Usrc Burleson

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 50181 Based on observation, record review, and staff interview, the facility’s staff failed to: A. ensure their hands were washed or sanitized between glove changes, when moving from station to station, and after touching patients per facility policy. (Cross Reference to Tag V0113) B. ensure all patients (pt) susceptible to Hepatitis B had a monthly Hepatitis B Antigen (Ag) drawn (Cross Reference to Tag V0126) C. ensure expired supplies were discarded on or before the expiration date and not available for patient use in the facility. (Cross Reference to Tag V0142) D. ensure expired medications were discarded on or before the expiration date and not available for patient use in the facility. (Cross Reference to Tag V0143) E. ensure that the wall boxes (dispensing outlets) at the dialysis stations were properly disinfected between each patient treatment. (Cross Reference to Tag V0246) *monitor and provide a safe sanitary environment to minimize the transmission of infectious agents. (Cross Reference to Tag V0401) These findings have the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility by increasing the potential of cross-contamination between patients.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(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. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 50181 Based on observation and staff interview, the facility failed to ensure the crash cart was maintained with up-to-date supplies and medications in the event of an emergency within the facility. The following expired medications and supplies were found in the crash cart during a tour on 04/23/2024: 4 packaged hypodermic needles found in the crash cart with an expiration date of 05/31/2023 4 packaged sterile syringes with needles found in the crash cart with an expiration date of 03/31/2024 1 ampule of Lidocaine was found in the crash cart with an expiration date of 03/2024 An interview with the Facility Administrator (Staff #1) on 04/23/2024 confirmed the above findings.”

“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: 30377 Based on direct observation and policy review the staff failed to ensure their hands were washed or sanitized between glove changes, when moving from station to station, and after touching patients per facility policy. These findings have the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility by increasing the potential of cross-contamination between patients. Findings: A review of the Incenter Hemodialysis Policies, Policy: Hand Hygiene C-IC-0060 last revision 8/2020 revealed the following related to hand hygiene, Purpose: To give guidance on proper hand hygiene and avoid transmission of harmful germs and prevent health care associated infections. Hand Hygiene will be performed: 1. Before and after touching a patient 2. Prior to entering and on exiting station to provide care to the patient 3. Prior to contact with vascular access site 4. Prior to adjusting or removing cannulation needles 5. Before medication preparation 6. Before clean/aseptic procedure 7. After body fluid exposure risk 8. After touching patient surroundings (e.g., Dialysis machine, any items in the dialysis area or chairside computer) 9. After gloves are removed 10. Before and after touching PPE 11. After contact with inanimate objects, including medical equipment or environmental surfaces at the patient station 12. Before entering and on exiting the patient treatment areas 13. When moving from a contaminated body site to a clean body site of the same patient 14. After handling biohazardous waste. During observation of care of the facility’s in-center treatment area on 04/23/2024 the following was observed: At 10:10 am: The patient care technician staff member # 9 was observed gloved placing the patient’s headset on their head after hemodialysis was initiated. She than removed and disposed of the gloves and walked to the cart that contained a box of clean gloves. She than preceded to place on a new pair of gloves. The patient care technician did not perform hand hygiene after touching the patient, prior to exiting station, and or after gloves were removed. At 10:15 am: The patient care technician staff member # 9 was observed gloved at station 12 assisting her assigned patient. The patient care technician removed and disposed of the gloves and walked to the clean cart that contained a box of clean gloves. She than proceeded to place on a new pair of gloves to answer a machine alarm at station 11. The patient care technician did not perform hand hygiene prior to exiting station and after gloves removed. In an interview conducted, with the facility administrator, on 4/23/24 at 4:30 pm confirmed that staff were required to wash or sanitize hands between glove changes, when moving from station to station, and after touching patients to prevent cross contamination.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 50181 Based on record review and staff interview, the facility failed to ensure all patients (pt) susceptible to Hepatitis B had a monthly Hepatitis B Antigen (Ag) drawn during the month of March 2024. This deficient practice had the likelihood to expose susceptible patients and staff members to the Hepatitis B virus. Findings: In review of the Ascend Laboratory Report for the facility titled, “Hepatitis”, 30 out of 71 in-center hemodialysis (ICHD) patients in the facility are susceptible to Hepatitis B as indicated by their most recent Hepatitis B antibody lab value being less than 10mlU/mL. (Patient #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33 and #34) Based on the review of the Ascend Laboratory Report for the facility titled, “Hepatitis”, 29 out of 30 susceptible patients did not have a monthly Hepatitis B antigen drawn during the month of March 2024. (Patient #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33 and #34). The facility failed to follow its policy and procedure (Policy # C-IC-0110; revision date 11/2022) titled, “Patient Hepatitis B Test/Vaccination/Seroconversion.” A review of the facility policy titled, “Patient Hepatitis B Test/Vaccination/Seroconversion” dated 11/2022 revealed the following: “PURPOSE: To prevent the transmission of Hepatitis B Virus (HBV) infection with timely testing, assessment, and vaccination ... POLICY: All patients will be tested for Hepatitis B status following the Centers for Disease Control and Prevention recommendations and offered the Hepatitis B vaccination as indicated. Schedule for Routine Testing for Hepatitis B (HBV) Infections: 1. Obtain Hepatitis B Surface Antigen monthly for all HBV-susceptible patients. Susceptible patients include any patient: a. In a vaccine series; b. anti-HBs (Hepatitis B surface antibody) <10mIU/mL; c. non-responders to the vaccine after two series; and/or d. Anti-HBs<10mIU/mL and refusing the vaccine.” An interview on 04/24/2024, with the Facility Administrator confirmed the 29 patients did not have a monthly Hepatitis B antigen drawn during the month of March 2024.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 50181 Based on observation and staff interview during a facility tour on 04/23/2024 the facility failed to ensure expired supplies were discarded on or before the expiration date and not available for patient use in the facility. Findings included: During a tour of the facility treatment floor on the morning of 04/23/2024, the following expired supplies were found and available for patient use: 2 Hand sanitizers installed at clean sinks on the treatment floor with an expiration date of 12/2023 4 packaged hypodermic needles found in the crash cart with an expiration date of 05/31/2023 4 packaged sterile syringes with needles found in the crash cart with an expiration date of 03/31/2024 5 Recirculate connectors found in the isolation room with an expiration date of 02/18/2022 In an interview with the Facility Administrator (Staff #1) on 04/23/2024 she confirmed the supplies were expired and still available for patient use.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 50181 Based on observation and staff interview during a facility tour on 04/23/2024 the facility failed to ensure expired medications were discarded on or before the expiration date and not available for patient use in the facility. Findings included: During a tour of the facility treatment floor on the morning of 04/23/2024, the following expired medications were found and available for patient use: 1 ampule of Lidocaine was found in the crash cart with an expiration date of 03/2024 5 packages of triple antibiotic ointment was found in the isolation room with an expiration date of 03/2024 In an interview with the Facility Administrator (Staff #1) on 04/23/2024 she confirmed the medications were expired and still available for patient use.”

“BICARB CONC DIST-COLOR CODED BLUE & SEALED CFR(s): 494.40(a) 5.5.4 Bicarbonate concentrate distribution systems: color coded blue & sealed Bicarbonate concentrate delivery piping should be color-coded blue at the point of use (at the jug filling station or dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. This Standard is not met as evidenced by: 50181 Based on observation and interview, the facility failed to ensure that the wall boxes (dispensing outlets) at the dialysis stations were properly disinfected between each patient treatment. This deficient practice had the likelihood to cause bacterial grow in the wall boxes and infect the patients that were receiving in-center hemodialysis at the facility. Findings included: During a tour of the facility treatment floor on the morning of 04/23/2024 the wall boxes were noted to have a crusted, white sediment and build-up around the connectors of the wall box. The Facility Administrator (Staff #1) confirmed the findings noted on the wall boxes on the treatment floor during the tour on 04/23/2024.”

“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: 50181 Based on observation and interview, the facility failed to monitor and provide a safe sanitary environment to minimize the transmission of infectious agents. Also, the facility failed to ensure wheelchairs were placed in the designated wheelchair storage area. During a tour of the facility on 04/23/2024 the following physical plant related infection control issues and safety issues were noted: Four wheelchairs were parked in the patient lobby not the facility’s designated wheelchair storage location. Multiple stained ceiling tiles noted throughout the facility. Dust noted throughout the facility. Missing trim on the floor at the scale location. Ice build-up in the laboratory freezer. Area of wall damage needing repair on the treatment floor near the scale. Wet area under one sink on treatment floor with yellow and white staining present. Items stored under one sink on the treatment floor. Dried bicarbonate residual noted near the bicarbonate mixer and acid distribution system in the water room. Opened cardboard box stored on the back wall chaise behind the isolation machine and chair. An interview with the Facility Administrator (Staff #1) on 04/23/2024 confirmed the above findings.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 50181 Based on observation and staff interview, the facility staff failed to ensure the emergency pull cord (a call light strategically placed throughout the facility to provide a user with a convenient means of summoning help in an emergency) was accessible for a patient in the event of an emergency. The emergency pull cord should be within 6 inches of the floor, hanging freely, and accessible to patients. Upon arrival to the facility on 04/23/2024 the pull cord in the patient restroom was noted to be wrapped around the grab bar and not within 6 inches of the floor. The Facility Administrator (Staff #1) acknowledged the pull cord was wrapped around the grab bar and inaccessible to patients in the event of an emergency during interview and observation on 04/23/2024.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 50181 Based on record review, observation, and interview, the facility failed to change the ultra-filter (Diasafe) every 90 days as indicated by the manufacturer’s guidelines for 15 of 15 machines dedicated to the facility. Findings included: The ultra-filter (Diasafe) on the dialysis machines was dated, “1/24”. On 4/23/2024, the facility bio-medical technician (Staff #14) indicated the actual date the diasafe filters were changed was 01/09/2024. He provided the service records for each machine verifying the date of 01/09/2024. He also reported he had planned to change them the date of this interview (04/23/2024). The reported timeline exceeds the 90-day manufacturer’s guidelines. This was confirmed by the bio-medical technician (Staff #14) and the Area Bio-med Manager (Staff #15) on 04/23/2024. A review of the Operators instructions for the Fresenius model machines with diasafe filters revealed the following guidelines: “Replace the Diasafe filter at least every 90 days. After replacing the Diasafe filter, perform either the automated test function or a manual pressure holding test AND then perform the Diasafe filter integrity test.” An interview with Staff #14 and Staff #15 on 04/23/2024 confirmed that the Diasafe filters had not been changed since 01/09/2024 on 15 of 15 machines dedicated to the facility.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 30377 Based on observation, policy review, and staff interview the facility failed to ensure that patients and or the hemodialysis access site was visible while the patient was receiving treatment. The patient and the access site (needle insertion sites and line connections) for all patients on treatment must always be visible to staff, to ensure the lines and needles do not become dislodged or disconnected. Excessive blood loss can result from needle dislodgement, resulting in dire consequences such as severe hypotension, blood transfusions, hospitalization, and death. This practice could affect all in-center hemodialysis patients receiving treatment in the facility. Findings: A review of the Incenter Hemodialysis Policies, Policy: Initiation of Dialysis Treatment revision date last 8/2020 revealed the following, 14. Prior to walking away from the patient’s dialysis machine, Verify all prescribed orders are followed. Prescription orders and safety measures include, but not limited to the following: a. Blood Flow is a prescribed rate. b. Heparin pump if used is turned on and delivering the correct dose. c. Correct dialysate flow rate. d. Dialysis machine temperature. e. Bloodlines are secured. f. Access Purpose: To provide, bloodline connections, and face are visible. g. Fluid removal goal is programmed to volume depletion guidance to prevent complications related to initiation of the hemodialysis procedure. A review of the Incenter Hemodialysis Policies, Policy: Nursing Care Assignments revision date last 01/2020 revealed the following, 1. The Charge RN shall make daily written assignments for nursing care based on degree of supervision required. a. All patients must be in direct view of a staff member at all times. During observation of care of the facility’s in-center treatment area on 04/23/2024 the following was observed: At 10:25 am: Patient care technician staff member # 8 assigned to bay station 1-4 was observed outside his assigned work area to assist needle placement on a patient in a different bay. This left bay station 1-4 with no staff member to observe the patients that were receiving hemodialysis for approximately 10 minutes. At 10:40 am: The patient at station 8, had his access site covered by a blanket. The patient was observed for approximately 20 minutes, and their sites were covered the entire time. In an interview conducted with the facility administrator on 4/23/24 at 4:30 pm stated that patient care technician staff member # 8 was considered an expert cannulator and would move around the unit to assist with difficult sticks. The facility manager confirmed that patients must remain in view at all times. In an interview conducted, with Charge Nurse staff member # 2, on 4/23/24 at 11:00 am confirmed that the access site for the patient at station 8 was not visible. The charge nurse confirmed that access and lines should be visible at all times.”

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 50181 Based on record review and interview, it was determined that the facility failed to ensure the patients were informed about their plan of care meeting on or before the meeting date to allow them the opportunity to participate, if desired. Findings include: Patient #35 medical records review revealed the patient’s initial plan of care meeting invitation was signed on 04/11/2024 after the plan of care meeting on 04/09/2024. Patient #22 medical records review revealed the patient’s initial plan of care meeting invitation was signed on 12/14/2023 after the plan of care meeting on 12/08/2023. An interview with the Facility Administrator (Staff #1) on 4/24/2024 confirmed the patient plan of care invitation was completed after the plan of care meeting was held.”

“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: 30377 Based on observation, medical record review, job description, and interview, the facility failed to ensure that the registered nurse completed a pre-treatment nursing assessment and that the patient received a post-treatment nursing assessment before discharge from the facility. Findings: Review of Job Description titled: RN Charge Nurse revealed the following: The RN Charge Nurse is responsible for overseeing nursing services each shift and functions as a nursing supervisor. This position provides daily supervision of staff on duty during operational hours. Complete pre and post treatment physical assessments. Communicate results of patient assessment, reassessment, and ongoing monitoring to the physician, team members, and others as appropriate to the individual needs of the patient. During observation of care of the facility’s in-center treatment area on 04/23/2024 from 2:00 pm to 4:25 pm the following was observed: From 2:00 pm to 3:15 pm observed 4 patients’ initiation of hemodialysis treatment at machine 11 station 6, machine 2 station 7, machine 8 station 8 and machine 12 station 9 by direct patient care staff. The registered nurse was observed during the first hour of treatment at each patient’s chairside interacting with the patient. The registered nurse was not observed conducting auscultation of the heart and lung sounds of those 4 patients. At 4:15 pm review of flow sheet documentation at chairside revealed that 2 of the 4 patients (machine 11 station 6 and patient at machine 2 station 7) had pre dialysis assessments completed with heart sounds documented as regular and lung fields documented as clear. At 2:28 pm observed patient at station 7 machine #2 complete treatment. The patient walked alone to the scale. The patient exited the building with no post assessment completed by the registered nurse. At 2:33 pm observed patient at station 12 machine #1 complete treatment. Patient was escorted to scale by his assigned patient care technician. The patient exited the building with no post assessment completed by the registered nurse. At 2:44 pm observed patient at station 5 machine #13 complete treatment. The patient was escorted to scale by his assigned patient care technician. The patient exited the building with no post assessment completed by the registered nurse. An interview conducted with the charge nurse staff member # 2 on 4/23/24 at 4:20 pm confirmed that the registered nurse did not complete auscultation of the heart and lung fields per facility policy. When asked if auscultation of the heart and lung fields were completed for the patients at machine 11 station 6, machine 2 station 7, machine 8 station 8 and machine 12 station 9 the registered nurse stated, “Today has been hectic and I have not listened to any patient’s lung fields today.” The registered nurse stated that was not his normal practice.”

“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: 50181 Based on record review, the facility failed to follow the patient’s ordered plan of care by not following the ordered blood flow rate (BFR) and/or dialysate flow rate (DFR) for one or more treatment records reviewed. The specific BFR/DFR is needed to ensure that the blood pump is at constant speed to push the patient’s blood through the dialyzer and back into the patient’s body and is a part the patient’s dialysis prescription. Review of Patient #35 treatment record for 04/20/2024 revealed the DFR was ordered to run at 600mL/min. Review of the intradialytic records revealed the DFR ran at 500mL/min for the duration of the treatment 0947-1248 with no documentation reporting the variation in the DFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #35 treatment record for 04/18/2024 revealed the BFR was ordered to run at 350mL/min and the DFR was ordered to run at 600mL/min. Review of the intradialytic records revealed the DFR ran at 500mL/min for the duration of the treatment 0901-1159 with no documentation reporting the variation in the DFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. At 1401, the BFR was decreased to 300mL/min with no documentation reporting the change in prescription to the charge nurse and no supporting documentation from the nurse related to the reason for the variation in hemodialysis orders for the treatment. Review of Patient #18 treatment record for 04/20/2024 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR was decreased to 375mL/min from 1435 to 1724 with no documentation reporting the change in prescription to the charge nurse and no supporting documentation from the nurse related to the reason for the variation in hemodialysis orders for the treatment. Review of Patient #18 treatment record for 04/18/2024 revealed the BFR was ordered to run at 400mL/min. Review of the intradialytic records revealed the BFR was decreased to 350mL/min from 1131 to 1448 with no documentation reporting the change in prescription to the charge nurse and no supporting documentation from the nurse related to the reason for the variation in hemodialysis orders for the treatment. Review of Patient #36 treatment record for 04/23/2024 revealed the DFR was ordered to run at 800mL/min. Review of the intradialytic records revealed the DFR ran at 700mL/min for the duration of the treatment 0543-0943 with no documentation reporting the variation in the DFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #36 treatment record for 04/20/2024 revealed the DFR was ordered to run at 800mL/min. Review of the intradialytic records revealed the DFR ran at 700mL/min for the duration of the treatment 0547-0948 with no documentation reporting the variation in the DFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. Review of Patient #36 treatment record for 04/18/2024 revealed the BFR was ordered to run at 450mL/min and the DFR was ordered to run at 800mL/min. Review of the intradialytic records revealed the DFR ran at 700mL/min for the duration of the treatment 0543-1015 with no documentation reporting the variation in the DFR to the charge nurse by the patient care technician and no supporting documentation from the nurse related to the variation in hemodialysis orders for the treatment. At 0930, the BFR was decreased to 400mL/min with no documentation reporting the change in prescription to the charge nurse and no supporting documentation from the nurse related to the reason for the variation in hemodialysis orders for the 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: 50181 Based on record review and interview, the facility staff failed to ensure direct patient care (DPC) 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. This deficient practice had the likelihood to cause harm and delay in care to all in-center hemodialysis patients receiving care at the facility. Findings Include: A review of C-FORMS-0081, “PCT/CCHT/LVN Report to the Charge Nurse” revealed, “PRE-DIALYSIS Weight: At or below estimated dry weight (EDW) or weight gain >13ml/kg/hr B/P (Blood Pressure) Systolic: >180 or <90 B/P Diastolic: >110 or <50 Pulse: <50 or >100 beats per minute INTRA-DIALYSIS B/P Systolic: >180 or <90 Diastolic: >110 or <50 Pulse: <50 or >100 beats per minute POST DIALYSIS Weight: >1kg above or below EDW B/P Systolic: >180 or <90 Diastolic: >110 or <50 Pulse: <50 or >100” Patient #22 A review of the treatment sheet dated 04/16/2024 revealed the following vital signs documented by the DPC staff (Staff #8) prior to treatment without documentation to support the CN (Staff #2) was notified of the out of parameter findings. 1317: Pulse 46 1319: Pulse 45 Patient #16 A review of the treatment sheet dated 03/23/2024 revealed the following vital signs documented by the DPC staff (Staff #7) during treatment without documentation to support the CN (Staff #2) was notified of the out of parameter findings. 1334: Blood Pressure 183/97 Pulse 107 1337: Blood Pressure 196/90 Pulse 101 1405: Pulse 104 A review of the treatment sheet dated 03/23/2024 revealed the following vitals signs documented by the DPC staff (Staff #7) was acknowledged with documentation indicating the CN was notified; however, there is no follow-up documentation by the CN (Staff #2) in response to the out of parameter vital signs reported. 1337: Blood Pressure 196/90 “notified CN of pts bp will cont to monitor” 1553: Blood Pressure 186/87 “notified CN of pts bp pt has no complaints” A review of the treatment sheet dated 03/26/2024 revealed the following vital signs documented by the DPC staff (Staff #4) during treatment without documentation to support the CN (Staff #2) was notified of the out of parameter findings. 1101: Pulse 103 1504: Pulse 107 A review of the treatment sheet dated 03/26/2024 revealed the following vital signs documented by the DPC staff (Staff #4) was acknowledged with documentation indicating the CN was notified; however, there is no follow-up documentation by the CN (Staff #2) in response to the out of parameter vital signs reported. 1103: Pulse 104 “CN notified of elevated hr and fluid overload” 1104: Pulse 103 “hr remains elevated, O2 applied via nc @3L/min. cn notified” 1203: Pulse 105 “Late Entry: pt care. Dbp and hr elevated, pt asymptomatic, cn notified” A review of the treatment sheet dated 03/28/2024 revealed the following vital signs documented by the DPC staff (Staff #10) during treatment without documentation to support the CN (Staff #2) was notified of the out of parameter findings. 1111: Pulse 115 1115: Pulse 102 1202: Pulse 112 1332: Pulse 107 1402: Pulse 105 1432: Pulse 102 1503: Blood Pressure 188/85 Pulse 107 An interview with the Facility Administrator (Staff # 1) on 04/24/2024 confirmed the facility staff did not consistently report out-of-parameter vital signs to the Charge Nurse. Staff #1 confirmed the facility staff did not follow the facility’s reportable parameters to the Charge Nurse and there was area of opportunity with the CN follow-up component of documentation.”