Fmc Texas Avenue

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by:”

“CFC-CARE AT HOME CFR(s): 494.100 This Condition is not met as evidenced by: 48020 Based on record review and interview, facility’s governing body failed to ensure Pneumococcal vaccinations were administered to patients according to policy in 3 of 6 home therapy patients of the 12 sampled records: Patient #s 6, 9 and 8. B) Based on record review and interview, the facility’s home therapy nurses failed to ensure the patients’ home therapy treatments were administered by the patients based on physicians’ orders in 1 of 6 home therapy patients of the 12 sampled records: Patient #8 Cross reference V 581 C) Based on record review and interview, the facility interdisciplinary team failed to complete comprehensive interdisciplinary patient assessment and plan of care on patients in 4 of 6 home therapy patients of the 12 sampled records: #s 5, 7, 8 and 9 Cross reference V 591 Findings: Pneumonia Vaccination Review of Patient’s 6, 9 and 8 sampled records revealed facility’s governing body failed to ensure Pneumococcal vaccinations were administered according to policy. Interview with the Home Program Therapy Manager on 09/10/2024 at 9:30 a.m. confirmed there was no documentation that the Patient #’s 6, 8, and 9 consented or declined the pneumococcal vaccination nor documentation of the reason the patient was not administered the pneumonia vaccination in the electronic record. Prescription Verification Review of Patient 8’s sampled record revealed the facility’s home therapy nurses failed to ensure the patient’s home therapy treatments were administered by the patient based on physician’s order from June - August 2024. Interview with the Home Program Manager on 09/10/2024 at 9:49 a.m. confirmed there was no documentation by the home therapy nurses found to address the patient not running at the prescribed blood flow rates for his home hemodialysis treatments in June, July, and August 2024. Cross Reference V 581 Interdisciplinary Assessment and Plan of Care Review of the facility’s current Policy and Procedure on Comprehensive Interdisciplinary Assessment and Plan of Care, Reference #45283, published 07/03/2023 directs staff as follows: “Background The Comprehensive Interdisciplinary Assessment and Plan of Care must be completed by the interdisciplinary team members, per the frequency outlined in the Conditions for Coverage. Review of Patient’s 5, 7, 8 and 9 sampled patients comprehensive interdisciplinary assessment plan of care were not completed according to policy. Cross reference V 591”

“H-IDT RESP FOR SERVICES=IN-CENTER PTS CFR(s): 494.100 A dialysis facility that is certified to provide services to home patients must ensure through its interdisciplinary team, that home dialysis services are at least equivalent to those provided to in-facility patients and meet all applicable conditions of this part. This Standard is not met as evidenced by: 48020 Based on record review and interview, facility’s governing body failed to ensure Pneumococcal vaccinations were administered to patients according to policy in 3 of 6 home therapy patients of the 12 sampled records: Patient #s 6, 9 and 8. B) Based on record review and interview, the facility’s home therapy nurses failed to ensure the patients’ home therapy treatments were administered by the patients based on physicians’ orders in 1 of 6 home therapy patients of the 12 sampled records: Patient #8 Findings: Pneumonia: Policy Review of the facility’s current policy and procedure: Pneumococcal Vaccine for Adults: published 02/05/2024, reference number 47714, version 6 directs the staff as follows: “Policy “ The Corporate Medical Advisory Board (CMAB) Recommended Evaluation and Immunization Against Pneumococcal Infection Algorithm is recommended to assist the physician with the required vaccines based upon patient vaccination history. “ Obtain a declination statement for any patient who declines the pneumococcal vaccine. o Patients should be offered pneumococcal vaccination on an annual basis, at minimum ... “ The vaccine declination must be signed by the patient for each refusal and documented in the patient’s medical record. Recommended Pneumococcal Administration Schedule NOTE: Adults who have previously been vaccinated with Prevnar 13 (PCV13) and/or Pneumovax 23 (PPSV23) should follow the CMAB algorithm for recommended vaccine schedule. Vaccination Status: Source of Data “ Review vaccination status of all new patients to the facility. “ Review the following sources for vaccination status: o Medical records o Discharge summaries from the hospital o Correspondence from the primary care physician office o State vaccination registry o Speak with patient and/or family Documentation “ Document vaccine administration in the electronic medical record and maintain the consent or declination. o If the pneumonia vaccine is not administered, document the reason in the electronic medical record.” Pneumonia Vaccination Report Review of the Pneumonia Vaccination Report (Report Results are as of 09/08/2024) on 09/09/2024 provided by the facility revealed 9 patients (1- ICHD [new admit], 8- Home Therapies [3 unaccounted, 2 late series, 2 new admits, 1 declination in physical chart]) of with the “Next Due Date” of 09/09/2024. Governing Body Meeting Minutes Review of the governing body meeting minutes on 09/10/2024 for 02/01/2024 revealed approval of: “ Standing Orders: Pneumonia Vaccine o Pneumovax 0.5ml IM, Q 5 years X 2 doses, lifetime max. o Prevnar 0.5mL IM 8 weeks prior to Pneumovax or 1 year after. (prophylactic vaccination) PER ALGORITHM o Signed by the Medical Director and noted by Clinical Manager on 02/01/2024 “ MAB Recommended Evaluation and Immunization Against Pneumococcal Infection 3.0 algorithm Review of the governing body meeting minutes on 09/10/2024 for 08/15/2024 revealed: 07 patients were pending the PCV 20 pneumonia vaccination. The plan of care for the deficiency revealed: the Clinical Manager (CM) and Registered Nurses (RN) would educate and offer the pneumonia vaccinations to eligible patients. They would obtain the consent and administer the pneumonia vaccinations as scheduled per their attending physician. The CM would assign an RN as Vaccination Champion “to ensure compliance to vaccination policy.” Interview with the Clinical Manager on 09/10/2024 confirmed the RN Vaccination Champion resigned, there has not been a new RN Vaccination Champion assigned to the role and the plan is yet to be implemented. Prescription Verification: Review of the facility’s current Policy and Procedure on Review and Documentation of Home Therapies Patient Health Data, Reference #23557, published 05/01/2023 directs staff as follows: “Background Clinicians are responsible for completing documentation within the medical record that captures an accurate representation of the care and services provided to each patient. The information in the medical record supports the ongoing plan of care and allows the health care team to provide continuity of care to individual patients. All documentation must be completed at the time of service and be accessible to all the members of the health care team. Policy The patient will create a treatment record for every dialysis treatment according to policy and regulatory requirements. Treatment data will be reviewed by the home therapies nurse in order to identify trends, determine if patients are following their treatment plans or having problems with their dialysis at home. Review and Documentation of Health Data Electronically transmitted data will be reviewed in CareTeamHub by the home therapies nurse or appropriate staff member on a routine and ongoing basis between clinic visits. Actionable health data will be reviewed and addressed by the home therapies nurse or appropriate staff member in a timely manner. Follow up communication with the patient, including interventions or instructions as needed, will be documented in the patient’s medical record.” Pneumonia: Patient #6 Review of the patient’s clinical record on 09/09/2024 revealed the patient was admitted to the facility for peritoneal dialysis on 12/18/2023 with diagnoses of end stage renal disease, hypertension, and diabetes on insulin. Review of the patient’s medical record revealed no documentation of a physician order, standing order or algorithm assigned to the patient for pneumonia vaccination. Review of the patient’s clinical record revealed no consent/declination signed by the patient nor documented reason the patient was not administered the pneumonia vaccination in the electronic record. Patient #9 Review of the patient’s clinical record on 09/09/2024 revealed the patient was admitted to the facility for home hemodialysis on 03/04/2024 with diagnoses of end stage renal disease and multiple myeloma not having achieved remission. Review of the patient’s medical record revealed no documentation of a physician order, standing order or algorithm assigned to the patient for pneumonia vaccination. Review of the patient’s clinical record revealed no consent/declination signed by the patient nor documented reason the patient was not administered the pneumonia vaccination in the electronic record. Patient #8 Review of the patient’s clinical record on 09/10/2024 revealed the patient was admitted to the facility for in-center hemodialysis on 08/03/2022 and change modalities to home hemodialysis on 10/26/2023, with diagnoses of end stage renal disease, hypertension, and diabetes on insulin. Review of the patient’s clinical record revealed Physician’s Admit/Standing Orders for Home Hemodialysis - NxStage electronically signed by the attending physician on 11/17/2023. The document revealed a checkmark next to the standing order for Pneumococcal Vaccine (PSV 23) IM if not previously vaccinated or if prior vaccination status is unknown. Give 8 weeks after giving PCV 13. Repeat dose 1 time after 5 years and Pneumococcal Vaccine (PCV 13) IM if not previously vaccinated or if prior vaccination status is unknown. Give 8 weeks before given PSV 13. One time dose. Review of the patient’s clinical record revealed no consent/declination signed by the patient nor documented reason the patient was not administered the pneumonia vaccination in the electronic record. Review of the facilities Home Therapies - Absence and Hospitalization Record on 09/10/2024 revealed the patient was hospitalized 05/05/2024 - 05/10/2024 with viral pneumonia. Interview with the Home Program Therapy Manager on 09/10/2024 at 9:30 a.m. confirmed there was no documentation that the Patient #’s 6, 8, and 9 consented or declined the pneumococcal vaccination nor documentation of the reason the patient was not administered the pneumonia vaccination in the electronic record. Prescription Verification: Patient #8 Home Hemodialysis Orders (05/20/2024) Review of the physician’s home hemodialysis order dated 05/20/2024 revealed: Home HD using NxStage with PureFlow 4X Week, Monday, Tuesday, Thursday, Friday, Estimated Treatment Time: 3 hours 0 minutes, CAR (cartridge) 172, Therapy Fluid 2.0 K 45 Lactate, Volume per Tx 25 (liters), Max FF: 200%, BFR 400, DFR 8 L/hr, Ordered Max UFR: 8 mL/Kg/hr, EDW 9(kg), Access: AVFistula- Standard. KNX Treatment Summary: HHD (06/01/2024 - 07/01/2024) Review of the patient’s KNX Treatment Summary: HHD for 06/01/2024 - 07/01/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min but received home hemodialysis treatment at a blood flow rate average of 132-250 mL/min for the month of June. There was no justification documented for the blood flow rate average of 132-250 mL/min. Review of the Monthly Clinic Visit for Home Patients Form dated 06/27/2024 revealed the home therapy nurse circled “Y” for “All treatments completed per prescription since last visit.” The “Comments & Interventions” was left blank. KNX Treatment Summary: HHD (07/01/2024 - 07/31/2024) Review of the patient’s KNX Treatment Summary: HHD for 07/01/2024 - 07/31/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min but received home hemodialysis treatment at a blood flow rate average of 153-260 mL/min for the month of July. There was no justification documented for the blood flow rate average of 153-260 mL/min. Review of the Monthly Clinic Visit for Home Patients Form dated 07/18/2024 revealed the home therapy nurse circled “Y” for “All treatments completed per prescription since last visit.” The “Comments & Interventions” was left blank. KNX Treatment Summary: HHD (08/01/2024 - 08/31/2024) Review of the patient’s KNX Treatment Summary: HHD for 08/01/2024 - 08/31/2024 revealed documentation which indicated the patient was prescribed a blood flow rate of 400 mL/min but received home hemodialysis treatment at a blood flow rate average of 119-274 mL/min for the month of August. There was no justification documented for the blood flow rate average of 153-260 mL/min. Review of the Monthly Clinic Visit for Home Patients Form dated 08/15/2024 revealed the home therapy nurse circled “Y” for “All treatments completed per prescription since last visit.” The “Comments & Interventions” was left blank. Interview with the Home Program Manager on 09/10/2024 at 9:49 a.m. confirmed there was no documentation by the home therapy nurses found to address the patient not running at the prescribed blood flow rates for his home hemodialysis treatments in June, July, and August 2024.”

“H-HOME PT PLAN OF CARE DEV/UPDATED CFR(s): 494.100(b)(1)(iii) Services include, but are not limited to, the following: (iii) Development and periodic review of the patient’s individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs and meets the measurable and expected outcomes as specified in §494.90 of this part. This Standard is not met as evidenced by: 48020 Based on record review and interview, the facility interdisciplinary team failed to complete comprehensive interdisciplinary patient assessment and plan of care on patients per policy in 4 of 6 home therapy patients of the 12 sampled records: #s 5, 7, 8 and 9 Findings Review of the facility’s current Policy and Procedure on Comprehensive Interdisciplinary Assessment and Plan of Care, Reference #45283, published 07/03/2023 directs staff as follows: “Background The Comprehensive Interdisciplinary Assessment and Plan of Care must be completed by the interdisciplinary team members, per the frequency outlined in the Conditions for Coverage. Review of the facility’s current Policy and Procedure on Review and Documentation of Home Therapies Patient Health Data, Reference #23557, published 05/01/2023 directs staff as follows: “Background Clinicians are responsible for completing documentation within the medical record that captures an accurate representation of the care and services provided to each patient. The information in the medical record supports the ongoing plan of care and allows the health care team to provide continuity of care to individual patients. All documentation must be completed at the time of service and be accessible to all the members of the health care team. Policy Review and Documentation of Health Data Electronically transmitted data will be reviewed in CareTeamHub by the home therapies nurse or appropriate staff member on a routine and ongoing basis between clinic visits. Actionable health data will be reviewed and addressed by the home therapies nurse or appropriate staff member in a timely manner. Follow up communication with the patient, including interventions or instructions as needed, will be documented in the patient’s medical record.” Patient #5 Review of Patient #5’s clinical record on 09/09/2024 revealed the patient was admitted to the facility for peritoneal dialysis on 06/07/2021 with diagnoses of end stage renal disease, hypertension, amputation, diabetes on insulin, diabetic retinopathy and tobacco use. Review of the patient’s clinical record revealed following nurse progress notes documented by the home therapies nurse: 08/01/2024- Spectra call about a potassium lab alert- 2.7. Pt has a history of hypokalemia ... 08/06/2024- ...patient went to the ER because of severe headaches. The patient’s blood pressure was elevated post treatment- 187/89. 08/12/2024- on 08/11/2024 the patient’s blood sugar was 400 and the blood pressure was elevated. The patient’s daughter notified the nurse that the patient had COVID, and the patient’s heart issues caused the hospital admission. 08/13/2024- patient had a fever of 102.9 08/14/2024- patient’s temp is up to 103.7; pt was taken to ER 08/15/2024- pt was hospitalized for COVID/pneumonia 08/23/24- WBC lab was elevated- 12.5. Patient was hospitalized (8/14-8/18) for covid, pneumonia, sepsis, and other chronic problems. Review of the patient’s clinical record revealed the most current interdisciplinary comprehensive assessment was dated 07/26/2023 and the next POC meeting was due 07/25/2024. Patient #7 Review of Patient #7’s clinical record on 09/09/2024 revealed the patient was admitted to the facility for peritoneal dialysis on 07/15/2024 with diagnoses of end stage renal disease, hypertension, amputation, diabetes on insulin, diabetic retinopathy and tobacco use. Review of the patient’s clinical record revealed the patient had a clinic visit on 08/12/2024 and home therapies nurse documented the patient’s peritoneal catheter exit site had redness and the patient complained of dizziness and fatigue. Review of the patient’s KNX Treatment Summary: PD for August 2024 revealed the patient documented a blood pressure 151/104 and a pulse 119 on 08/31/2024. Review of the patient’s clinical record revealed no documentation by the home therapies nurse of the communication with the patient, including interventions or instructions for the elevated blood pressure and heart rate. Review of the patient’s clinical record revealed no documentation of an interdisciplinary comprehensive assessment. Interview with Home Program Manager on 09/10/2024 at 11:38 a.m. confirmed there was no documented communication with the patient, interventions or instructions on the elevated blood pressure and heart rate on 08/31/2024. There was no plan of care completed on the patient. Patient #8 Review of the Patient #8’s clinical record on 09/10/2024 revealed the patient was admitted to the facility for in-center hemodialysis on 08/03/2022 and change modalities to home hemodialysis on 10/26/2023, with a diagnoses of end stage renal disease, hypertension, and diabetes on insulin. Review of the patient’s clinical record revealed the most current interdisciplinary comprehensive assessment was dated 07/27/2023 and the next POC meeting was due 07/26/2024. Patient #9 Review of the Patient #9’s clinical record on 09/10/2024 revealed the patient was admitted to the facility for home hemodialysis on 03/04/2024 with diagnoses of end stage renal disease and multiple myeloma not having achieved remission. Review with the physician progress note dated 08/19/2024 revealed the following comments: PMHx of plasma cell leukemia, hyperlipidemia, and heart failure with reduced ejection fraction ... Recent hospitalized for C diff and E. coli bacteremia, received po Vanc, flagyl and abx ... Came to incenter HD today as still pending setting home hemo at her new residence.” Review of the patient’s clinical record revealed the patient visited the ER on 07/27/2024 and the patient’s labs showed leukocytosis, hypokalemia, and stool for C. diff. Review of the patient’s clinical record revealed no laboratory results for the month of August 2024. Interview with the Home Program Manager on 09/10/2024 revealed there were no laboratory results due to the patient receiving 2 backup treatments in ICHD, then the patient was hospitalized and came back for 2 more backup treatments in ICHD. The Home Program Manager stated, “The labs were missed.” The Home Program Manager confirmed that there was no coordination between the home program and ICHD to draw the patient’s monthly laboratory specimens for the month of August. Review of the patient’s clinical record revealed no documentation of an interdisciplinary comprehensive assessment. Interview with the Home Program Manager on 09/10/2024 at 11:40 a.m. confirmed the Comprehensive Interdisciplinary Assessment and Plan of Care for Patient #’s 5, 7, 8 and 9 were not completed according to policy.”

“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 wash/sanitize hands after cleaning the dialysis station and failed to encourage patients to remove gloves and wash/sanitize hands after holding vascular access site post hemodialysis treatment in 1 of 4 staff observed: Patient Care Technician (B) and Patient #’s 4 and 5 Findings: Review of the facility’s current policy and procedure: Hand Hygiene: published 11/06/2023, reference number 47664, version 8 directs the staff as follows: “Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water “ Entering and leaving the treatment area ... “ Immediately after removing gloves ... “ After contact with the dialysis wall box, concentrate, drain or water lines, “ 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.” Patient Care Technician (B) Observation on 11/27/2023 at 10:00 a.m. revealed Patient Care Technician (B) cleaning the chair at station #3. Patient Care Technician (B) walked over to throw the bleach towels in the biohazard container, removed the contaminated gloves, grabbed clean gloves from the glove box, donned the gloves and continued to clean station #3 without washing/sanitizing her hands. Subsequent observation at 1:09 p.m., revealed Patient Care Technician (B) cleaning the hemodialysis machine at station #2. Patient Care Technician (B) walked over to throw the bleach towels in the biohazard container, removed the contaminated gloves, grabbed clean gloves from the glove box, donned the gloves and continued to clean station #2 without washing/sanitizing her hands. On 11/27/2023 at 1:10 p.m., the Surveyor notified Patient Care Technician (B) that she did not wash/sanitize her hands after glove removal. Patient Care Technician (B) said, “Sometimes I miss doing it when I get busy.” Patient #4 Observation on 11/27/2023 at 10:58 a.m., revealed Patient #4 holding his vascular access with a gloved hand at station #4. After the bleeding ceased, Patient Care Technician (B) taped the patient’s vascular access site. The patient removed the contaminated glove, left station #4 and touched the button at the weigh station. After being weighed by Patient Care Technician (B), the patient returned to station #4, picked up his belongings and left the unit without being encouraged to clean/sanitize hands after holding his vascular access. Patient #5 Observation on 11/27/2023 at 12:38 p.m., revealed Patient #5 holding his vascular access with a gloved hand at station #2. After the bleeding ceased, Patient Care Technician (B) taped the patient’s vascular access site. The patient removed the contaminated glove, left station #2 and was weighed by Patient Care Technician (B). The patient returned to station #2, picked up his belongings and left the unit without being encouraged to clean/sanitize hands after holding his vascular access. On 11/27/2023 at 12:55 p.m., the Surveyor notified Patient Care Technician (B) patients #4 and #5 did not wash/sanitize their hands after glove removal. Patient Care Technician (B) said, “okay.””

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, facility’s direct care staff failed to clean/sanitize contaminated prime bucket, Hansen connectors, stethoscope, laminates, hoses, chase, and water box during terminal cleaning of the hemodialysis unit and failed to clean and disinfect stethoscope in between assessment of patients in 4 of 5 staff observed. Patient Care Technician (D), (C), (B) and Registered Nurse (A) Findings: Review of the facility’s current policy and procedure on Cleaning and Disinfecting the Dialysis Station; policy # 47806, revised 09/05/2023 directed staff as follows: “Purpose: “The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations and to maintain a clean, safe and aesthetically pleasant environment for patients, staff and visitors.” Definition: Dialysis Station: “Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment, patient training, and /or patient clinic visits. Equipment in the dialysis station may include (but is not limited to) the following: Dialysis machine / cycler and attachments such as IV pole, BP cuff and hand sanitizer holder, organizer Chair/bed PureFlow SL Individual television and remote Dialysis Wall Box: a box designed to connect central distribution systems to a hemodialysis machine that is in the chase wall behind the machine.” “General Cleaning: The dialysis station become contaminated with blood and other body fluids during treatment. After use, any non-disposable equipment and supplies brought into the dialysis station (ex. Stethoscope) must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station.” Station 9 Hemodialysis machine #2 On 11/27/2023 at 10:15 a.m. Patient Care Technician (D) was observed terminally cleaning station 9, hemodialysis machine #2 Observation revealed during terminally cleaning of the hemodialysis unit, post hemodialysis treatment of a patient, Patient Care Technician (D) did not clean/ sanitize the contaminated prime bucket, Hansen connectors, chase, stethoscope, laminate hanging on the intravenous pole, water hoses, water box. A roll of tape from the previous patient’s hemodialysis treatment remained on the contaminated chase after terminally cleaning of the unit. Observation on 11/27/2023 at 10:20 a.m. Patient Care Technician (D) was observed setting up clean external blood lines and dialyzer and priming the external blood line and dialyzer with Normal Saline into the contaminated prime bucket, in preparation for an on coming patient. Patient #2 was then weighed and proceeded to the station for hemodialysis treatment. The Surveyor asked the patient to kindly wait into the lobby until the station was ready for him. Station 12 Machine #14 On 11/27/2023 at 10:30 a.m. Patient Care Technician (D) was observed terminally cleaning station 12. Observation revealed during terminally cleaning of the hemodialysis unit, post hemodialysis treatment of the patient, Patient Care Technician (D) did not clean/ sanitize the contaminated prime bucket, Hansen connectors, chase, stethoscope, laminate hanging on the intravenous pole, water hoses, water box. On 11/27/2023 at 10:35 a.m. the Surveyor notified Patient Care Technician (D) that she did not clean/ sanitize the contaminated prime bucket, Hansen connectors, chase, stethoscope, laminate hanging on the intravenous pole, water hoses, water box. Patient Care Technician (D) said “Yes ma’am I am sorry. “ On 11/27/2023 at 12:03 p.m. Registered Nurse (A) was observed in hemodialysis station #13. The registered nurse was conducting pre- treatment assessment on the patient. Observation revealed the registered nurse used her personal stethoscope to examine Patient #3’s chest and back. After examining the patient, Registered Nurse (A) placed the contaminated stethoscope around her neck and left the room. Registered Nurse (A) did not clean/ disinfect the contaminated stethoscope used to examine the patient. On 11/27/2023 at 12:08 p.m. Registered Nurse (A) was observed at hemodialysis station #3. The registered nurse was conducting pre- treatment assessment on the Random Patient #8. Observation revealed the registered nurse used her personal contaminated stethoscope which she had used to examine Patient #3 to conduct assessment on Patient #8. The Registered Nurse did not clean/ disinfect the stethoscope in between patient use. After assessing patient #8 with the contaminated stethoscope, Registered Nurse (A) proceeded to Random Patient #9. Registered Nurse (A) examined the chest and back of Random Patient #9 with her contaminated stethoscope. After examination of the patient Registered Nurse squirted alcohol hand sanitizer in the palm of her hand and wiped the bell of her personal stethoscope. During an interview on 11/27/2023 at 12:30 p.m. with Registered Nurse (A), the Surveyor informed the Registered Nurse that she did not clean and disinfect the stethoscope in between patients and that she was observed using alcohol gel in the palm of her hand to wipe the bell of the stethoscope after the third patient examination. Registered Nurse (A) said “I did not know the entire stethoscope had to be cleaned and disinfected.” 48020 Patient Care Technician (C) Station #5 Observation on 11/27/2023 at 11:13 a.m. revealed Patient Care Technician (C) terminally cleaning station #5 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #9 at station #5, Patient Care Technician (C) failed to clean the dialysate lines, wall box and chase wall behind the machine. During an interview at 10:59 a.m., the Surveyor notified Patient Care Technician (C) that the dialysate lines, wall boxes and chase wall behind the machine were not cleaned during station disinfection. Patient Care Technician (C) said, “I’ll clean it.” Patient Care Technician (B) Station #4 Observation on 11/27/2023 at 9:23 a.m. revealed Patient #4 receiving hemodialysis treatment at station #4, machine #10. The patient’s jacket was lying on the countertop behind his chair. Subsequent observation at 11:27 a.m. revealed Patient Care Technician (B) terminally cleaning station #4 post hemodialysis treatment of the patient. During terminal cleaning of the hemodialysis machine #10 at station #4, Patient Care Technician (B) failed to clean the chase wall countertop behind the machine where the patient laid his jacket during hemodialysis treatment. Station #2 Observation on 11/27/2023 at 9:26 a.m. revealed Patient #5 receiving hemodialysis treatment at station #2, machine #6. The patient’s jacket was lying on the countertop behind his chair. Subsequent observation at 1:09 p.m. revealed Patient Care Technician (B) terminally cleaning station #2 post hemodialysis treatment of the patient. During terminal cleaning of the hemodialysis machine #6 at station #2, Patient Care Technician (B) failed to clean the chase wall countertop behind the machine where the patient laid his jacket during hemodialysis treatment. During an interview at 1:20 p.m., the Surveyor notified Patient Care Technician (B) that the countertops behind the station were not cleaned during station disinfection. Patient Care Technician (B) said, “I thought the cleaning people cleaned it.””

“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, facility’s registered nurses failed to ensure patients’ hemodialysis physician prescriptions were followed during administration of hemodialysis treatment in 2 of 10 sampled and closed patients observed and patients’ clinical records reviewed; Patient #’s 7 and 10 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. On 11/28/2023 at 8:42 a.m. Patient # 7 was observed on the treatment floor of the facility at station #9, hemodialysis machine #2. The patient was receiving hemodialysis treatment at a blood flow of 350 mls/ minute and dialysate flow rate of 800 mls/ minute via a right upper arm vascular access. The patient was utilizing a dialysate solution of 2 mEq potassium and 2.5 mEq calcium for her hemodialysis treatment. The patient was observed receiving oxygen at 2 liters/minute via nasal cannula. The Surveyor requested Patient Care Technician (B) open the panel on the patient’s hemodialysis machine to verify the setting on the hemodialysis machine with the patient’s prescription. Observation of the setting of the hemodialysis machine, revealed the hemodialysis machine was set to mix and deliver potassium 2.9 mEq, and calcium 2.5 mEq. Review of the patient’s prescription located in the computer attached to the hemodialysis machine, revealed a physician’s order dated 08/01/2023 for of 2 mEq potassium and Calcium 2.5 mEq. Review of the patient’s treatment sheet revealed the patient’s hemodialysis was initiated at 6:30 a.m. by the patient care technician assigned to the patient. The Surveyor immediately notified RN (A) that the patient’s hemodialysis machine was not set to mix and deliver the physician’s prescription of 2 mEq and Calcium 2.5 mEq, but the hemodialysis machine is set to deliver 2.9 mEq and Calcium 2.5. Registered Nurse (A) said she is not assigned to the patient and did not validate the prescription. She said the Facility’s Charge Nurse who is on break was responsible for validation of the patient’s prescription. On 11/28/2023 at 9:10 a.m. The Surveyor reviewed the prescription and the setting on the hemodialysis machine of the patient with Registered Nurse Charge Nurse (H). Registered Nurse (H) said she had validated the prescription. 48020 Patient #10 Review of the patient’s clinical record (demographic data) on 11/27/2023 revealed the patient was admitted to the facility 04/19/2019. Review of the physician’s order dated 06/09/2023 revealed the prescribed blood flow rate of 350 mL/min. Treatment sheet dated 06/12/2023 Review of the patient’s treatment sheet dated 06/12/2023 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 400 mL/min from 12:03 p.m. - 15:53 p.m. There was no justification documented for the blood flow rate of 400 mL/min. Treatment sheet dated 06/14/2023 Review of the patient’s treatment sheet dated 06/14/2023 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 400 mL/min from 12:03 p.m. - 15:40 p.m. There was no justification documented for the blood flow rate of 400 mL/min. Interview on 11/28/2023 at 12:25 p.m. with Patient Care Technician (B), the Surveyor informed her that the patient was not administered the blood flow rate prescribed by the physician. Patient Care Technician (B) said, “I am unsure why it was moved up. I just signed off on what was on the machine.””

“POC-OUTCOME NOT ACHIEVED-ADJUST POC CFR(s): 494.90(b)(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient’s current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, the facility’s interdisciplinary team failed to update patient’s interdisciplinary comprehensive care plan to reflect a patient’s surgical intervention at the hospital and plan of care to address post operatively needs in 1 of 10 sampled patients. Patient #3. Findings: On 11/27/2023 at 12:34 p.m. Patient #3 was observed in station #13. The patient was receiving hemodialysis treatment, at a blood flow rate of 400 mls/ minute and dialysate flow rate of 800 mls/ minute via an arterio venous fistula. Review on 11/28/2023 of Patient #3’s clinical record (Physician’s history and Physical) revealed the following documentation.: “ESRD Polycystic kidney disease. 8/23/2023 s/p nephrectomies on 08/23/2023 with lysis of liver lesion to kidneys. The bowel was also adherent to the left kidney.” Review of Patient #3’s hospital encounter notes dated 08/23/2023 - 08/31/2023 revealed the following findings: “The patient is a 49 -year-old female patient with ESRD secondary to autosomal polycystic kidney disease. She has been on dialysis since 2018. Changed to hemodialysis in 2022. She is symptomatic from her kidneys, discomfort difficulty breathing, shortness of breath when lying down and early satiety. She underwent a Roux- en- Y gastric bypass and has lost approximately 60 pounds. She is here for definitive management and removal of her polycystic kidneys.” The record revealed during the procedure, “The liver was adherent to the kidney, we had to perform a lysis of the adhesions of the liver to the kidney. “ “The gonadal vein was stuck to the kidney.” “This case did take 30% more time and effort due to large autosomal kidneys. It was very difficult to lift and the plane between the kidneys and the bowel was adherent, especially on the left side. “ The record revealed the patient had sutures and a 19 French JP drain left in place. Review of the patient’s laboratory values post surgical intervention revealed the following findings: September 2023: Albumin 3.2 and 3.3. Range above 4. 10/25/2023: hemoglobin 8.9 g/dl. Range: above 10 g/dl 11/01/2023: hemoglobin 8.7 g/ dl 11/15/2023: hemoglobin 9.3 g/dl Review of the Patient’s clinical record revealed the most current interdisciplinary plan of care was dated 12/01/2022. It was not updated to reflect the surgical intervention done at the hospital on the patient. Documentation on the plan of care revealed the patient’s last admission to hospital was 4/12/2022. There was no interdisciplinary care plan to address the patient having sutures and a 19 French JP drain left in place post-surgical intervention with the potential for infection and pain. Interview on 11/28/2023 at 9:30 a.m. with the Facility’s Manager, the Surveyor requested an updated interdisciplinary plan of care. She said there was no current updated interdisciplinary plan of care but a meeting was scheduled for December to review the patient’s interdisciplinary plan of care.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 48020 Based on observation, interview and record review facility’s Registered nurses failed to conduct post treatment assessment on patients when patients present with unusual findings during pre-treatment assessment and when patients experienced a change in condition during hemodialysis treatment in 6 of 10 sampled and closed patients #s 4, 5, 10, 7, 1 and 2 Findings: Texas Board of Nursing RN Scope of practice. Rule 15.28. Assessment The comprehensive assessment is the first step, and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis and interpretation of data. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence- based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed. Patient Diagnosis/Problem Identification/Planning The second step in the nursing process is analyzing data gathered during the assessment and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary health care team, as appropriate for their educational background and scope. The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, participate in the patient diagnoses, and to formulate goals, teaching plans and outcomes. A nursing plan of care for patients is developed by the RN, who has the overall responsibility to coordinate nursing care for patients. Teaching plans address health promotion, maintenance, restoration, and prevention of risk factors. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary health care team during the planning process. Implementation Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate certain nursing tasks within the plan of care for patients within legal, ethical, and regulatory parameters and in consideration of health restoration, disease prevention, patient independence, wellness, and promotion of healthy lifestyles. The RN ’ s duty to patient safety when making assignments to other nurses or when delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN scope of practice may include the supervision of LVNs or other RNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual ’ s performance and activity. 5 The RN may have to directly observe and evaluate the nursing care provided depending on the LVN ’ s skills and competence, patient conditions, and level of urgency in emergent situations. The RN may determine when it is appropriate to delegate tasks to unlicensed personnel and maintains accountability for how the unlicensed personnel perform the tasks. The RN is responsible for supervising the unlicensed personnel when tasks are delegated. The proximity of supervision is dependent upon patient conditions and skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process. Evaluation and Re-assessment A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings, and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary. Review of the facility’s current Policy and Procedure on Patient Assessment and Monitoring; Policy # 45284, published 05/01/2023 directs staff as follows: “Lung sounds, edema, heart sounds. The registered nurse will assess/ reassess post treatment as indicated” Patient #4 On 11/27/2023 at 09:23 a.m., Patient #4 was seated at station #4 receiving hemodialysis via a left upper arm vascular access. Review of the patient’s clinical record (treatment sheet) revealed the following documentation: Treatment sheet dated 11/21/2023: Review of the patient’s clinical record (treatment sheet) dated 11/21/2023 revealed the following documentation: 06:59 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms None Lungs - Clear Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: None Lungs - Sound Location: Bilateral Edema Ankle - Location: Bilateral” 11:21 a.m.: registered nurse documented the post treatment assessment which revealed “pt d/c stable; ambulatory to home, aox3, v/s wnl, tx well tolerated, edw met, +t/b avf, hemostasis achieved.” The edema reassessment was not documented. Treatment sheet dated 11/13/2023: Review of the patient’s clinical record (treatment sheet) dated 11/13/2023 revealed the following documentation: 07:15 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms None Lungs - Clear Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: None Lungs - Sound Location: Bilateral Edema Ankle - Location: Bilateral” 11:13 a.m.: registered nurse documented the post treatment assessment which revealed “pt d/c stable; ambulatory to home, aox3, v/s wnl, tx well tolerated, edw met, +t/b avf, hemostasis achieved.” The edema reassessment was not documented. Patient #5 On 11/27/2023 at 09:26 a.m., Patient #5 was seated at station #2 receiving hemodialysis via a left upper arm vascular access. Review of the patient’s clinical record (treatment sheet) revealed the following documentation: Treatment sheet dated 11/14/2023: Review of the patient’s clinical record (treatment sheet) dated 11/14/2023 revealed the following documentation: 07:00 a.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms None Lungs - Decreased breath sounds Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: None Edema Ankle - Location: Bilateral Lungs - Sound Location: Bilateral” 10:42 a.m.: registered nurse documented the post treatment assessment which revealed “pt d/c stable; ambulatory to home, aox3, v/s wnl, tx well tolerated, edw met, +t/b avf, hemostasis achieved. Pt reminded about the importance fluid/na+/k+ diet restriction; fluid mgmt. and its importance; pt voiced understanding.” The lungs and edema reassessments were not documented. Patient #10 Review of the patient’s clinical record (demographic data) on 11/27/2023 revealed the patient was admitted to the facility 04/19/2019. Treatment sheet dated 06/19/2023: Review of the patient’s clinical record (treatment sheet) dated 06/19/2023 revealed the following documentation: 08:29 a.m.: registered nurse documented the pretreatment assessment which revealed “Calm, Content, Pleasant; Oriented to person, Oriented to place, Oriented to time; Ambulates with walker Symptoms: None Lungs - Clear Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Lungs - Sound Location: Bilateral Edema Ankle - Location: Bilateral Pulse - Rhythm: Regular” 15:31 p.m.: registered nurse did not document the post treatment assessment Treatment sheet dated 06/14/2023: Review of the patient’s clinical record (treatment sheet) dated 06/14/2023 revealed the following documentation: 12:45 p.m.: registered nurse documented the pretreatment assessment which revealed, “RN Evaluation - No Unusual findings noted Symptoms None Lungs - Clear Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Lungs - Sound Location: Bilateral Edema Ankle - Location: Left Edema Lower Leg - Location: Left” 15:40 p.m.: registered nurse documented the post treatment assessment which revealed “pt discharged stable, v/s wnl, pt voiced no complaints, tx well treated.” The edema reassessment was not documented. Treatment sheet dated 06/12/2023: Review of the patient’s clinical record (treatment sheet) dated 06/12/2023 revealed the following documentation: 12:00 p.m.: registered nurse documented the pretreatment assessment which revealed “Symptoms None Lungs - Clear Ankle - Severity: 1+: 2 mm or less, disappears rapidly Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Lungs - Sound Location: Bilateral Edema Ankle - Location: Bilateral” 15:55 p.m.: registered nurse documented the post treatment assessment which revealed “pt discharged stable, v/s wnl, tx well treated.” The edema reassessment was not documented. Treatment sheet dated 06/09/2023: Review of the patient’s clinical record (treatment sheet) dated 06/09/2023 revealed the following documentation: 12:15 p.m.: registered nurse documented the pretreatment assessment which revealed, “Patient stable on admit, no complaints voiced on admit, patient gained 0.3, aw 2.9, goal 3.0, ble and facial edema noted, lung sounds decreased bll, orders reviewed and verified, edu reinforced on fluids/low na+ diet/low bp/risk Symptoms None Lungs - Decreased breath sounds Lower Leg - Severity: 1+: 2 mm or less, disappears rapidly Ankle - Severity: 1+: 2 mm or less, disappears rapidly Edema Lower Leg - Location: Bilateral Edema Ankle - Location: Bilateral Lungs - Sound Location: Bilateral” 15:59 p.m.: registered nurse documented the post treatment assessment which revealed “Patient stable on dc, tolerated tx well, goal met, no edema noted, patient edu reinforced on fluids/low na+ diet risks.” The lungs reassessment was not documented. Interview on 11/28/2023 at 1:55 p.m. with Clinical Manager (E), the surveyor notified her of the edema and lung reassessments not being documented post treatment. Clinical Manager (E) said, “That’s a problem, we need to document the change. I will educate on this.” 10802 Patient # 7 On 11/28/2023 at 8:42 a.m. Patient # 7 was observed on the treatment floor of the facility at station #9, hemodialysis machine #2. The patient was receiving hemodialysis treatment at a blood flow of 350 mls/ minute and dialysate flow rate of 800 mls/ minute via a right upper arm vascular access. The patient was utilizing a dialysate solution of 2 mEq potassium and 2.5 mEq calcium for her hemodialysis treatment. The patient was observed receiving oxygen at 2 liters/minute via nasal cannula. Review of the patient’s treatment sheet for the following dates revealed a pre-treatment assessment by registered nurses which indicated the patient has dyspnea on exertion, fatigue/weakness, decreased breath sounds and edema of lower legs bilateral. Treatment sheet dated 11/22/2023 11/22/2023: Review of the patient’s treatment sheet dated 11/22/2023 revealed the following findings: Patient has “dyspnea on exertion, fatigue/ weakness, decreased breath sounds and edema of lower legs bilateral.” The registered nurse documented: new complaint or observation since last treatment (including fall or injury): “AW.4.4 kgs; Uf goal set 4L max tolerance by Pt. Pt educated about the importance fluid diet restriction, fluid overload and the effects to heart. Pt stated understanding.” Review of the patient’s clinical record (nurses’ notes) revealed a physician’s order dated 8/02/2023 for oxygen via nasal cannula 2 LPM for shortness of breath. There was no indication documented that the patient’s symptom of dyspnea required or did not require the use of PRN oxygen that was ordered by the patient’s nephrologist. Review of the patient’s clinical record (treatment sheet) revealed the following post treatment assessment by the registered nurse “Pt d/c stable, ambulatory to home, aox3. Vs wnl, tx well tolerated. EDW met + t/b aVF. Homeostasis achieved.” Review of the patient’s treatment sheet revealed no assessment by the registered nurse addressing the pre- treatment symptoms of dyspnea on exertion, decreased breath sounds, lower leg and edema of lower legs bilateral. Treatment sheet dated 11/16/2023 11/16/2023: Review of the patient’s treatment dated 11/16/2023 sheet revealed the following findings documented by the registered nurse: Patient has “decreased breath sounds and edema of lower legs and ankle bilateral, 1+ 2 mm or less, which disappears rapidly.” The registered nurse documented: new complaint or observation since last treatment (including fall or injury): “AW.3.3 kgs; Uf goal set @4L max tolerance by Pt. Pt educated about the importance fluid/ na+ diet restriction, fluid overload and its effects to heart. Pt stated understanding.” Review of the patient’s treatment sheet revealed the following assessment by the registered nurse “Pt d/c stable, ambulatory to home, aoX3. Vs wnl, tx well tolerated. EDW met + t/b aVF, hemostasis achieved.” Review of the treatment sheet of post treatment documentation revealed no assessment by the registered nurse addressing the pre- treatment symptoms of decreased breath sounds, lower leg and edema of lower legs bilateral. Patient #1 On 11/27/ 2023 at 9:15 a.m. Patient #1 was observed on the treatment floor of the facility at station # 9 hemodialysis machine #2. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 600 mls/ minute via a right upper arm vascular access. The patient’ blood pressure reading on the hemodialysis machine was 213/ 90. The Nephrologist was present on the unit and evaluated the patient. Review of the patient’s treatment sheet revealed a documented pre- treatment blood pressure of 123/63 sitting and 113/65 standing and pulse of 70 beats per minute. Treatment sheet dated 11/20/2023 Review of the patient’s treatment sheet dated 11/20/2023 revealed the patient’s hemodialysis treatment was initiated by the patient care technician assigned to the patient at 06:37 a.m. with documented vital sign of blood pressure 109/62 and pulse of 64 beats per minute. Review of the patient’s treatment sheet revealed documentation that a pre- treatment assessment was done by the registered nurse at 07:13 a.m. 07:35 a.m.: Patient’s documented blood pressure 95/53, pulse 60 beats per minute. The patient care technician assigned to the patient documented “UF off patient alert.” 08:07 a.m.: Patient’s documented blood pressure 95/51, pulse 59 beats per minute. The Patient Care Technician assigned to the patient documented “UF off; pt bp is still low, uf remains off.” 08:31 a.m.: Patient’s documented blood pressure 95/50, pulse 59 beats per minute. The patient care technician assigned to the patient documented “pt bp is still low, uf remains off.” 09:06 a.m.: Patient’s documented blood pressure 102/65, pulse 77 beats per minute. 09:36 a.m.: Patient’s documented blood pressure 123/66, pulse 63 beats per minute. Patient’s hemodialysis treatment discontinued by the patient care technician assigned to the patient. Review of the patient’s treatment sheet revealed no intradialytic or post treatment assessment by the registered nurse although the patient experienced low blood pressure intradialytic. Patient #2 Review of the patient’s treatment sheet for the following dates revealed pre-treatment assessment by registered nurses which indicated the patient has, decreased breath sounds and edema of lower ankle bilateral 1: 2 mm or less disappears rapidly. Treatment sheet dated 11/19/2023 11/19/2023: review of the patient’s treatment sheet dated 11/19/2023 revealed the registered nurse conducted a pre- treatment assessment on the patient at 10:32 a.m. The pre-treatment assessment by registered nurse indicated the patient has, decreased breath sounds and edema of lower leg and ankle bilateral 1: 2 mm or less disappears rapidly. Review of the patient’s treatment sheet dated 11/19/2023 revealed the patient’s hemodialysis treatment was initiated by the patient care technician assigned to the patient at 10:32 a.m. with documented vital signs of blood pressure 121/65 and pulse of 59 beats per minute. 13:46 p.m.: The registered nurse documented “UF off; Patient alert, cramping in left shin.” Documented blood pressure 91/58, pulse 60 beats per minute. 15:02 p.m.: the patient’s hemodialysis treatment was discontinued by the patient care technician assigned to the patient. Review of the patient’s treatment sheet revealed no documented post treatment assessment by the registered nurse, although the patient experienced cramping during hemodialysis treatment and his pre- treatment assessment indicated the patient had decreased breath sounds and edema of lower ankle bilateral 1: 2 mm or less disappears rapidly. Documentation on the treatment sheet indicated the patient was discharged to home by the patient care technician assigned to the patient. Treatment sheet dated 11/13/2023 11/13/2023: Review of the patient’s treatment sheet dated 11/13/2023 revealed the registered nurse conducted a pre- treatment assessment on the patient at 10:45 a.m. Pre-treatment assessment by registered nurse indicated the patient has, d”decreased breath sounds and edema of lower leg and ankle bilateral 1: 2 mm or less disappears rapidly.” Review of the patient’s clinical record (treatment sheet) revealed the following post treatment assessment by the registered nurse “pt d/c stable, ambulatory to home, aox3. v/s wnl, tx well tolerated, edw met, +t/b hemostasis achieved. “ Review of the record revealed no assessment by the registered nurse addressing the pre- treatment findings of decreased breath sounds and edema of lower leg and ankle bilateral 1: 2 mm or less disappears rapidly.”