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left central venous catheter. Review of the patient’s clinical record on 12/18/2024 revealed the following: Treatment sheet review: Review of treatment sheet dated 12/17/2024 revealed the following documentation: 13:41 9.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lungs: Decreased breath sounds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lungs - Sound Location: Bilateral Edema Ankle - Location: Bilateral” 14:57 p.m.: registered nurse documented the post treatment assessment which revealed “Note: RN Evaluation - No Unusual findings noted Notes: Pt is Ax Ox 4, V/S wnl. UF goal not met d/t low bp. Access is clean dry and intact. Treatment completed. No acute distress noted. Tolerated well.” The registered nurse did not document a reassessment of decreased breath sounds and edema found during the pretreatment assessment. Review of the patient’s treatment sheets dated 11/28/2024, 11/30/2024 and 12/12/2024 revealed the registered nurse did not document a reassessment of edema found during the pretreatment assessment. Patient #12 Review of the patient’s clinical record revealed the patient was admitted to the facility on 06/07/2022 with diagnoses of acquired absence of kidney, spina bifida w/Arnold-Chari malformation, neurogenic bladder, left nephrectomy related to stone disease, on in-center hemodialysis three times weekly. Review of the patient’s clinical record on 12/17/2024 revealed the following: Treatment sheet review: Review of treatment sheet dated 08/16/2023 revealed the following documentation: 6:55 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms General Survey: Pain or Discomfort, c/o Left shoulder pain Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral” 10:58 a.m.: registered nurse documented the post treatment assessment which revealed “Notes: D/c patient home. Alert, ox3, no sob/cp. UFG not met d/t hemodynamic instability. Advised to watch fluid and salt intake closely, verbalized understanding. Post v/s stable, cvc [sic] capped and secured. d/c stable. Opted to go for AMA today, feeling tired.” The registered nurse did not document a reassessment of edema and left shoulder pain found during the pretreatment assessment. Assessment of cramping: Patient #6 On 12/18/2024 at 1:53 p.m. Patient #6 was observed on the treatment floor of the facility at station #1 machine #26. The patient was receiving hemodialysis treatment at a blood flow rate of 425 mL/min and dialysate flow rate of 500 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left upper arm vascular access. Review of the patient’s clinical record on 12/18/2024 revealed the following: Treatment sheet review: Review of treatment sheet dated 12/14/2024 mmHg revealed the following documentation: 14:24 p.m.: documented blood pressure of 121/61 mmHg and pulse rate of 74 beats per minute - patient care technician documented “ ...denies complaints” 14:48 a.m.: documented blood pressure of 69/53 mmHg and pulse rate of 58 beats per minute - patient care technician documented “ ...denies complaints” 14:49 a.m.: documented blood pressure of 101/67 mmHg and pulse rate of 72 beats per minute - patient care technician documented “RN Notified; UF Off; Patient Alert; bp low, 100ml n/s bolus given, bp rechecked” 15:05 p.m.: documented blood pressure of 102/56 mmHg and pulse rate of 72 beats per minute - patient care technician documented “Denies complaints; UF Off; Patient Alert; bp low, pt /o cramping, 100 ml n.s. bolus given, bp rechecked” 15:54 p.m.: documented blood pressure of 135/73 mmHg and pulse rate of 71 beats per minute - patient care technician documented “Denies Complaints; Treatment Discontinued Without Problem 15:54 p.m.: Post treatment vital signs: blood pressure of 133/73 mmHg sitting, 118/64 mmHg standing, pulse of 71 beats per minute. 16:03 p.m.: registered nurse documented the post treatment assessment which revealed “General Survey: Alert, Oriented Ambulation Status: Ambulates w/assistive device General Overview: No Complaint Symptoms: None Lungs: Clear No Edema Lungs - Sound Location Pulse - Rhythm: Regular There was no assessment documented for patient cramping by the registered nurse. Record review and interview with Clinical Coordinator (B) on 12/18/2024 at 12:54 p.m. confirmed the registered nurses did not complete the reassessments of breath sounds, edema and pain post treatment and the assessment for cramping during the treatment for the patients above. Observation of the emergency cart on 12/17/2024 revealed: “ 2 vials Solu-Cortef, lot #GA3146, expiration date 10/2024 Observation of the emergency evacuation box on 08/09/2023 revealed: “ 1 box Tempa Dot Single-Use Clinical Thermometer, lot #07163, expiration date 2024-11-16 “ 24 individually wrapped SysLoc Mini Safety A.V. Fistula Needle Set 15 gauge, lot# 181212332, expiration 2023-12-12 On 12/17/2024 at 2:45 p.m., the Surveyor notified Clinical Coordinator (B) of the expired supplies in the emergency cart and evacuation box during a walk-through of the treatment floor. Clinical Coordinator (B) confirmed the above supplies were expired.”