Davita Renal Center of Waterton

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 48653 Based on record review and interview, the facility staff failed to provide documented evidence that fire drills were conducted with facility staff and facility patients on a quarterly basis. Also, the facility staff failed to follow the “Emergency Management Plan”. During a review of the facility’s “Emergency Exercise Drill Evaluations” for 2024, the surveyor observed there were 3 fire drill evaluations completed in 2024. Fire drill evaluations were not completed quarterly in 2024. A review of the facility’s “Emergency Management Plan” with a date of 05/2024 revealed, “ ...Fire Safety Preparedness 1. FA, or designee, is responsible to: a. Maintain a fire safety preparedness program to prevent or minimize the likelihood of a fire that may result in death, injury, or property damage in accordance with CMS and OSHA regulations and National Fire Protection Association (NFPA) and applicable local and state life safety code requirements b. Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional training and education needs ...” An interview with Staff # 2 on 02/25/2025 at 2:00 PM confirmed the facility staff was unable to provide documented evidence that a fire drill evaluation was conducted in every quarter of 2024.”

“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: 29191 Based on observation, record review, and staff interview, the facility failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the facility’s in-center treatment area. The facility staff failed to follow the “Infection Control for Dialysis Facilities” policy. This deficient practice had the likelihood to cause harm to patients, staff members, and the public by increasing the risk of transmission of infectious agents within the facility. Findings include: During a tour of the facility with Staff #2 on 02/25/2025 at 2:00 PM the surveyor observed the following: Laboratory Area * The laboratory refrigerator had spots of blood with dirt and dust build-up on the bottom shelf. * The temperature of the lab refrigerator was recorded as below 36 degrees. The range for the refrigerator was 36-46 degrees. A review of the January 2025 lab temperature record log revealed the following: January 19 - 33.3 January 23 - 35.8 A review of the February 2025 lab temperature record log revealed the following: February 12 - 32.9 February 21 - 35.1 There was no documentation that the temperature had been adjusted or reported to the biomedical technician. Observed a box of 100 green tubes expired on 1/31/2025. In-Center Treatment Area * The entrance to the in-center treatment had a black discoloration, which gave the treatment area an unclean appearance. * Observed 3 different areas of the treatment area that had water-stained, brown colored ceiling tiles. * There were 20 blood pressure cuffs with a large amount of unknown debris affixed to the Velcro portion of the cuff. * The medication refrigerator had a dirt and dust build-up on the bottom shelf. * Underneath the 2 clean sinks on the treatment floor, rust flakes, dust, and dirt particles along with water stains were observed. The drain on one of the sinks was completely rusted. * Observed a plastic container of white and blue clamps on the bottom shelf of a 3-shelf wire rack. The container was open with no lid. The surveyor asked staff #2 if the clamps were clean or dirty. Staff #2 stated, “The clamps are clean.” There was no way to determine if the clamps were clean or dirty. There was no label indicating if the clamps were clean or dirty. The container was next to the floor where if housekeeping was sweeping or mopping the splatter would enter the container. There were 3 sets of the setup around the in-treatment care area. A review of facility policy, “Infection Control for Dialysis Facilities,” dated April 2023, revealed the following: “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 the transmission of infections among chronic hemodialysis patients (Dialysis Precautions) will be followed when caring for all patients. Additional precautions recommended by the CDC are to be observed for patients with infectious hepatitis B ... DISINFECTION 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. a. Prior to routine disinfection, remove all visible blood i. For visible blood or gross blood spills, a 1: 10 (one to ten) bleach solution must be utilized. ii. After all visible blood is cleaned with the 1: 10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1: 10 (one to ten) bleach solution and clean area a second time. iii. Cleaning of visible blood should be performed when first observed b. Use an appropriate disinfectant such as 1: 100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. i. Disinfection should be completed by using a wiping motion with friction. ii. Sufficient disinfectant should be applied so that surfaces are visibly wet. iii. Surfaces should be allowed to air dry in order to provide sufficient disinfectant contact time iv. Items disinfected via submersion will be fully submerged 13. At the end of each treatment, the dialysis stations will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (i.e., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (i.e., control panel, top, front, and sides of a dialysis machine; touchscreens; countertops). i. The wall box, drain and water supply lines are considered part of the dialysis delivery system ... FACILITY HYGIENE 16. 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.” An interview with Staff # 2 was conducted on 02/25/2025 at 3:00 PM. Staff #2 acknowledged the infection control findings in the facility’s in-center treatment area.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 29191 Based on observation, policy review, and staff interview, the facility failed to ensure staff followed their policy of changing the external wet transducer protector when wet. Observed 1 (#3) of 12 dialysis machines with wet transducers, and the staff failed to recognize a wet transducer. This deficient practice had the likelihood of placing the patients being dialyzed at risk for cross-contamination, venous chamber clotting, and blood loss. Findings include: During a facility tour on 02/25/2025 at 1:30 PM, the surveyor observed that dialysis machine #11 had a wet transducer and was wetted with a pinkish-red tint. The surveyor had to notify Staff #18 and #2 (Charge Nurse) to come to the chairside. Staff #18 was asked if there was an issue with the dialysis machine tubing. After a few minutes, Staff #18 did recognize that the transducer had been wetted. The surveyor had to explain the process of determining if a wet transducer was found on a dialysis machine. Staff #18 stated, “I will get the transducer changed.” Observed Staff #18 change the wet transducer. The surveyor had to explain to Staff #16 that the back of the transducer must be checked to make sure there was no strikethrough on the back side of the transducer going to the dialysis machine. If there is blood on the backside, then the machine must be pulled, and the internal transducer must be checked for blood by the biomedical technician. Staff #18 stated, “I forgot about checking the back side of the transducer.” A review of the facility policy titled; “CHANGING TRANSDUCER ROTECTORS” dated April/2021 revealed the following: “PURPOSE: To provide guidance for changing transducer protectors and preventing cross-contamination. POLICY: 1. This policy is intended for all dialysis delivery systems that utilize blood tubing sets with external pressure transducer protectors in the arterial and venous pressure monitoring system. 2. During intradialytic treatment monitoring, the arterial and venous drip chamber levels should be observed and adjusted as needed. 3.External transducer protectors will be inspected for the presence of blood or saline every 30 minutes during patient treatment and included as part of the monitoring process. 4. The external transducer protector will be replaced: * Prior to each patient’s use * Whenever blood or saline is observed in contact with the patient side of the transducer protector 5. If the external transducer protector becomes contaminated with blood or saline, the teammate will replace the external transducer protector and adjust the arterial and/or venous drip chamber as needed. After adjusting the arterial and/or venous drip chamber levels, the patient’s arterial and venous pressures should be compared to previous treatment readings. 6. If the pressure readings appear to be inaccurate, the treatment is to be discontinued, and the dialysis delivery system must be removed from service and labeled with the date, time, description of the problem, and the name of the teammate reporting the problem. The patient’s treatment is to be continued using another delivery system. 7. The back of the wet external transducer protector and the delivery system pressure module lure locks will be visually inspected for blood or saline contamination prior to placing the new sterile external transducer protector on the delivery system. If blood or saline is noted on the back of the wet external transducer protector, strikethrough has occurred. The treatment can continue for this patient on this delivery system if accurate pressures are observed as described in (#5 above). Upon completion of treatment, the delivery system is to be removed from service and labeled with the date, time, description of the problem, and the name of the teammate reporting the problem. 8. The internal transducer protector will be changed only by a trained Biomed teammate and the delivery system will be disinfected prior to return to use.” An interview with Staff #18 and Staff #22 on 02/25/2025 at 1:30 PM confirmed there was 1 wet transducer found on dialysis machines while patients were being dialyzed and that the staff did not recognize the wet transducer. Also, the staff did not know the procedure to follow when wet transducers are found on dialysis machines.”

“ACID CONC DIST-CONC LABELED & COLOR-CODED RED CFR(s): 494.40(a) 5.5.3 Acid concentrate distribution systems: labeled & color-coded red Acid concentrate delivery piping should be labeled and color-coded red at the point of use (at the jug filling station or the dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. If the acid system remains intact, no rinsing or disinfection is necessary. More than one type of acid concentrate may be delivered, and each line should clearly indicate the type of acid concentrate it contains. This Standard is not met as evidenced by: 29191 Based on observation and interview, the facility’s staff failed to ensure that the dialysis stations’ wall boxes (acid dispensing outlets) had no leaks and were properly cleaned for 20 of 20 stations. Also, the facility’s staff did not follow the policy “Infection Control for the Dialysis Facilities” for cleaning the wall boxes. This deficient practice has the likelihood to cause nonbacterial contamination and evaporation in the wall boxes and infect the patients receiving in-center hemodialysis at the facility. Findings include: During a tour of the in-center treatment area on 02/25/2024 at 2:30 PM, the surveyor observed that the wall boxes had dried and that there was crusted white sediment in the wall boxes. Some of the stations were not in use and should have been cleaned, but crusted white sediment was seen on the wall boxes after the dialysis treatment area had been cleaned. Staff #2 and #19 were on the tour and observed that the wall boxes had dried, crusted white sediment. The surveyor asked who was responsible for cleaning the wall boxes. Staff #2 stated, “The staff is responsible for cleaning the wall boxes”. A review of the CDC guidelines related to dialysis wall boxes revealed the following: “Dialysis wall boxes are frames recessed into the wall at each hemodialysis station that contain connections for the dialysis machine to receive acid and base concentrates and treated water, and dispose of waste products. There are several infection prevention and control issues unique to wall boxes. They can become easily contaminated with microorganisms, which can subsequently be transferred to dialysis patients, a vulnerable group at high risk of infection. Thus, wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections.” A review of the facility policy titled; “Infection Control for the Dialysis Facilities” revealed the following: “WALL BOX AND DRAIN/WATER LINE CARE AND MAINTENANCE: 58. The Wall box, Drain, and Water supply lines are considered part of the dialysis delivery system and should be cleaned with 1:100 (one to one hundred) bleach as part of routine station disinfection between each patient treatment. This process will also be completed for the wall boxes in the biomedical repair area once daily. This process of cleaning the drain and water supply lines will also be completed prior to bringing a machine to the treatment floor. NOTE: Do not wipe wall boxes during any active disinfection process in order to avoid chemical reactions (i.e. bleach and citric acid).” An interview with Staff #2 on 02/25/2024 at 2:30 PM confirmed the wall boxes had dried crusted white sediment in all the in-center station wall boxes.”

“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 record review and interview, the Registered Nurse failed to ensure the pre-treatment nursing assessments were completed and documented within (1) hour of treatment initiation on 2 (# 6 and # 7) of 5 patient medical records reviewed. Also, the Registered Nurse failed to ensure the post-treatment nursing assessments were completed and documented before the patient was discharged on 5 (# 5, # 6, # 7, # 9, # 10) of 5 patient medical records reviewed. The facility staff failed to follow the facility policy “Pre-Intra-Post Treatment Data Collection Monitoring and Nursing Assessment”. Patient # 5 A review of 1 of 6 treatment sheets for Patient # 5 revealed that post-treatment nursing assessments were not completed prior to the patient’s discharge. A review of the treatment sheet dated 02/12/2025 revealed Staff # 13 did not complete the post-treatment nursing assessment (documented at 4:22 PM) before the patient was discharged. Treatment ended at 1:31 PM. Patient # 6 A review of 2 of 6 treatment sheets for Patient # 6 revealed that pre and post-treatment nursing assessments were not completed prior to the patient’s discharge. A review of the treatment sheet dated 02/12/2025 revealed Staff # 13 did not complete the post-treatment nursing assessment (documented at 5:54 PM) before the patient was discharged. Treatment ended at 3:32 PM. A review of the treatment sheet dated 02/24/2025 revealed Staff # 2 did not complete the pre-treatment nursing assessment (documented at 12:34 PM) before the patient was discharged. Treatment ended at 11:20 AM. A review of the treatment sheet dated 02/24/2025 revealed Staff # 2 did not complete the post-treatment nursing assessment (documented at 4:42 PM) before the patient was discharged. Treatment ended at 3:09 PM. Patient # 7 A review of 2 of 6 treatment sheets for Patient # 7 revealed that the post-treatment nursing assessments were not completed prior to the patient’s discharge. A review of the treatment sheet dated 02/10/2025 revealed Staff # 2 did not complete the post-treatment nursing assessment before the patient was discharged. There was no documented post-treatment nursing assessment on 02/10/2025. A review of the treatment sheet dated 02/14/2025 revealed Staff # 13 did not complete the post-treatment nursing assessment (documented at 3:29 PM) before the patient was discharged. Treatment ended at 2:03 PM. Patient # 9 A review of 1 of 6 treatment sheets for Patient # 9 revealed that the post-treatment nursing assessments were not completed prior to the patient’s discharge. A review of the treatment sheet dated 02/13/2025 revealed Staff # 2 did not complete the post-treatment nursing assessment (documented at 11:01 AM) before the patient was discharged. Treatment ended at 9:04 AM. Patient # 10 A review of 4 of 6 treatment sheets for Patient # 10 revealed that the post-treatment nursing assessments were not completed prior to the patient’s discharge. A review of the treatment sheet dated 02/12/2025 revealed Staff # 13 did not complete the post-treatment nursing assessment (documented at 4:46 PM) before the patient was discharged. Treatment ended at 2:45 PM. A review of the treatment sheet dated 02/14/2025 revealed Staff # 13 did not complete the post-treatment nursing assessment (documented at 5:16 PM) before the patient was discharged. Treatment ended at 2:24 PM. A review of the treatment sheet dated 02/19/2025 revealed Staff # 13 did not complete the post-treatment nursing assessment (documented at 12:17 PM) before the patient was discharged. Treatment ended at 10:22 AM. A review of the treatment sheet dated 02/21/2025 revealed Staff # 13 did not complete the post-treatment nursing assessment (documented at 4:35 PM) before the patient was discharged. Treatment ended at 2:34 PM. A review of the facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” with a revision 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: 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 (B) 1. Sitting and standing blood pressure measurement required pre and post-treatment ... 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 or if performance of a nursing assessment is permitted by state law, a licensed practice nurse 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 v. Review of documentation for accuracy, completion and patient data vi. A physical assessment of the patient which includes 1. Apical heart rate and rhythm 2. Auscultation of the lungs 3. Evaluation of volume status including edema 4. Bruising or bleeding 5. Patient statement of well-being, level of pain or discomfort 6. And other components which if observed/informed will be documented, including but not necessarily limited to the following: o Change in the normal level of consciousness, mobility, or mental status o Complaint of nausea, vomiting, diarrhea, constipation, skin changes, headache, respiratory distress, angina, weakness, fever, cramping, dizziness o Reports of illness and/or injuries, falls, conditions/complications or other problems the patient has experienced since the last dialysis treatment. 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR and Max UFR e. UF Profiling f. Blood flow rate g. Dialysate flow rate h. All accesses evaluated i. Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings j. Heparinization (intradialytic infusion setting) 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: a. Vital signs and treatment monitoring i. Nocturnal Programs: Treatment checks should be completed at least every 30 minutes prior to the established “lights out” time for the nocturnal program. ii. After the established “lights out” time, treatment checks will remain every 30 minutes with the exception of blood pressure and heart rate. After “lights out” time, blood pressure and heart rate checks will be performed every 60 minutes while the patient is awake and then every three (3) hours once the patient is noted to be sleeping. iii. Non-nocturnal treatments are completed at least every thirty (30) minutes. b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures iv. Fluid removal and/or replacement v. Vascular access is visible and line connections are intact vi. Patient subjective statement(s) i.e., patient report on overall health, any complaints c. The vascular access site, bloodline connections, and the patient’s face should be visible throughout the dialysis treatment. d. Hourly heparin infusion ordered by the physician/NPP should be monitored every 60 minutes. e. The arterial and venous drip chamber levels should be observed and adjusted as needed. f. External transducer protectors will be inspected for the presence of blood or saline every 30 minutes during patient treatment and included as part of the monitoring process. If blood or saline is observed in the external transducer protector, refer to policy: Changing Transducer Protectors OR if Streamline bloodlines are used, and if POD membrane rupture occurs, the whole Streamline bloodline needs to be changed. i. The treatment can continue for this patient on this dialysis delivery system if accurate pressures are observed. Document events and patients’ responses in the electronic treatment record. ii. Upon completion of treatment, the delivery system is to be removed from service and labeled with the date, time, description of the problem, and the name of the teammate reporting the problem. The internal transducer protector will be changed only by a trained Biomed teammate and the dialysis delivery system will be disinfected prior to return to use. 10. If the dialysis prescription is not being met (including dialysis flow rate or change to /inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. 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 response will be documented in the patient’s medical record. 14. Additional documentation if applicable includes the following: a. All medications including time administered, dose, route, and initials of the person administering the medication (Insulin is verified with a second patient care teammate) b. Indication and patient response to PRN medication c. Lab work 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. ABNORMAL FINDINGS Unless other abnormal parameters are established by the facility 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 patient is not able to stand, document reason and sitting BP Sitting BP for patient’s 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 heart beat Temperature Pre/Post/PRN: Greater than 100? F or 2 degree rise over baseline Respirations Pre/PRN: Patient complaints of shortness of breath, difficulty breathing Pre/Intra/Post Patient Reports/ Complaints and/or teammate observation of: Pain, chest pain Bleeding or blood in stool Diarrhea, nausea or vomiting Chills New onset of rash, skin lesions, ulcers or change in skin color, new bruising or cuts Weakness or numbness Cramping Changes in mobility, ambulation, or reports of falls Changes in level of consciousness, ability to communicate ...” During an interview with Staff # 2 on 02/26/2025 at 10:30 AM, Staff # 2 acknowledged there were issues with the staff documenting pre and post nursing assessments within the appropriate timeframe.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility staff failed to follow the physician’s prescribed orders for blood flow rate (BFR) and dialysate flow rate (DFR) in 2 (# 9, # 10) of 5 medical records reviewed. The facility staff failed to verify the ordered prescription matched the prescription the patient was receiving. Also, the facility staff failed to follow the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. This deficient practice had the likelihood to harm patients by not following the physician’s dialysis orders, which could negatively impact the effectiveness and adequacy of the dialysis treatment for all 51 in-center hemodialysis patients receiving care at this facility. Findings include: Patient # 9 A review of 1 of 6 treatment sheets revealed facility staff did not follow the physician’s prescribed orders for BFR. A review of the treatment sheet dated 02/11/2025 revealed the following, “Dialysis Prescription: Blood Flow Rate: 450ml/min (milliliters per minute) Dialysate Flow Rate: 800.00 ml/min” Staff # 10 documented the following BFR throughout the patient’s treatment, “06:31 AM- 9:15 AM: BFR: 400 ml/min” Staff # 17 documented the following on 02/11/2025 at 6:11 AM, “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment” There was no documented order from the physician to adjust the BFR for this treatment date. Patient # 10 A review of 1 of 6 treatment sheets revealed facility staff did not follow the physician’s prescribed orders for BFR. A review of the treatment sheet dated 02/24/2025 revealed the following, “Dialysis Prescription: Blood Flow Rate: 350ml/min (milliliters per minute) Dialysate Flow Rate: 500.00 ml/min” Staff # 12 documented the following BFR throughout the patient’s treatment, “07:00 AM- 09:30 AM: BFR: 300” Staff # 13 documented the following on 02/24/2025 at 6:45 AM, “I verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment” There was no documented order from the physician to adjust the BFR for this treatment date. A review of the facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” with a revision 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: 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 (B) 1. Sitting and standing blood pressure measurement required pre and post-treatment ... 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 or if performance of a nursing assessment is permitted by state law, a licensed practice nurse 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 v. Review of documentation for accuracy, completion and patient data vi. A physical assessment of the patient which includes 1. Apical heart rate and rhythm 2. Auscultation of the lungs 3. Evaluation of volume status including edema 4. Bruising or bleeding 5. Patient statement of well-being, level of pain or discomfort 6. And other components which if observed/informed will be documented, including but not necessarily limited to the following: o Change in the normal level of consciousness, mobility, or mental status o Complaint of nausea, vomiting, diarrhea, constipation, skin changes, headache, respiratory distress, angina, weakness, fever, cramping, dizziness o Reports of illness and/or injuries, falls, conditions/complications or other problems the patient has experienced since the last dialysis treatment. 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR and Max UFR e. UF Profiling f. Blood flow rate g. Dialysate flow rate h. All accesses evaluated i. Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings j. Heparinization (intradialytic infusion setting) 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: a. Vital signs and treatment monitoring i. Nocturnal Programs: Treatment checks should be completed at least every 30 minutes prior to the established “lights out” time for the nocturnal program. ii. After the established “lights out” time, treatment checks will remain every 30 minutes with the exception of blood pressure and heart rate. After “lights out” time, blood pressure and heart rate checks will be performed every 60 minutes while the patient is awake and then every three (3) hours once the patient is noted to be sleeping. iii. Non-nocturnal treatments are completed at least every thirty (30) minutes. b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures iv. Fluid removal and/or replacement v. Vascular access is visible and line connections are intact vi. Patient subjective statement(s) i.e., patient report on overall health, any complaints c. The vascular access site, bloodline connections, and the patient’s face should be visible throughout the dialysis treatment. d. Hourly heparin infusion ordered by the physician/NPP should be monitored every 60 minutes. e. The arterial and venous drip chamber levels should be observed and adjusted as needed. f. External transducer protectors will be inspected for the presence of blood or saline every 30 minutes during patient treatment and included as part of the monitoring process. If blood or saline is observed in the external transducer protector, refer to policy: Changing Transducer Protectors OR if Streamline bloodlines are used, and if POD membrane rupture occurs, the whole Streamline bloodline needs to be changed. i. The treatment can continue for this patient on this dialysis delivery system if accurate pressures are observed. Document events and patients’ responses in the electronic treatment record. ii. Upon completion of treatment, the delivery system is to be removed from service and labeled with the date, time, description of the problem, and the name of the teammate reporting the problem. The internal transducer protector will be changed only by a trained Biomed teammate and the dialysis delivery system will be disinfected prior to return to use. 10. If the dialysis prescription is not being met (including dialysis flow rate or change to /inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. 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 response will be documented in the patient’s medical record. 14. Additional documentation if applicable includes the following: a. All medications including time administered, dose, route, and initials of the person administering the medication (Insulin is verified with a second patient care teammate) b. Indication and patient response to PRN medication c. Lab work 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. ABNORMAL FINDINGS Unless other abnormal parameters are established by the facility 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 patient is not able to stand, document reason and sitting BP Sitting BP for patient’s 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 heart beat Temperature Pre/Post/PRN: Greater than 100? F or 2 degree rise over baseline Respirations Pre/PRN: Patient complaints of shortness of breath, difficulty breathing Pre/Intra/Post Patient Reports/ Complaints and/or teammate observation of: Pain, chest pain Bleeding or blood in stool Diarrhea, nausea or vomiting Chills New onset of rash, skin lesions, ulcers or change in skin color, new bruising or cuts Weakness or numbness Cramping Changes in mobility, ambulation, or reports of falls Changes in level of consciousness, ability to communicate ...” During an interview with Staff # 16 on 02/26/2025 at 10:30 AM, Staff # 16 acknowledged the staff was not following the physician’s orders for dialysis treatment.”

“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 facility staff failed to ensure direct care staff were reporting patient vital signs that fell outside of the facility’s set parameters to the CN (charge nurse) for further assessment and intervention on 4 (# 5, # 6, # 9, # 10) of 5 patient charts reviewed. The facility staff failed to follow the facility policy “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. Findings include: Patient # 5 A review of the treatment sheet dated 02/20/2025 for Patient # 5 revealed Staff # 6 (PCT) did not alert the charge nurse (CN) of abnormal vital signs during treatment. Staff # 6 documented the following on 02/20/2025, “1:03 PM: Heart Rate (HR): 49” There was no documentation from Staff # 6 to support the charge nurse being made aware of these abnormal vital signs during Patient # 5’s treatment on 02/20/2025. Patient # 6 A review of the treatment sheet dated 02/24/2025 for Patient # 6 revealed Staff # 14 (PCT) did not alert the charge nurse (CN) of abnormal vital signs during treatment. Staff # 14 documented the following on 02/24/2025, “3:00 PM: Heart Rate (HR): 111 3:09 PM: Heart Rate (HR): 111 3:19 PM: Heart Rate (HR): 116” There was no documentation from Staff # 14 to support the charge nurse being made aware of these abnormal vital signs during Patient # 6’s treatment on 02/24/2025. Patient # 9 A review of the treatment sheet dated 02/11/2025 for Patient # 9 revealed Staff # 10 (PCT) did not alert the charge nurse (CN) of abnormal vital signs during treatment. Staff # 10 documented the following on 02/11/2025, “07:31 AM: Blood Pressure (BP): 173/105 08:01 AM: Heart Rate (HR): 113 08:31 AM: Heart Rate (HR): 119 08:59 AM: Blood Pressure (BP): 77/44” There was no documentation from Staff # 10 to support the charge nurse being made aware of these abnormal vital signs during Patient # 9’s treatment on 02/11/2025. Patient # 10 A review of the treatment sheet dated 02/24/2025 for Patient #10 revealed Staff # 12 (PCT) did not alert the charge nurse (CN) of abnormal vital signs during treatment. Staff # 12 documented the following on 02/24/2025, “07:30 AM: Blood Pressure (BP): 186/103 08:30 AM: Blood Pressure (BP): 192/109 09:00 AM: Blood Pressure (BP): 198/106” There was no documentation from Staff # 12 to support the charge nurse being made aware of these abnormal vital signs during Patient # 10’s treatment on 02/24/2025. A review of the facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” with a revision 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: 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 (B) 1. Sitting and standing blood pressure measurement required pre and post-treatment ... 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 or if performance of a nursing assessment is permitted by state law, a licensed practice nurse 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 v. Review of documentation for accuracy, completion and patient data vi. A physical assessment of the patient which includes 1. Apical heart rate and rhythm 2. Auscultation of the lungs 3. Evaluation of volume status including edema 4. Bruising or bleeding 5. Patient statement of well-being, level of pain or discomfort 6. And other components which if observed/informed will be documented, including but not necessarily limited to the following: o Change in the normal level of consciousness, mobility, or mental status o Complaint of nausea, vomiting, diarrhea, constipation, skin changes, headache, respiratory distress, angina, weakness, fever, cramping, dizziness o Reports of illness and/or injuries, falls, conditions/complications or other problems the patient has experienced since the last dialysis treatment. 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: a. Dialyzer make and model b. Treatment time c. Target weight d. UFR and Max UFR e. UF Profiling f. Blood flow rate g. Dialysate flow rate h. All accesses evaluated i. Correct dialysate composition (potassium, calcium, base sodium and bicarb) and settings j. Heparinization (intradialytic infusion setting) 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: a. Vital signs and treatment monitoring i. Nocturnal Programs: Treatment checks should be completed at least every 30 minutes prior to the established “lights out” time for the nocturnal program. ii. After the established “lights out” time, treatment checks will remain every 30 minutes with the exception of blood pressure and heart rate. After “lights out” time, blood pressure and heart rate checks will be performed every 60 minutes while the patient is awake and then every three (3) hours once the patient is noted to be sleeping. iii. Non-nocturnal treatments are completed at least every thirty (30) minutes. b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures iv. Fluid removal and/or replacement v. Vascular access is visible and line connections are intact vi. Patient subjective statement(s) i.e., patient report on overall health, any complaints c. The vascular access site, bloodline connections, and the patient’s face should be visible throughout the dialysis treatment. d. Hourly heparin infusion ordered by the physician/NPP should be monitored every 60 minutes. e. The arterial and venous drip chamber levels should be observed and adjusted as needed. f. External transducer protectors will be inspected for the presence of blood or saline every 30 minutes during patient treatment and included as part of the monitoring process. If blood or saline is observed in the external transducer protector, refer to policy: Changing Transducer Protectors OR if Streamline bloodlines are used, and if POD membrane rupture occurs, the whole Streamline bloodline needs to be changed. i. The treatment can continue for this patient on this dialysis delivery system if accurate pressures are observed. Document events and patients’ responses in the electronic treatment record. ii. Upon completion of treatment, the delivery system is to be removed from service and labeled with the date, time, description of the problem, and the name of the teammate reporting the problem. The internal transducer protector will be changed only by a trained Biomed teammate and the dialysis delivery system will be disinfected prior to return to use. 10. If the dialysis prescription is not being met (including dialysis flow rate or change to /inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. 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 response will be documented in the patient’s medical record. 14. Additional documentation if applicable includes the following: a. All medications including time administered, dose, route, and initials of the person administering the medication (Insulin is verified with a second patient care teammate) b. Indication and patient response to PRN medication c. Lab work 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. ABNORMAL FINDINGS Unless other abnormal parameters are established by the facility 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 patient is not able to stand, document reason and sitting BP Sitting BP for patient’s 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 heart beat Temperature Pre/Post/PRN: Greater than 100? F or 2 degree rise over baseline Respirations Pre/PRN: Patient complaints of shortness of breath, difficulty breathing Pre/Intra/Post Patient Reports/ Complaints and/or teammate observation of: Pain, chest pain Bleeding or blood in stool Diarrhea, nausea or vomiting Chills New onset of rash, skin lesions, ulcers or change in skin color, new bruising or cuts Weakness or numbness Cramping Changes in mobility, ambulation, or reports of falls Changes in level of consciousness, ability to communicate ...” An interview with Staff # 16 on 02/26/2025 at 10:30 AM confirmed the facility staff were not reporting out of parameter vital signs to the charge nurse for further evaluation and treatment.”