Davita Sagemeadow Dialysis

“CFC-PATIENTS- RIGHTS CFR(s): 494.70 This Condition is not met as evidenced by: 10802 Based on observation, interview and record review, the facility’s direct care staff failed to ensure a patient receives hemodialysis treatment utilizing dialysate concentrate prescribed by the physician. A patient utilizing the incorrect dialysate concentrate with an elevated potassium level can further increase in the patient’s blood potassium which can potentially lead to increase mortality. Findings: On 04/17/2024 Patient #8 was observed utilizing a dialysate concentrate not prescribed by the physician. The record revealed a physician’s order dated 4/08/2024 for a 1 mEq potassium and 2.5 mEq calcium dialysate concentrate. The patient has a potassium level was of 6.1 mEq/L which is above the range of 3.5 - 5.5 mEq. The patient was observed utilizing a 3 mEq potassium and 2.5 mEq calcium dialysate concentrate and not the prescribed dose of 1 mEq potassium. Review of the patient’s home medication record located in the patient’s clinical record revealed the patient currently takes Losartan Potassium 100 milligram oral tablet once daily for his blood pressure. Losartan can increase the levels of a substance called potassium in the blood. Taking Losartan with drugs that contain potassium, potassium supplements, or salt substitutes with potassium can increase the risk of hyperkalemia (high levels of potassium). Cross reference V 463”

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 10802 The facility’s governing body failed to ensure medication prescribed by patients’ physicians are available for administration to patients in 4 of 8 sampled patients. Patient #s 2, 5, 4 and 7. (B) Based on observation, record review and interview the facility failed to assess, develop and implement interdisciplinary plan of care to address patient’s care needs in 2 of 8 sampled patients Patient #s 1 and 2 Findings: Observation on 04/17/2024 and record review of patient #s 2, 5, 4 and 7’s clinical records revealed physician orders for intravenous Venofer. Review of the patients’ clinical records ( medication administration records ) revealed Venofer were not administered to patients as prescribed by patients’ physicians on 04/01/2024, 04/03/2024, 04/05/2024 and 04/08/ 2024. Cross reference V 507 Reviewed of the patient’s clinical record revealed a physician’s order for involuntary discharge. Review of the patient’s clinical record revealed a physician’s order dated 3/19/2024 as follows: “ Per MD orders, patient mentioned above has been discharged from the facility on 03/15/24 for physically assaulting RN on duty. Pt and attending MD notified on 03/15/2024.” Review of patient #1’s clinical record (treatment sheets) revealed documentation which indicated, on 11/17/2023 the patient hit a licensed vocational nurse while she was assisting the patient in adjusting her telephone for a video call. The record revealed the patient had episodes of outburst, screaming at teammates to terminate her treatment early, refusing medication on multiple occasions, refusing to wear mask while catheter care in process and refusing to sign against medical advice. Review of the record revealed no documentation in the interdisciplinary plan of care that the interdisciplinary team addressed the behavioral history of hitting staff and the patient continued refusal of care. Patient #2 Review of the patient’s hospitalization record dated 1/04/2024 revealed the was sent to the hospital for seizure activities prior to dialysis. 02/04/202: the patient was admitted to the hospital for “Chief complaint : PER EMS pt from dialysis with C/O seizure while in waiting room chair, fell to floor. Pt seized approx. 30 sec. PT has a laceration to bridge of nose, hematoma above left eye, possible bit his tongue. AAX1 to self Pt in C- Collar.” Review of the patient’s most current interdisciplinary comprehensive care plan dated 11/1/2023 revealed the patient comprehensive care plan was not updated to reflect the patient’s diagnosis seizure disorder and the potential for injury. Cross refrence V520”

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 10802 Based on record review and interview, the facility staff failed to conduct fire quarterly drill on patient and staff as required in its emergency plan in 3 of 8 sampled patients. Patient #s 4, 5 and 8 Findings: Review of the facility’s current emergency plan directs staff as follows: “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 (NAPA) 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.” Patient #4 Review on 04/16/2024 of Patient #4’s clinical record revealed documentation which indicated the patient participated in emergency procedure fire drills at the facility on 12/05/2023 and 9/29/2023. There was no documentation that the patient participated in an emergency procedure fire drill since 2024. Patient #5 Review on 04/16/2024 of Patient #4’s clinical record revealed documentation which indicated the patient participated in emergency procedure fire drills at the facility on 12/05/2023 and 9/29/2023. There was no documentation that the patient participated in an emergency procedure fire drill since 2024. Patient #8 Review on 04/16/2024 of Patient #8’s clinical record revealed documentation which indicated the patient participated in emergency procedure fire drills at the facility on 12/08/2023 and 9/27/2023. There was no documentation that the patient participated in an emergency procedure fire drill since 2024. Interview on 04/17/2024 at 2:00 p.m. with the facility’s medical clinical support personnel revealed she said quarterly fire drill was not completed since January 2024,”

“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: 10802 Based on observation, interview and record review, facility’s direct care staff failed to wash/ sanitize hands after removing contaminated gloves in 2 or 4 staff observed. Patient Care Technicians (F and E) Findings: Review of the facility’s current policy and procedure on infection control for dialysis facilities; Policy #1-05-01 ;revised April 2023 directs staff as follows: “HAND HYGIENE 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area.” Patient Care Technician (F) On 04/17/2024 at 8:18 a.m. Patient Care Technician (F) was observed in the isolation room of the facility. The patient care technician was resetting the patient’s hemodialysis machine which was alarming. Observation revealed the patient care technician attempted to flush the patient’s external blood line with Normal Saline from a syringe. After flushing the lines, the patient care technician removed his contaminated gloves, walked over to the box of clean gloves stored on the computer station and picked up clean gloves with his hands and reset the patient’s hemodialysis machine. The patient care technician did not wash/ sanitize his hands after removing the contaminated gloves. After resetting the patient’s hemodialysis machine, the patient care technician removed his gown, gloves and mask, walked out of the isolation room and donned his gown stored outside the room. He did not wash and sanitize his hands in the room after handling the patients’ blood lines and prior to exiting the isolation room. The Surveyor notified the patient care technician of her observation, he states “I understand.” Patient Care Technician (E) On 04/17/2024 at 9:02 a.m. Patient Care Technician (E) was observed at station 7, hemodialysis machine #4. The patient care technician wearing a pair of gloves which he used to reset the panel of the patient’s hemodialysis machine. After resetting the patient’s contaminated hemodialysis machine, the patient care technician removed her contaminated gloves, picked up clean gloves from the box of gloves stored on the computer station and proceeded to Patient #6’s hemodialysis station and took the patient’s post hemodialysis treatment blood pressure. After Patient#6 left the unit, the surveyor notified her of the observation of her not washing/ sanitizing her hands after removal of contaminated gloves. Patient Care Technician ( E) states “ I don’t recall.” On 04/17/2024 at 9:40 a.m. Patient Care Technician ( E) was observed at station #9, the patient care technician was monitoring the patient’s blood pressure. After monitoring the patient’s blood pressure and adjusting the blood pressure cuff on the patient’s arm, the patient care technician removed her contaminated gloves, walked over to station #8 hemodialysis machine #20 and proceeded to string the machine which was terminally clean in preparation for an on coming patient. The patient care technician did not wash/ sanitize her hands after removing her contaminated gloves in between monitoring the patient’s blood pressure and stringing the clean hemodialysis machine . The surveyor immediately notified her of not washing or sanitizing her hands after removing her contaminated gloves. The patient care Technician ( E) states “ But I change my gloves.” Patient Care Technician ( F ) On 04/17/2024 at 1:30 p.m. Patient Care Technician (F) was observed in the isolation room of the facility. The patient care technician was resetting the patient’s hemodialysis machine which was alarming. Observation revealed the patient picked up a glove which he did not don. He then used the glove to reset the contaminated hemodialysis machine. A staff member in training who was present observed the deficient practice and notified other staff.”

“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: 10802 Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment. Findings: Observation on 04/16/2024 and 04/17/2024 of the facility’s treatment unit revealed the sheet rock adjacent to station 1 and the scale is peeling. Observation of the sheet rock at station # 17 is peeling. Observation on 04/16/2024 and 04/17/2024 of the stock room accompanied by the facility’s chief biomedical technician revealed a double door with entry to the facility’s stock room. The double doors had an opening of approximately one inch between both doors. The doors do not have any form of weather stripping between them. Hot air from the outside was noted coming from the opening between the double doors. This opening has the potential of insects entering the stock room which holds supplies for treatment of hemodialysis patients. Interview on 04/17/2024 at 3:00 p.m. during tour with the facility’s chief biomedical technician revealed he said he was waiting on GFS for repairs. Review of the facility’s quality assessment performance improvement meeting minutes for February 2024 revealed documentation which indicates the following “ Damage to walls on Tx floor. Station 17 and 1. Double door broken in storage room. October 2023 GFS inspected damage waiting for date when repairs.””

“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: 10802 Based on observation, interview and record review, the facility’s direct care staff failed to ensure a patient receives hemodialysis treatment utilizing dialysate concentrate prescribed by the physician. A patient utilizing the incorrect dialysate concentrate with an elevated potassium level can further increase in the patient’s blood potassium which can potentially lead to increase mortality. Findings: Patient #8 On 04/17/2024 at 15:50 p.m. Patient #8 was observed on the treatment unit at station # 12, hemodialysis machine #18. The patient was receiving hemodialysis treatment at a blood flow of 350 mls/ minute and dialysate flow rate of 500 mls/ per minute. The patient was utilizing a 3 mEq potassium and 2.5 mEq calcium dialysate concentrate in a jug attached to the hemodialysis machine. Observation revealed the hemodialysis machine was programmed to deliver 3 mEq potassium and 2.5 mEq calcium dialysate concentrate. Review of the patient’s clinical record located in the chairside computer revealed a physician’s order dated 4/08/2024 for a 1 mEq potassium and 2.5 mEq calcium dialysate concentrate. The surveyor immediately notified the registered nurse assigned to the patient that the patient was not utilizing the dialysate concentrate prescribed by the physician. The registered nurse checked the prescription and validated that the patient was not using the dialysate concentrate prescribed by the physician. Review of the patient’s laboratory values dated 04/01/2024 and 4/8/2024 revealed a potassium value of 6.1 mEq; Potassium range 3.5 - 5.5 mEq. Interview during the observation with the Patient Care Technician assigned to the patient revealed she states “I made an error and did not look at the bottle. “ Review of the patient’s treatment sheet dated 04/17/2024 revealed documentation which indicated the patient’s hemodialysis treatment was initiated by the patient care technician assigned to the patient at 15:05 p.m. with pre- treatment assessment by the registered nurse assigned to the patient at 15:36 p.m. Review of the patient’s treatment sheet dated 04/17/2024 and timed at 15:36 p.m. revealed documentation by the registered nurse assigned to the patient as follows: “ I very verify that the patient’s prescription matches what is currently being delivered during the dialysis treatment.” Review of the registered nurse assigned to the patient nurse’s note dated 04/17/2024 at 16:19 p.m. revealed the following documentation: “ Patient was connected to incorrect bath at tx initiation: mistake was discovered after patient had been connected for 20 minutes; once discovered bath was removed and prescription bath was connected. MD notified and gave orders to re-check potassium. Pt stable; denies any related symptoms.” This notation was made after the Surveyor identified the incorrect dialysate concentrate being utilized by the patient for his hemodialysis treatment. Review of the patient’s interdisciplinary comprehensive care plan dated 11/1/2023 revealed the following documentation : potassium 1.0 mEq/L and Calcium 2.5 mEq /L. Review of the patient’s home medication record located in the patient’s clinical record revealed the patient currently takes Losartan Potassium 100 milligram oral tablet once daily for his blood pressure. During an interview on 04/18/2024 at 9:00 a.m , the Surveyor asked the facility’s Clinical Coordinator if the patient is currently taking Losartan Potassium 100 milligram. She states “ yes” Losartan can increase the levels of a substance called potassium in the blood. Taking Losartan with drugs that contain potassium, potassium supplements, or salt substitutes with potassium can increase the risk of hyperkalemia (high levels of potassium). During an interview via the telephone on 04/18/2024 with the patient’s attending nephrologist, the surveyor notified the patient’s attending nephrologist that the patient is currently taking Losartan Potassium 100 milligram and his potassium is above the acceptable range. The patient’s attending nephrologist said he would discuss with the patient regarding the drug and alternative drug available.”

“PA-ASSESS ANEMIA CFR(s): 494.80(a)(4) The patient’s comprehensive assessment must include, but is not limited to, the following: (4) Evaluation of factors associated with anemia, such as hematocrit, hemoglobin, iron stores, and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agent(s). This Standard is not met as evidenced by: 10802 The facility’s governing body failed to ensure medication prescribed by patients’ physicians are available for administration to patients in 4 of 8 sampled patients. Patient #s 2, 5, 4 and 7. Findings: Patient #2 On 04/17/2024 at 3:30 p.m. Patient #2 was observed on the treatment unit at station # 3. The patient was alert and oriented to person, place time and situation. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute via a right double lumen central venous catheter. Review of Patient #2’s clinical record revealed a physician’s order dated 3/14/2024 for Venofer 100 milligram intravenous push every dialysis treatment. Review of the patient’s treatment sheet dated 4/03/2024 and 4/05/2024 revealed the patient was not administered Venofer as prescribed. Documentation by the registered nurse were as follows: “ Not given. Reason not given not in stock.” Patient #5 On 04/17/2024 at 7:29 a.m. Patient #5 was observed on the treatment unit at station # 17. The patient was receiving hemodialysis treatment at a blood flow rate of 400 and dialysate flow rate of 500 mls/ minute via a left lower arm vascular access. Review of the patient’s clinical record located in the chair side computer revealed the following laboratory values. 4/08/2024 Hemoglobin 10.8 gms/ dl, Ferritin 6.29 and Iron 42. Review of the patient’s clinical record revealed a physician’s order for Venofer 100 mg one time weekly from 3/14/2024 - 04/11/2024 and order dated 04/11/2024 for Venofer 50 mg one time weekly. Review of the patient’s clinical record (treatment sheet) dated 04/08/2024, 04/05/2024 , 04/03/ 2024 and 4/1/2024 . Documentation by the registered nurse were as follows: “ Not given . Reason not given not in stock.” Patient #4 On 04/17/2024 at 8:05 a.m. Patient #4 was observed on the hemodialysis unit in the isolation. The patient was alert and oriented to person, place, time and situation. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mls/ hour and dialysate flow rate of 500 mls/ hour via a right upper arm vascular access. Review of the patient’s clinical record located in the chair side computer revealed the following laboratory values. 4/01/2024 Hemoglobin 7.86 gms/ dl, 4/5/2024 Ferritin 288 and 4/5/2024 Iron saturation = 26. Review of the patient’s clinical record revealed a physician’s order dated 3/28/2024 for Venofer 100 mg intravenous every treatment. Review of the patient’s clinical record (treatment sheet) dated 04/08/2024, 04/05/2024. Documentation by the registered nurse were as follows: “ Not given. Reason not given not in stock.” Patient #7 Review of the patient’s clinical record revealed a physician’s order dated 4/1/2024 for Venofer 100 mg intravenous every dialysis treatment. Review of the patient’s clinical record (treatment sheet) dated 04/05/2024, 04/01/2024. Documentation by the registered nurse were as follows: “ Not given. Reason not given not in stock.” On 04/17/2024 at 9:30 a.m. the surveyor notified the Facility’s Clinical Coordinator that patients did not receive Venofer prescribed by their physicians. The facility’s clinical coordinator states” We ran out of Venofer and it’s on back order.” The surveyor asked the facility’s Clinical Coordinator if patients who did not receive Venofer were notified that the medication was not available for administration. The Clinical Coordinator stated “ no.””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 10802 Based on observation, record review and interview the facility failed to assess, develop and implement interdisciplinary plan of care to address patient’s care needs in 2 of 8 sampled patients Patient #s 1 and 2 Findings: Review of the facility’s current policy on Interdisciplinary Team IDT Patient Assessment Plan of Care Plan; Policy # 1-14-01/ revised July 2023 directs staff as follows: “PLAN OF CARE: 8. The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and will include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care will be consistent with current evidence-based professionally accepted clinical practice standards. Reviewed of the patient’s clinical record revealed a physician’s order for involuntary discharge. Review of the patient’s clinical record revealed a physician’s order dated 3/19/2024 as follows: “ Per MD orders, patient mentioned above has been discharged from the facility on 03/15/24 for physically assaulting RN on duty. Pt and attending MD notified on 03/15/2024.” Patient #1 Review of patient #1’s clinical record (treatment sheets) revealed documentation which indicated, on 11/17/2023 the patient hit a licensed vocational nurse while she was assisting the patient in adjusting her telephone for a video call. The record revealed the patient had episodes of outburst, screaming at teammates to terminate her treatment early, refusing medication on multiple occasions, refusing to wear mask while catheter care in process and refusing to sign against medical advice. During an interview on 04/16/2024 at 12:43 p.m. via the telephone with Registered Nurse (B) revealed she said on 03/15/2024 the patient had requested to have her treatment cut short. She said the patient was accustomed to cutting her treatment. She said teammate (I) and her told the patient she needed to sign an AMA ( against medical advice). She said during taking off the patient from hemodialysis treatment she attempted doing the patient’s blood pressure and the patient’s arm was bent so the machine kept alarming, and so she could not get an accurate blood pressure reading. She said the patient became irritated and threatened to hit her. She said while disconnecting the patient’s external blood lines from the central venous catheter, the patient leaned forward which made it difficult to gain access to the central venous catheter. She said the patient sat up then hit her on left on side of her forehead with her hand. She states “I did not get hurt because I was wearing a face shield and mask. She was about to hit me a second time and the patient care technician held her hands. She had been rude to me a couple of times before that, but I did not expect her to actually hit me.” Interviewed Patient Care Technician (I) Interview on 04/17/2024 at 2:10 p.m. with the Patient Care Technician revealed she said she was taking care of a patient when she heard the patient said to the nurse hurry up and take me off I need to get off. She then told the nurse I am going to slap you.” The patient care technician said after hearing this she walked over to the patient, and saw the patient slapped the nurse and the nurse’s face shield came off. She states, “she was about to hit her again when and I held her hand and told her you can’t hit the nurse.” She said the patient then proceeded to curse her and told he said she was going to #### everybody a--. She said the patient wore a boot on one foot and so she grabbed her walker and continued to curse as she left the unit without assistance. She said the patient always gave the nurse “a hard time when she was providing care to her.” Interviewed random Patient #9 Interview with random patient #9 on 04/17/2024 at 2:40 p.m. when asked by the surveyor about the altercation between a patient and a staff, random patient #9 said he heard the patient tell the nurse “ Don’t do that no more I am going to slap you.” He said he did not see when the patient slapped the nurse but when he turned in the direction of the nurse and the patient, he saw the nurse’s face shield “ Messed up.” He said prior to this incident he recall the patient telling the nurse at times “ Leave me alone with an attitude as if she implied “ I am going to hurt you.” Review of the patient’s clinical record revealed the following documentation: “ Per MD orders, patient mentioned above has been discharged from the facility on 03/15/24 for physically assaulting RN on duty. Pt and attending MD notified on 03/15/2024.” Review of the patient’s treatment sheets revealed the following findings: March 2024: 03/01/2024; the patient refused assessment of post treatment blood pressure. March 8 2024; the patient terminated hemodialysis treatment early; 17 minutes left prior to termination of hemodialysis treatment. February 2024: 02/06/2024, 2/19/2024, 2/26/2024, 2/19/2024, 2/9/2024; the patient refused post treatment monitoring of blood pressure. 02/05/2024: the patient terminated her hemodialysis treatment early 02/09/2024 and 2/07/2024; the patient refused administration of Mircera. 02/16/2024: the patient refused to stay for further monitoring. January 2024: 1/26/2024, 1/22/2024; the patient refused assessment of post treatment blood pressure. 1/24/2024: the patient demanded to terminate hemodialysis treatment 23 minutes early. 1/19/2024, 1/15/2024, 1/12/2024 1/10/2024 and 1/8/2024; the patient refused administration of Mircera, Venofer, and Calcitriol. 01/03/2024: the patient complained of chest pain but refused medication of nitroglycerine. The patient was sent to hospital. December 2023: 12/29/2023, 12/27/2023, 12/24/2023 and 12/18/2023; the patient refused administration of Mircera. 12/29/2023, 12/27/2023, 12/18/2023, 12/15/2023 and 12/13/2023; the patient requested early termination of hemodialysis treatment. 12/22/2023: the patient complained of chest pain but refused intervention by staff. 12/06/2023; the patient refused to allow assigned nurse (nurse allegedly hit by patient) terminate her hemodialysis treatment. Review of the patient’s interdisciplinary care plan revealed it was last revised on 06/21/2023. Review of the record revealed no documentation in the patient’s interdisciplinary plan of care addressing the behavioral history of hitting staff and the patient continued refusal of care. On 04/17/2024 at 2:30 p.m. the surveyor requested an updated comprehensive interdisciplinary plan of care from the facility’s medical clinical safety personnel, she said there was none. Patient #2 On 04/17/2024 at 3:30 p.m. Patient #2 was observed on the treatment unit at station # 3. The patient was alert and oriented to person, place, time and situation. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute via a right double lumen central venous catheter. Interview on 04/17/2024 at 3:30 p.m. with the patient revealed he said he went to the hospital on 1/29/2024 because he had a syncope episode. He said the hospital did some test then discharged him. He could not recall his next hospital visit. Review of the patient’s clinical record ( Patient Summary of Information Sheet) revealed he was admitted to the facility on 05/16/2023 with admitting diagnosis of Hypertension, Large Vessel Disease, Chronic Kidney Disease Stage 1- 4. Review of the patient’s clinical record ( treatment sheets and hospital record) revealed the patient was admitted to the hospital on 1/29/2024, 2/5/2024 for seizure activity which resulted in injury to patient. Review of the patient’s hospitalization record dated 1/04/2024 revealed the following findings: “ 65 years of age gentleman with history of ESRD on hemodialysis Monday Wednesday, Friday for hypertension, was sent in for seizure activities prior to dialysis. 02/04/2024: the patient was admitted to the hospital for “Chief complaint : PER EMS pt from dialysis with C/O seizure while in waiting room chair, fell to floor. Pt seized approx. 30 sec. PT has a laceration to bridge of nose, hematoma above left eye, possible bit his tongue. AAX1 to self Pt in C- Collar.” Review of the patient’s most current interdisciplinary comprehensive care plan dated 11/1/2023 revealed the patient interdisciplinary comprehensive care plan was not updated to reflect the patient’s diagnosis seizure disorder and the potential for injury. On 04/16/2024 at 11:15 a.m. during an interview with the facility’s clinical coordinator revealed the most current interdisciplinary care plan is dated 11/1/2023.”