Fkc Woodlands Park

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility failed to ensure patient’s nephrologist round and assess patient’s every two weeks in 8 of 12 sampled patients: Patient #s 1, 2, 3, 4, Random 5, 12, 6 and 7 Findings: Patient #1 On 11/04/2024 at 7:32 a.m. Patient #1 was observed on the treatment floor of the facility at station #3 machine #6. The patient was receiving hemodialysis treatment at a blood flow rate of 300 mL/min and dialysate flow rate of 400 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a right upper arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 01/06/1921 with diagnosis of end stage renal disease, hypertension and diabetes mellitus type 2, on in-center hemodialysis three times weekly. Review of the patient’s physician progress note revealed the most recent physician progress note was documented on 10/14/2024. There was no physician visit between 10/14/2024 and 11/04/2024. There was no documented physician progress note every two weeks as required by the state regulations. Patient #2 On 11/04/2024 at 7:50 a.m. Patient #2 was observed on the treatment floor of the facility at station #9 machine 13. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 700 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left lower arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was readmitted to the facility on 08/21/2024 with diagnosis of end stage renal disease, hypertension, congestive heart failure, and diabetes mellitus type 2, on in-center hemodialysis three times weekly. Review of the patient’s physician progress note revealed the most recent physician progress note was documented on 10/14/2024. There was no physician visit between 10/14/2024 and 11/04/2024. Review of the physician progress notes for the month of September 2024 revealed the patient was seen by the physician on 09/06/2024 and 09/16/2024. There was no physician visit between 09/16/2024 and 10/14/2024. There was no documented physician progress note every two weeks as required by the state regulations. Patient #3 On 11/04/2024 at 7:53 a.m. Patient #3 was observed on the treatment floor of the facility at station #10. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of Autoflow 600 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a right upper arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 01/06/2020 with diagnosis of end stage renal disease, hypertension, diabetes mellitus type 2, and diabetic retinopathy, on in-center hemodialysis three times weekly. Review of the patient’s physician progress note revealed the most recent physician progress note was documented on 10/14/2024. There was no physician visit between 10/14/2024 and 11/04/2024. There was no documented physician progress note every two weeks as required by the state regulations. Patient #4 On 11/04/2024 at 10:20 a.m. Patient #4 was observed on the treatment floor of the facility at station #6. The patient was holding his left upper arm vascular access after the hemodialysis treatment. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 01/06/2020 with diagnosis of end stage renal disease and hypertension, on in-center hemodialysis three times weekly. Review of the patient’s physician progress note revealed the most recent physician progress note was documented on 10/14/2024. There was no physician visit between 10/14/2024 and 11/04/2024. There was no documented physician progress note every two weeks as required by the state regulations. Random Patient #5 On 11/04/2024 at 10:38 a.m. Random Patient #5 was observed on the treatment floor of the facility at station #7. The patient was holding his left upper arm vascular access after the completion of the hemodialysis treatment. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 11/08/2023 with diagnosis of end stage renal disease and hypertension, on in-center hemodialysis three times weekly. Review of the patient’s physician progress note revealed the most recent physician progress note was documented on 10/14/2024. There was no physician visit between 10/14/2024 and 11/04/2024. There was no documented physician progress note every two weeks as required by the state regulations. Patient #12 Review of the patient’s clinical record (demographic data) on 11/04/2024 revealed the patient was admitted to the facility 11/07/2023 with diagnosis of end stage renal disease, hypertension and diabetes on oral medications, on in-center hemodialysis three times weekly. Review of the patient’s physician progress note revealed a physician progress note was documented on 06/06/2024, 06/24/2024, 07/01/2024. Review of the patient’s clinical record revealed the patient received hemodialysis treatments 07/15/2024 and 07/17/2024. There was no physician visit between 07/01/2024 and 07/17/2024. There was no documented physician progress note every two weeks as required by the state regulations. Review of the Facility’s Absence and Hospitalization log revealed the patient was hospitalized on 07/22/2024 - 07/24/2024. The patient was discharged from the facility after the hospitalization. Patient #6 On 11/05/2024 at 9:02 a.m. Patient #6 was observed on the treatment floor of the facility at station #5 machine #10. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 700 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left lower arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 07/08/2022 with diagnosis of end stage renal disease, hypertension, and diabetes currently on insulin, on in-center hemodialysis three times weekly. Review of the patient’s physician progress note revealed the most recent physician progress note was documented on 10/15/2024. There was no physician visit between 10/15/2024 and 11/05/2024. There was no documented physician progress note every two weeks as required by the state regulations. Patient #7 Review of the patient’s clinical record (demographic data) on 11/05/2024 revealed the patient was admitted to the facility 05/27/2024 with diagnosis of end stage renal disease, atherosclerotic heart disease, history of hypertension, diabetes on oral medications, and chronic obstructive pulmonary disease, on in-center hemodialysis three times weekly. Review of the patient’s physician progress note revealed the most recent physician progress note was documented on 10/16/2024. There was no physician visit between 10/16/2024 and 11/05/2024. Review of the physician progress notes for the month of September 2024 revealed the patient was seen by the physician on 09/16/2024. There was no physician visit between 09/16/2024 and 10/16/2024. There was no documented physician progress note every two weeks as required by the state regulations. Interview with the attending physician on 11/05/2024 at 1:50 p.m. revealed he confirmed the state requirement to see the patient every two weeks. He also confirmed that he should have coverage by another physician when he is unable to see his patients every two weeks.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to encourage patients to remove gloves and wash or sanitize hands after holding vascular access site post hemodialysis treatment: 2 of 3 staff observed: Registered Nurse (D): Random Patient #10 and Patient Care Technician (B): Patient #4 and Random Patient #5 Findings: Review of the facility’s current policy and procedure: Hand Hygiene: published 03/17/2023, reference number 47664, version 7 directs the staff as follows: “Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water “ Entering and leaving the treatment area ... “ Immediately after removing gloves ... “ After contact with inanimate objects near the patient “ After contact with other objects within the patient station or treatment space Hand Hygiene Patients: Patients should perform hand hygiene if able, prior to and after each dialysis treatment ... To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed.” Registered Nurse (D) Random Patient #10 Observation on 11/04/2024 at 10:12 a.m., revealed Random Patient #10 holding his vascular access with a gloved hand at station #2. After the bleeding ceased, Registered Nurse (D) taped the patient’s vascular access site. The patient picked up his bag with the glove still on his right hand, left station #2 and walked to the weigh scale. After being weighed the touched the door opener on the wall with his gloved knuckle, the door opened, and the patient walked into the lobby with the glove still on his right hand. Registered Nurse (D) did not remind the patient to remove his glove while at chairside or encourage the patient to clean or sanitize hands after holding his vascular access. The Surveyor immediately notified Registered Nurse (D) of the break in infection control when Random Patient #10 left station #2 with the glove on his right hand, touched the door opener on the wall with the gloved hand and left the treatment area without washing or sanitizing his hands. Registered Nurse (D) stated “We are going to have to educate him. Thank you.” Patient Care Technician (B) Patient #4 Observation on 11/04/2024 at 10:20 a.m., revealed Patient #4 holding his left upper arm vascular access with a gloved hand at station #6. After the bleeding ceased, Patient Care Technician (B) taped the patient’s vascular access site, the patient removed his glove, picked up his belongings and left the dialysis station and the treatment area without being encouraged to clean or sanitize hands after holding his vascular access. Random Patient #5 Observation on 11/04/2024 at 10:38 a.m., revealed Random Patient #5 holding his left upper arm vascular access with a gloved hand at station #7. After the bleeding ceased, Patient Care Technician (B) taped the patient’s vascular access site, the patient removed his glove, picked up his belongings and left the dialysis station and the treatment area without being encouraged to clean or sanitize hands after holding his vascular access. On 11/04/2024 at 10:57 a.m., the Surveyor interviewed Patient Care Technician (B) about Patient #4 and Random Patient #5 leaving the dialysis station without washing or sanitizing their hands after glove removal. Patient Care Technician (B) said “I know. Okay.””

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility’s licensed nurses and direct care staff failed to administer patients’ hemodialysis treatments based on physicians’ orders in 6 of 12 sampled and closed patients: Patient #s 1, 2, 11, 6, 8 and 9 Findings: Review of the facility’s current Policy and Procedure on Nursing Supervision and Delegation; Policy #45265, published 11/06/2023 directs staff as follows: Policy The registered nurse must evaluate each patient preferably within an hour or according to state requirements to: ... “ Review accuracy and completeness of treatment and patient data “ Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. Patient #1 On 11/04/2024 at 7:32 a.m. Patient #1 was observed on the treatment floor of the facility at station #3. The patient was receiving hemodialysis treatment at a blood flow rate of 300 mL/min and dialysate flow rate of 400 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer. The dialysate settings were: potassium 2 mEq/L, calcium 2.5 mEq/L , bicarbonate 35 mEq/L, sodium 137 mEq/L. Review of the patient’s physician’s order located in the chairside computer revealed an order for bicarbonate 30 mEq/L. Subsequent review of the patient’s clinical record located in the chairside computer revealed the hemodialysis treatment began at 6:21 a.m. The Surveyor immediately notified Registered Nurse (A) who was assigned to the patient. Registered Nurse (A) said, “We should have followed the orders.” Patient #2 On 11/04/2024 at 7:50 a.m. Patient #2 was observed on the treatment floor of the facility at station #9. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 700 mL/min. Review of the physician’s order dated 11/04/2024 revealed the prescribed blood flow rate of 350 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 10/23/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 350 mL/min but received hemodialysis treatment at a blood flow rate of 300 mL/min from 7:02 a.m. - 9:16 a.m. There was no justification documented for the blood flow rate of 300 mL/min. The physician’s order on the treatment sheet revealed a blood flow rate of 350 mL/min. Patient #11 Review of the patient’s clinical record (demographic data) on 11/04/2024 revealed the patient was admitted to the facility 01/08/2020. Review of the physician’s order dated 08/12/2024 revealed the prescribed blood flow rate of 350 mL/min and a dialysate flow rate of Manual 300 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 09/02/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 350mL/min but received hemodialysis treatment at a blood flow rate of 300 mL/min from 11:47 a.m. - 15:31 p.m. There was no justification documented for the blood flow rate of 300 mL/min. Review of the patient’s treatment sheet dated 09/04/2024 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 300 mL/min but received hemodialysis treatment at a dialysate flow rate of 500 mL/min from 11:59 a.m. - 13:30 p.m. There was no justification documented for the dialysate flow rate of 500 mL/min. Patient #6 On 11/05/2024 at 9:02 a.m. Patient #6 was observed on the treatment floor of the facility at station #5. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 700 mL/min. Review of the physician’s order dated 04/13/2024 revealed the prescribed blood flow rate of 350 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 10/31/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 350 mL/min but received hemodialysis treatment at a blood flow rate of 300 mL/min from 9:02 a.m. - 11:01 a.m. There was no justification documented for the blood flow rate of 300 mL/min. Patient #8 On 11/05/2024 at 9:02 a.m. Patient #8 was observed on the treatment floor of the facility at station #5. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 700 mL/min. Review of the physician’s order dated 08/12/2024 revealed the prescribed dialysate flow rate of Manual 700 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 10/24/2024 revealed documentation which indicated the patient was prescribed a dialysate flow rate of 700 mL/min but received hemodialysis treatment at a dialysate flow rate of 800 mL/min from 13:29 p.m. - 17:03 p.m. There was no justification documented for the dialysate flow rate of 800 mL/min. Patient #9 Review of the patient’s clinical record (demographic data) on 11/04/2024 revealed the patient was admitted to the facility 01/08/2020. Review of the physician’s order dated 08/12/2024 revealed the prescribed blood flow rate of 350 mL/min. Treatment sheet review: Review of the patient’s treatment sheet dated 10/29/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min but received hemodialysis treatment at a blood flow rate of 350 mL/min from 16:02 p.m. - 18:37 p.m. There was no justification documented for the blood flow rate of 350 mL/min. Interview on 11/05/2024 at 1:55 p.m. with the Facility’s Clinical Manager (E) confirmed Patient #s 2, 11, 6, 8 and 9 did not receive their hemodialysis treatments as prescribed for the dates in question.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 48020 Based on observation, record review and interview: the facility’s registered nurses failed to conduct assessments during and post hemodialysis treatment per policy on patients when patients experienced a change in condition pre or during hemodialysis treatment in 3 of 12 sampled patients: Patient #s 1, 2 and 9 B) the facility’s registered nurses failed to conduct assessments pre-hemodialysis treatment per policy on patients 1 of 12 sampled patients: Patient #6 C) the facility’s governing body failed to ensure all patients participated in quarterly fire drill in the facility per policy in 3 of 12 sampled patients: Patient #s 6, 7 and 9 Findings: Review of the facility’s current Policy and Procedure on Patient Assessment and Monitoring; Policy # 45284, published 05/01/2023 directs staff as follows: “Data Collection ... The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. Pre-Treatment Step Action/Rationale 2 During nursing rounds, the Registered Nurse will review the data collected above and assess the following parameters as needed: Data Collected Above- Review data collected above. Determined if any clinical interventions are necessary. Review the previous treatment data on the Fluid Assessment Tab. Assess patient for symptoms- The nurse should ask the patient if they have had shortness of breath, chest pain or cough, cramping, loss of appetite or vomiting or diarrhea. Lungs sounds (As indicated by patient condition) Auscultate lung sounds for: Sound: o Clear o Decreased breath sounds o Rales (crackles)Rhonchi o Wheezing Location: o Right o Left o Bilateral Edema (As indicated by patient condition) Assess the patient for edema: o Location: foot, ankle, lower leg and sacrum. o Right, Left or Bilateral o Severity (None, 1+, 2+. 3+ or - 4+) Heart sounds (As indicated by patient condition) Listen for: Rate Rhythm 3 Document findings and interventions in the medical record. Contact the physician as needed for additional orders based on assessment findings and clinical judgement. Post-Treatment 1 Lungs sounds Edema Heart sounds The registered nurse will assess/re-assess post treatment as indicated.” Review of the facility’s current Policy and Procedure on Fire Drill; published 08/02/2017 directs staff as follows: “Fire Drills o Quarterly, all FKC facilities shall perform a fire drill for each shift of patients and staff including Home Therapies patients present in the facility and Nocturnal shifts.” No Post Treatment Reassessment: Patient #1 On 11/04/2024 at 7:32 a.m. Patient #1 was observed on the treatment floor of the facility at station #3 machine #6. The patient was receiving hemodialysis treatment at a blood flow rate of 300 mL/min and dialysate flow rate of 400 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a right upper arm vascular access. Vital signs were as follows: blood pressure 150/93 mmHg and pulse 82 beats per minute. Review of the patient’s clinical record on 11/04/2024 revealed the following: Treatment sheet data: Review of treatment sheet dated 10/21/2024 revealed the following documentation: 06:24 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms: Dizziness/Lightheadedness Lungs - Decreased breath sounds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Lungs - Sound Location: Bilateral” 10:27 a.m.: registered nurse documented the post treatment assessment which revealed “Tx completed. EDW no [sic] met pt left with 1.0kg above his DW. Pt educated about fluid intake and risk. Pt discharge stable.” The registered nursed did not document a reassessment post hemodialysis treatment of dizziness/lightheadedness, decreased breath sounds in the lungs or edema found bilaterally in the lower legs during the pretreatment assessment. Review of Review of treatment sheets dated 10/23/2027 and 10/25/2024, revealed the registered nurse did not document a reassessment post hemodialysis treatment of the symptoms: dizziness/lightheadedness, decreased breath sounds in the lungs or edema found bilaterally in the lower legs during the pretreatment assessment. Patient #2 On 11/04/2024 at 7:50 a.m. Patient #2 was observed on the treatment floor of the facility at station #9 machine 13. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 700 mL/min. The patient was utilizing an Optiflux 180 non reuse dialyzer via a left lower arm vascular access. Review of the patient’s clinical record on 11/04/2024 revealed the following: Treatment sheet data: Review of treatment sheet dated 10/21/2024 revealed the following documentation: 05:45 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms: Cough, Fatigue/Weakness, Shortness of Breath Lungs - Decreased breath sounds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Lungs - Sound Location: Bilateral Edema Lower Leg - Location: Bilateral” 09:09 a.m.: registered nurse documented the post treatment assessment which revealed “Tx completed. EDW met. Pt discharge stable.” The registered nursed did not document a reassessment post hemodialysis treatment of the symptoms: cough, fatigue/weakness, shortness of breath decreased breath sounds in the lungs or edema found bilaterally in the lower legs during the pretreatment assessment. Review of treatment sheet dated 10/23/2024 revealed the following documentation: 06:12 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms: Cough Lungs - Decreased breath sounds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Lungs - Sound Location: Bilateral” 09:15 a.m.: registered nurse documented the post treatment assessment which revealed “Tx completed. Pt left with 0.6 below her DW. Pt discharge stable.” The registered nursed did not document a reassessment post hemodialysis treatment of the symptoms: cough, decreased breath sounds in the lungs or edema found bilaterally in the lower legs during the pretreatment assessment. Interview with the Registered Nurse (A) on 11/04/2024 at 2:00 p.m. confirmed the reassessments of symptoms (cough, dizziness), lung sounds, and edema were not completed post treatment. Registered Nurse (A) said, “I know I need to work on that. I sometimes put it and then I forget.” Patient #9 Review of the patient’s clinical record (demographic data) on 11/05/2024 revealed the patient was admitted to the facility 01/08/2020 with a diagnosis of end stage renal disease, history of hypertension, and tobacco use, on in-center hemodialysis three times a weekly. Review of the patient’s clinical record on 11/05/2024 revealed the following: Review of treatment sheet dated 11/02/2024 revealed the following documentation: 06:12 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms: Cough Lungs - Decreased breath sounds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Lungs - Sound Location: Bilateral” 09:15 a.m.: registered nurse documented the post treatment assessment which revealed “Tx completed. EDW no [sic] met pt left with 1.5kg above her DW. Pt educated about fluid intake and risk. Pt discharge stable.” The registered nursed did not document a reassessment post hemodialysis treatment of the symptoms: cough, decreased breath sounds in the lungs or edema found bilaterally in the lower legs during the pretreatment assessment. Review of treatment sheet dated 10/29/2024 revealed the following documentation: 15:32 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms: Lungs - Decreased breath sounds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Lungs - Sound Location: Bilateral Edema Lower Leg - Location: Bilateral” 09:15 a.m.: registered nurse documented the post treatment assessment which revealed “edw not met, pt tolerated tx and left stable.” The registered nursed did not document a reassessment post hemodialysis treatment of the decreased breath sounds in the lungs or edema found bilaterally in the lower legs during the pretreatment assessment. No Pre-Treatment Assessment: Patient #6 On 11/05/2024 at 9:02 a.m. Patient #6 was observed on the treatment floor of the facility at station #5 machine #10. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 700 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left lower arm vascular access. Review of the patient’s clinical record on 11/05/2024 revealed the following: Review of treatment sheet dated 10/31/2024 revealed the following documentation: No Pre-treatment nursing evaluation was documented. 11:36 a.m.: registered nurse documented the post treatment assessment which revealed “Tx completed. EDW no [sic] met pt left with 0.6 above her DW. Pt discharge stable.” The registered nursed did not document a pre-treatment assessment according to the facility’s policy. Interview with the Clinical Manager (E) on 11/05/2024 at 1:55 p.m. confirmed the pre-treatment assessment on Patient #6 and reassessments of symptoms lung sounds and edema on Patient #9 were not completed post treatment by the registered nurses. No Fire Drill Participation: Patient #6 On 11/05/2024 at 9:02 a.m. Patient #6 was observed on the treatment floor of the facility at station #5 machine #10. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mL/min and dialysate flow rate of 700 mL/min. The patient was utilizing an Optiflux 160 non reuse dialyzer via a left lower arm vascular access. Review of the patient’s record revealed the patient participated in the quarterly fire drill on 03/26/2024 and 06/20/2024. There was no documented fire drill participation by the patient for the third quarter of 2024. Patient #7 Review of the patient’s clinical record (demographic data) on 11/05/2024 revealed the patient was admitted to the facility 05/27/2024 with diagnosis of end stage renal disease, atherosclerotic heart disease, history of hypertension, diabetes on oral medications, and chronic obstructive pulmonary disease, on in-center hemodialysis three times weekly. Review of the patient’s record revealed the patient participated in the quarterly fire drill on 09/16/2024. There was no documented fire drill participation by the patient from 05/27/2024 - 09/16/2024. Patient #9 Review of the patient’s clinical record (demographic data) on 11/05/2024 revealed the patient was admitted to the facility 01/08/2020 with a diagnosis of end stage renal disease, history of hypertension, and tobacco use, on in-center hemodialysis three times a weekly. Review of the patient’s record revealed the patient participated in the quarterly fire drill on 03/26/2024 and 06/20/2024. There was no documented fire drill participation by the patient for the third quarter of 2024. During an interview with Clinical Manager (E) on 11/05/2024 at 1:55 p.m.: the Surveyor requested documentation of patient fire drill participation for the third quarter. Clinical Manager (E) said, “We did not complete the fire drill with all patients for the third quarter.””