Fmc Sunnyside

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility failed to ensure patient’s nephrologist round and assess patient’s every two weeks in 2 of 15 sampled patients: Patient #s 7 and 8 Findings: Patient #7 On 10/14/2024 at 11:40 a.m. Patient #7 was observed at station #1 hemodialysis machine #25 receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of Autoflow 600 mL/min via a right central venous catheter. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 06/03/2024 with diagnosis of other cardiac disease, history of hypertension and diabetes on insulin, on in-center hemodialysis three times weekly. Review of the patient’s physician progress note revealed the most recent physician progress note was documented on 07/26/2024. There was a note by the nurse practitioner on 08/14/2024. There was no documentation of a physician progress note for the month of August 2024. There was no documented physician progress note every two weeks as required by the state regulations. Review of the Facility’s Absence and Hospitalization report created 10/14/2024 revealed Patient #7 was hospitalized on 08/30/2024. On 10/15/2024 the Surveyor requested missing physician’s progress notes from Area Team Lead (H). He said, “There were no visits for August. The Nurse Practitioner came on 8/14 and then the patient was hospitalized.” Patient #8 On 10/14/2024 at 12:07 a.m. Patient #8 was observed at station #15 hemodialysis machine #16 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of Autoflow 600 mL/min via a left central venous catheter. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 10/09/2019 with diagnosis of history of hypertension and diabetes on insulin, on in-center hemodialysis three times weekly. Review of the patient’s clinical record revealed physician progress note dated 08/23/2024, 09/04/2024 and 10/02/2024. There was no documented physician progress note every two weeks as required by the state regulations. On 10/15/2024 the Surveyor requested missing physician’s progress notes from Area Team Lead (H). He said, “There were no other visits.””

“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: remove contaminated gloves, wash/sanitize hands and don new gloves before reaching into the bleach bucket to get clean bleach towels: 2 of 6 staff observed: Patient Care Technician (C) and (D) Findings: Review of the facility’s current policy and procedure: Hand Hygiene: published 11/06/2023, reference number 47664, version 8 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 body fluids or excretion, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled “ After contact with inanimate objects near the patient “ After contact with other objects within the patient station or treatment space “ After contact with other objects within the patient station or treatment space” Patient Care Technician (C) Observation on 10/14/2024 at 10:29 a.m., revealed Patient Care Technician (C) donned clean gloves and taped the vascular access of the patient at station #2 after the bleeding ceased. Patient Care Technician (C) then assisted the patient to the weigh scale and had one of her gloved hand on the patient’s shoulder. Patient Care Technician (C) touched the weigh scale button to weigh the patient, documented the patient’s weight into the chairside computer at station #2, walked over to the bleach bucket and grabbed clean bleach towels with the contaminated gloves and wiped the weigh scale buttons and grab bar. Patient Care Technician (C) did not remove her contaminated gloves, wash/sanitize her hands, don new gloves before reaching into the bleach bucket to get clean bleach towels. Patient Care Technician (D) Observation on 10/14/2024 at 10:35 a.m., revealed Patient Care Technician (D) donned clean gloves and taped the vascular access of the patient at station #5 after the bleeding ceased. Patient Care Technician (D) accompanied the patient to the weigh scale with the contaminated gloves, touched the weigh scale button to weigh the patient, documented the patient’s weight into the chairside computer at station #5, walked over to the bleach bucket and grabbed clean bleach towels with the contaminated gloves and wiped the weigh scale buttons and grab bar. Patient Care Technician (D) did not remove her contaminated gloves, wash/sanitize her hands, don new gloves before reaching into the bleach bucket to get clean bleach towels. On 10/14/2024 at 10:45 a.m., the Surveyor notified Patient Care Technician (C) and (D) about failing to remove their contaminated gloves, washing/sanitizing their hands and donning new gloves before reaching into the bleach bucket to get clean bleach towels. Patient Care Technician (C) and (D) said “Okay.””

“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: 48020 Based on observation, review and interview, the facility’s direct care staff failed to prevent cross contamination by not maintaining sterility of suction supplies until time of use. Findings: Review of the manufacturer’s website (conmed.com) revealed a Suction Instruments and Tubing Product brochure which states the Rigid Yankauer is “Single use, sterile to prevent cross contamination.” Observation of the Emergency Cart Observation of the emergency cart on 10/14/2024 at 8:26 a.m. revealed a Yankauer and suction tubing attached to the suction machine. The Yankauer was placed in an opened manufacturer package with Conmed Yankauer Ref# 0034910 on the package and stored on top of the emergency cart. The sterility of the Yankauer was not maintained. Subsequent observation of the emergency cart on 10/15/2024 at 7:33 a.m. revealed the Yankauer and suction tubing was still stored in the opened manufacturer package on top of the emergency cart and the sterility of the Yankauer was not maintained. During an interview on 10/15/2024 at 7:42 a.m., the Senior Regulatory Manager confirmed the Yankauer, and tubing were stored in the opened manufacturer package on top of the emergency cart and sterility of the Yankauer was not maintained.”

“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: 48020 Based on observation, interview, and record review, the facility’s governing body failed to ensure that the floor tiles were free of buildup and cracks and the sheetrock was free of water damage and holes in the hemodialysis treatment area. Findings: Observation of the hemodialysis treatment floor on 10/14/2024 at 8:03 a.m. revealed the following: the floor tiles were dull starting from the door entering the floor from the lobby to the entire treatment floor. Each hemodialysis machine had a black buildup underneath them at each station. Station #6 had a 2-inch hole in the floor tile behind the hemodialysis machine. The floor tiles in front of the dirty sink between station #s 20 and 21 had black buildup in the seams and had cracks in them. The sheetrock near the baseboard on the right had water damage and left side had water damage and a 1½ inch hole in it. Interview on 10/14/2024 during a walk-through of the treatment floor, the Area Technical Operations Manager (I) verified the findings up above.”

“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 5 of 15 sampled and closed patients: Patient #s 2, 5, 10, 11 and 13 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 #2 On 10/14/2024 at 7:55 a.m. Patient #2 was observed on the treatment floor of the facility at station #4. The patient was receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of sequential ultrafiltration. The patient was utilizing an Optiflux 180 non reuse dialyzer. The dialysate settings were: potassium 2 mEq/L, calcium 2.5 mEq/L , bicarbonate 35 mEq/L, sodium 137 mEq/L. Review of the patient’s physician’s order located in the chairside computer revealed an order for sodium 138 mEq/L. Subsequent review of the patient’s clinical record located in the chairside computer revealed the hemodialysis treatment began at 6:23 a.m. Interview during observation with Patient Care Technician (D) assigned to the patient who was present at the chairside of the patient: the Surveyor informed her that the patient was not receiving hemodialysis treatment at the dialysate sodium prescribed by the Physician. Patient Care Technician (D) said, “Okay.” Patient #5 On 10/14/2024 at 7:45 a.m. Patient #5 was observed on the treatment floor of the facility at station #13. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 600 mL/min. Review of the physician’s order dated 08/21/2024 revealed the prescribed blood flow rate of 400 mL/min. Treatment sheet dated 10/04/2024 Review of the patient’s treatment sheet dated 10/04/2024 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 7:02 a.m. - 10:09 p.m. There was no justification documented for the blood flow rate of 350 mL/min. Interview on 10/14/2024 at 12:46 p.m. with Patient Care Technician (F), the Surveyor informed her that the patient was not administered the blood flow rate prescribed by the physician. Patient Care Technician (B) said, “I lowered it because the venous pressure was too high, but I did not document it or notify the nurse.” Patient #10 Review of the patient’s clinical record (demographic data) on 10/14/2024 revealed the patient was admitted to the facility 08/11/2023. Review of the physician’s order dated 08/14/2023 revealed the prescribed dialysate flow rate of 600 mL/min. Treatment sheet dated 08/21/2023 Review of the patient’s treatment sheet dated 08/21/2023 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 600 mL/min but received hemodialysis treatment at a dialysate flow rate of 800 mL/min from 16:00 p.m. - 17:00 p.m. The dialysate flow rate alternated from 600 to 800 for the rest of the treatment. There was no justification documented for the dialysate flow rate of 800 mL/min. Patient #11 Review of the patient’s clinical record (demographic data) on 10/14/2024 revealed the patient was admitted to the facility 08/30/2023. Review of the physician’s order dated 08/30/2023 revealed the prescribed dialysate flow rate of 700 mL/min. Treatment sheet dated 09/15/2023 Review of the patient’s treatment sheet dated 09/15/2023 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 700 mL/min but received hemodialysis treatment at a dialysate flow rate of 600 mL/min from 16:00 p.m. - 19:25 p.m. There was no justification documented for the dialysate flow rate of 600 mL/min. Treatment sheet dated 09/20/2023 Review of the patient’s treatment sheet dated 09/15/2023 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 700 mL/min but received hemodialysis treatment at a dialysate flow rate of 600 mL/min from 16:15 p.m. - 19:30 p.m. There was no justification documented for the dialysate flow rate of 600 mL/min. Patient #13 Review of the patient’s clinical record (demographic data) on 10/15/2024 revealed the patient was admitted to the facility 11/09/2018. Review of the physician’s order dated 10/26/2022 revealed the prescribed dialysate flow rate of 800 mL/min. Treatment sheet dated 10/31/2022 Review of the patient’s treatment sheet dated 10/31/2022 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 5:40 a.m. - 9:31 a.m. There was no justification documented for the dialysate flow rate of 600 mL/min. Treatment sheet dated 11/02/2022 Review of the patient’s treatment sheet dated 11/02/2022 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 700 mL/min from 5:20 a.m. - 9:06 a.m. There was no justification documented for the dialysate flow rate of 700 mL/min. Treatment sheet dated 11/04/2022 Review of the patient’s treatment sheet dated 11/04/2022 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 700 mL/min from 5:40 a.m. - 9:26 a.m. There was no justification documented for the dialysate flow rate of 700 mL/min. Interview on 10/15/2024 at 1:55 p.m. with the Facility’s Clinical Manager confirmed Patient #’s 10, 11 and 13 did not receive their hemodialysis treatments at the prescribed dialysate flow rate for the dates in question.”

“PA-ASSESS RENAL BONE DISEASE CFR(s): 494.80(a)(5) The patient’s comprehensive assessment must include, but is not limited to, the following: (5) Evaluation of factors associated with renal bone disease. This Standard is not met as evidenced by: 48020 Based on observation, interview, and record review the facility’s registered nurses failed to ensure medication prepared for patients are not left unsecured at patients’ chairside and are administered as prescribed by the physician in 4 of 15 patients observed: Patient #s 1, 4, 2 and 3 Findings Review of the facility’s current policy and procedure: Medication Preparation and Administration directs the staff as follows: Pre-drawing Medications “ Medications may be pre-drawn up to 4 hours prior to administration ... These pre-drawn medications shall be labeled and must be kept under the preparer’s control or in a locked designated medication storage area or refrigerated, if necessary, until delivery to the appropriate patient for administration. Documentation “ Medications administered must not be signed off prior to administration. Patient #1 On 10/14/2024 at 7:46 a.m. Patient #1 was observed on the treatment floor of the facility at station #14. The patient was asleep and receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 600 mL/min. Observation of the patient’s chairside table revealed a cup with one orange capsule left unsecured at the chairside. The medication was not in view of the registered nurse. The nurses were providing care to other patients. Review of the patient’s clinical record revealed a physician’s order dated 09/09/2024 for Vitamin D (calcitriol) Oral 0.25 ORAL 1X Week. Review of the patient’s treatment sheet, located in the chairside computer revealed documentation by the registered nurse that the patient was administered calcitriol 0.25 mcg at 7:40 am. The registered nurse documented that the patient was administered the medication although the medication was left unsecured at the patient’s chairside. Patient #4 On 10/14/2024 at 7:48 a.m. Patient #4 was observed on the treatment floor of the facility at station #16. The patient was receiving hemodialysis treatment at a blood flow rate of 500 mL/min and dialysate flow rate of 800 mL/min. Observation of the patient’s chairside table revealed a cup with two orange capsules left unsecured at the chairside. The medication was not in view of the registered nurse. The nurses were providing care to other patients. Review of the patient’s clinical record revealed a physician’s order dated 05/29/2024 for Vitamin D (calcitriol) Oral 1.0 ORAL Every Treatment. Review of the patient’s treatment sheet, located in the chairside computer revealed documentation by the registered nurse that the patient was administered calcitriol 1.0 mcg at 7:45 am. The registered nurse documented that the patient was administered the medication although the medication was left unsecured at the patient’s chairside. Patient #2 On 10/14/2024 at 7:55 a.m. Patient #2 was observed on the treatment floor of the facility at station #4. The patient was asleep and receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of sequential ultrafiltration. Observation of the patient’s chairside table revealed a cup with two orange capsules left unsecured at the chairside. The medication was not in view of the registered nurse. The nurses were providing care to other patients. Review of the patient’s clinical record revealed a physician’s order dated 06/12/2024 for Vitamin D (calcitriol) Oral 1.0 ORAL During Dialysis Every Treatment. Review of the patient’s treatment sheet, located in the chairside computer revealed documentation by the registered nurse that the patient was administered calcitriol 1.0 mcg at 7:40 am. The registered nurse documented that the patient was administered the medication although the medication was left unsecured at the patient’s chairside. Patient #3 On 10/14/2024 at 7:59 a.m. Patient #3 was observed on the treatment floor of the facility at station #20. The patient was asleep and receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 600 mL/min. Observation of the patient’s chairside table revealed a cup with three orange capsules left unsecured at the chairside. The medication was not in view of the registered nurse. The nurses were providing care to other patients. Review of the patient’s clinical record revealed a physician’s order dated 04/05/2024 for Vitamin D (calcitriol) Oral 1.5 ORAL During Dialysis Every Treatment. Review of the patient’s treatment sheet, located in the chairside computer revealed documentation by the registered nurse that the patient was administered calcitriol 1.5 mcg at 7:02 am. The registered nurse documented that the patient was administered the medication although the medication was left unsecured at the patient’s chairside. Interview with Registered Nurse (B) on 10/14/2024 at 12:00 p.m. revealed Registered Nurse (B) confirmed he left the calcitriol medication unattended at chairside for Patient #’s 1, 4, 2 and 3 despite documenting that the medication was administered.”

“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 and record review, the facility’s nurses: failed to prevent contamination by airborne nasal bacteria during central venous catheter (CVC) dressing changes per policy in 2 of 6 patients with CVCs observed: Registered Nurse (B), Registered Nurse (F) and Patient #s 7 and 8 B) failed to conduct assessments during and post hemodialysis treatment on patients when patients experienced a change in condition pre or during hemodialysis treatment in 4 of 15 sampled and closed patients: Patient #s 3, 8, 10 and 11 Findings: Review of the facility’s current policy and procedure on Changing the Catheter Dressing Procedure; published 02/05/2024, reference number 45664, version 8 directs staff as follows: “Policy Removal of Dressing and Inspection of Site Follow the steps below to remove a catheter dressing and inspect the exit site before the initiation of dialysis treatment: Important note: The patient and care partner must wear a mask for all procedures that require accessing the catheter. Step 2 Action/Rationale- Apply mask to patient and caregiver to help prevent contamination by airborne nasal bacteria ...” 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. During Treatment o Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. o Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations. Follow the steps below for monitoring patient and machine parameters during treatment: Step Action/Rationale 1 Pulse Record pulse. Verify pulses manually if automated readings display below 60 or greater than 100 beats per minute. o Report to the nurse patients whose heart rates have dropped below 60, risen above 100 or become irregular.” Catheter Care Registered Nurse (B) Patient #7 On 10/14/2024 at 11:11 a.m. Patient #7 was observed at station #1 receiving central venous catheter (CVC) care before the hemodialysis treatment. The mask was underneath the patient’s nose while Registered Nurse (B) performed the CVC dressing change, removed the dressing covering the CVC lumens, cleaned the CVC lumen and hubs with alcohol, connected the patient to the hemodialysis machine, and initiated the hemodialysis treatment. Registered Nurse (B) failed to prevent contamination by airborne nasal bacteria during CVC care. Registered Nurse (B) and (F), Patient #8 On 10/14/2024 at 11:47 a.m. Patient #8 was observed at station #15 receiving central venous catheter (CVC) care before the hemodialysis treatment. The mask was underneath the patient’s nose while Registered Nurse (B) began the CVC dressing change then Registered Nurse (F) took over the process. Registered Nurse (F) removed the dressing covering the CVC lumens, cleaned the CVC lumen and hubs with alcohol, connected the patient to the hemodialysis machine, and initiated the hemodialysis treatment with the patient’s mask below his nose. Registered Nurse (B) and (F) failed to prevent contamination by airborne nasal bacteria during CVC care. Interview with Registered Nurse (B) on 10/14/2024 at 11:59 a.m. confirmed Patient #s 7 and 8 did not have the mask covering their noses during CVC care. Nursing Assessments Patient #3 On 10/14/2024 at 7:59 a.m. Patient #3 was observed on the treatment floor of the facility at station #20. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 600 mL/min via a left upper arm vascular access. Vital signs were as follows: blood pressure 144/79 and pulse 84 beats per minute. Review of the patient’s clinical record on 10/14/2024 revealed the following: Treatment sheet dated 10/14/2024: Review of treatment sheet dated 10/14/2024 revealed the following documentation: 07:01 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral” 09:39 a.m.: registered nurse documented the post treatment assessment which revealed “Tx, tolerated well. Post assessment no c/o sob/cp/ha and nausea. No bleeding on exit site before leaving. Exit site wrapped with gauge [sic] and secured with tape. No voiced discomfort @ this time. Left clinic stable with vs wnl.” The registered nursed did not document a reassessment of edema found during the pretreatment assessment. Review of Review of treatment sheets dated 10/02/2027, 10/04/2024, 10/07/2024, 10/11/2024 and 10/11/2024 revealed the registered nursed did not document a reassessment of edema found during the pretreatment assessment. Patient #8 On 10/14/2024 at 12:07 a.m. Patient #8 was observed at station #15 hemodialysis machine #16 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of Autoflow 600 mL/min via a left central venous catheter. Vital signs were as follows: blood pressure 180/83 and pulse 58 beats per minute. Review of the patient’s clinical record on 10/14/2024 revealed the following: Treatment sheet dated 10/11/2024: Review of treatment sheet dated 10/11/2024 revealed the following documentation: 10:48 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Edema Ankle - Location: Bilateral” 15:28 a.m.: registered nurse documented the post treatment assessment which revealed “late entry. Tx ended w/o complaints. Post assessment no c/o sob/cp/ha/n. cvc packed with heparin, capped and clamped. No voiced discomfort @ this time. Seen by NP __ no new order.” The registered nursed did not document a reassessment of edema found during the pretreatment assessment. Treatment sheet dated 10/07/2024: Review of treatment sheet dated 10/07/2024 revealed the following documentation: 10:01 a.m.: documented blood pressure of 170/81 and pulse rate of 63 beats per minute - Treatment initiated 10:30 a.m.: documented blood pressure of 168/78 and pulse rate of 62 beats per minute, Fluid Removal 339 mL/hr 10:59 a.m.: documented blood pressure of 159/83 and pulse rate of 61 beats per minute, Fluid Removal 649 mL/hr 11:25 a.m.: documented blood pressure of 169/78 and pulse rate of 62 beats per minute, Fluid Removal 972 mL/hr 11:40 a.m.: documented blood pressure of 169/78 and pulse rate of 59 beats per minute, Fluid Removal 1190 mL/hr - PCT documented, “UF Off; Patient Alert; uf off due to pt cramping” 12:00 p.m.: documented blood pressure of 178/76 and pulse rate of 60 beats per minute, Fluid Removal 1190 mL/hr - PCT documented, “UF Off; Patient Alert” 12:30 p.m.: documented blood pressure of 160/76 and pulse rate of 59 beats per minute, Fluid Removal 1190 mL/hr 13:00 p.m.: documented blood pressure of 151/79 and pulse rate of 72 beats per minute, Fluid Removal 1459 mL/hr (UF was turned back on) 13:30 p.m.: documented blood pressure of 156/78 and pulse rate of 63 beats per minute, Fluid Removal 1859 mL/hr 14:09 p.m.: documented blood pressure of 165/77 and pulse rate of 50 beats per minute, Fluid Removal 2108 mL/hr - Treatment ended There was no nurse notification by the PCT of turning off the patient’s ultrafiltration and of the patient cramping. There was no nursing assessment of the patient for cramping. Treatment sheet dated 10/07/2024: Review of treatment sheet dated 10/07/2024 revealed the following documentation: 10:07 a.m.: documented blood pressure of 187/91 and pulse rate of 60 beats per minute - Treatment initiated 10:30 a.m.: documented blood pressure of 155/65 and pulse rate of 64 beats per minute, Fluid Removal 478 mL/hr 11:00 a.m.: documented blood pressure of 130/60 and pulse rate of 63 beats per minute, Fluid Removal 902 mL/hr 11:30 a.m.: documented blood pressure of 119/63 and pulse rate of 45 beats per minute, Fluid Removal 1440 mL/hr - PCT documented, “BP trending down; UF stopped; UF goal reduced to 2.5; Will cont to monitor” 12:00 p.m.: documented blood pressure of 129/61 and pulse rate of 48 beats per minute, Fluid Removal 1440 mL/hr 12:35 p.m.: documented blood pressure of 115/64 and pulse rate of 43 beats per minute, Fluid Removal 1440 mL/hr - PCT documented, “UF Off; Patient Alert” 12:57 p.m.: documented blood pressure of 147/70 and pulse rate of 65 beats per minute, Fluid Removal 1440 mL/hr - PCT documented, “UF resumed; Will cont to monitor” 13:28 p.m.: documented blood pressure of 137/72 and pulse rate of 61 beats per minute, Fluid Removal 1722 mL/hr 13:56 p.m.: documented blood pressure of 156/7154/518 and pulse rate of 54 beats per minute, Fluid Removal 2000 mL/hr - Treatment ended There was no nurse notification by the PCT for adjusting the ultrafiltration goal and turning off of the ultrafiltration during the hemodialysis treatment. Patient #10 Review of the patient’s clinical record (demographic data) on 10/14/2024 revealed the patient was admitted to the facility 08/11/2023. Treatment sheet dated 08/21/2023: Review of treatment sheet dated 08/21/2023 revealed the following documentation: 16:28 p.m.: registered nurse documented the pretreatment assessment which revealed “Associated Symptoms - Shortness of Breath Symptoms Lower Leg - Severity: 2+: 2-4 mm indent, disappears in 10-15 seconds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Edema Ankle - Location: Bilateral” 19:56 p.m.: registered nurse documented the post treatment assessment which revealed “Tx. Ended w/o complaints of pain. Cvc packed with heparin, capped and clamped. No voiced discomfort @ this time. Left unit stable with v/s wnl. Seen by Dr.__ during rounds.” The registered nursed did not document a reassessment of the lungs or the edema found during the pretreatment assessment. Review of treatment sheets dated 08/23/2023 and 08/25/2023 revealed the registered nursed did not document a reassessment of edema found during the pretreatment assessment. Patient #11 Review of the patient’s clinical record (demographic data) on 10/14/2024 revealed the patient was admitted to the facility 08/30/2023. Treatment sheet dated 09/13/2023: Review of treatment sheet dated 09/13/2023 revealed the following documentation: 16:29 p.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Ankle - Location: Bilateral” 19:17 p.m.: registered nurse documented the post treatment assessment which revealed “Pt left by WC, aaox3, post tx vitals wnl, UFgoal met, 2.0kg pulled, denies sob, ha, cp, n/v/d, afebrile, no dizziness, access clean, dry, intact, no concerns/complaints voiced.” Review of treatment sheets dated 09/15/2023 and 09/20/2023 revealed the registered nursed did not document a reassessment of edema found during the pretreatment assessment. Interview with the Clinical Manager (G) on 10/14/2024 at 2:55 p.m. confirmed the reassessments of edema and lung sounds were not completed post treatment by the registered nurses. Clinical Manager (G) also confirmed there was no nurse notification by the PCTs of patient cramping, adjusting the ultrafiltration goal, and turning off of the ultrafiltration during the hemodialysis treatments.”