Davita Williamsburg Dialysis

“CFC-PATIENTS- RIGHTS CFR(s): 494.70 This Condition is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to provide informed consent to treat for home dialysis services in a long term care (LTC) facility for three (3) of twelve (12) Patients, (P # 4, # 5 and # 6). After consultation with the State Agency and CMS, and based on document reviews, the surveyor identified and notified the facility staff on October 2, 2024, at 3:10 PM. of the finding of Immediate Jeopardy (IJ). The serious concerns regarding unsigned consents for treatment by Patients or Patient’s responsible party presenting Patient’s rights concerns were discussed with the facility leadership and an immediate plan of removal was requested. On October 3, 2024, at 12:30 PM, the facility presented an acceptable plan of removal. In summary, the plan of removal included a one hundred percent (100%) full review of all twelve (12) Patient consents. Any Patient identified without a completed informed consent will have one completed prior to Patient’s next treatment. On October 3, 2024, at 1:00 PM, after reviewing documentation and consultation with the State Agency and CMS, the surveyor notified the facility of the removal of the Immediate Jeopardy, however condition level noncompliance remained. Please refer to Tag # 451 and 456 for further information.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 34452 Based on observations, document review and interview, it was determined that the facility failed to maintain a sanitary environment in the treatment area by having dirty and clean items on top of the reverse osmosis (RO) system for five (5) of six (6) stations (# 1, # 2, # 3, # 4 and # 6), and failed to maintain clean areas for one (1) of one (1) rolling computer cart. The findings include: On October 2, 2024 between 8:30 AM and 10:30 AM, the following were observed during initiation and termination of treatments in the dialysis treatment area: At 8:55 AM during the initial tour of the dialysis treatment area, water test strips were observed on top of the RO at the dialysis station for stations # 1, # 2, # 3, # 4 and # 6. Also on top of each RO was hand sanitizer and gloves. At 8:58 AM, a conversation with Staff Member (SM) # 5 revealed the top of the RO is considered a “clean” area. SM # 5 indicated the water test strips are “dirty” and should not be placed with “clean” supplies. At 9:55 AM, SM # 9 was observed resting arm while wearing gown on a top of the RO where clean supplies (gloves and hand sanitizer) are kept. At 10:00 AM, SM # 8 was observed placing a “dirty” cup on the rolling computer cart. SM # 8 failed to clean the area. At 2:00 PM, a review of the facility policy titled “Infection Control for Dialysis Facilities” reads in part “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.””

“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: 34452 Based on observations, document review and interview, it was determined that the facility failed to ensure staff wear gloves when touching patient equipment at the dialysis station for one (1) of two (2) Staff Members (SM) (SM # 8), and failed to ensure staff perform hand hygiene correctly for two (2) of two (2) SM (SM # 8 and # 9). The findings include: On October 2, 2024 between 8:30 AM and 10:30 AM, the following were observed during initiation and termination of treatments in the dialysis treatment area: At 9:36 AM, SM # 8 was observed at Station # 1 donning one glove on one hand to adjust the machine. At 9:40 AM, SM # 9 was observed using hand gel to perform hand hygiene. SM # 9 failed to rub hands until dry. SM # 9’s hands remained visibly “wet”. At 10:00 AM, SM # 8 was observed using hand gel to perform hand hygiene before typing on rolling computer. SM # 8 failed to rub hands until dry. SM # 8’s hands remained visibly “wet”. At 10:02 AM, SM # 8 was observed at Station # 4. SM # 4 was observed with a glove wrapped around fingers to adjust machine. At 12:00 PM on October 2, 2024, an interview with SM # 5 revealed staff are expected to wear gloves when touching the dialysis equipment. SM # 5 indicated staff should rub hand until dry when using hand gel. At 2:00 PM, a review of the facility policy titled “Infection Control for Dialysis Facilities” reads in part “Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station. The policy titled “Use of alcohol based hand rubs” reads in part “rub hand together covering all surfaces of hands and fingers until hand rub has evaporated and hands are dry”.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34452 Based on observations, document review and interview, it was determined that the facility failed to ensure staff wear face masks correctly and perform hand hygiene after touching the front of the face mask for three (3) of three (3) Staff Members (SM), SM # 6, # 8, and # 9. The findings include: On October 2, 2024 between 8:30 AM and 10:30 AM, the following were observed during initiation and termination of treatments in the dialysis treatment area: At 8:55 AM during the initial tour of the treatment area, SM # 9 was observed wearing the face mask below the nose. SM # 8 was observed touching the front of the face mask and pulling the face mask up above nose and then down below nose without performing hand hygiene. SM # 6 was observed wearing the face mask inside out. At 9:20 AM, SM # 9 was observed touching face mask without performing hand hygiene before typing on the clean rolling computer. At 9:35 AM, SM # 8 was observed rubbing face and touching face mask without performing hand hygiene while in the treatment area. At 12:00 PM on October 2, 2024, an interview with SM # 5 revealed staff are expected to wear facemasks in the treatment area and the facility follows CDC (center for disease control) guidelines for infection control. SM # 5 indicated staff are expected to wear facemasks correctly and performing hand hygiene after touching the face masks. At 2:00 PM, a review of the facility policy titled “Infection Control for Dialysis Facilities” reads in part “Appropriate PPE (personal protective equipment) will be worn whenever there is the potential for contact with body fluids ... for example , patient care areas.” CDC guidelines include “ensure facemask covers nose and mouth. The outside of the mask is considered contaminated. If colored on one side, the colored side faces out (e.g. blue side faces out).””

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 41450 Based on observation, staff interview, and facility documentation review, the facility staff failed to disinfect medical equipment after patient use and prior to the removal from the treatment area in 2 out of 3 observations for patient assessment practices. The findings include: On 10/2/24 at approximately 9:05 AM, SM #8 was observed using a non-disposable stethoscope while performing a respiratory assessment on a patient seated at dialysis treatment station #2. The stethoscope was not cleaned or disinfected following its use and SM #8 returned it to a central computer station. On 10/2/24 at approximately 9:25 AM, SM #8 was observed using a non-disposable stethoscope while performing a respiratory assessment on a patient seated at dialysis treatment station #5. The stethoscope was not cleaned or disinfected following its use and SM #8 returned it to a central computer station. On 10/2/24 at approximately 11:15 AM, an interview was conducted with SM #5 who stated, “I expect any stethoscope to be cleaned thoroughly after using it on somebody, that is part of our infection control practices and our policy”. Review of the facility policy titled, “Infection Control for Dialysis Facilities”, revised April 2023, page 4, item 14 read, “Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station...” and item 14a read, “Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred) bleach solution...”.”

“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: 34452 Based on observations, document review and interview, it was determined that the facility failed to ensure staff maintain the medication preparation area as a clean area for medication preparation for two (2) of two (2) Staff Members (SM), SM # 8 and # 9. The findings include: On October 2, 2024 between 8:30 AM and 10:30 AM, the following were observed during initiation and termination of treatments in the dialysis treatment area: At 9:50 AM, SM # 9 was observed at the medication preparation area. SM # 9 removed keys from a drawer to open the cabinet then lay the “dirty” keys on the medication preparation area. SM # 9 failed to clean the medication preparation area. At 10:10 AM, SM # 8 placed a water bottle from the refrigerator on the medication preparation area. SM # 8 failed to clean the medication preparation area. At 12:00 AM on October 2, 2024, an interview with SM # 5 revealed the medication preparation area is a designated clean area. At 2:00 PM, a review of the facility policy titled “ Medication Preparation” reads in part “Prior to medication preparation, disinfect medication preparation surface area. Disinfecting medication preparation area helps prevent possible contamination.””

“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: 41450 Based on observation, staff interview, and facility documentation review, the facility staff failed to disinfect equipment at 1 out of 2 dialysis stations observed during cleaning practices. The findings include: On 10/2/24 at approximately 9:15 AM, Staff Member (SM) #8 was observed cleaning dialysis station #2 after patient use. SM #8 failed to clean and disinfect the IV pole and the non-disposable blood pressure cuff for dialysis station #2. On 10/2/24 at approximately 1:30 PM, an interview was conducted with SM #5 who stated, “It is part of our facility’s infection control practice, as well as our policy, that all equipment, including the IV poles and blood pressure cuffs, at the dialysis stations, be cleaned thoroughly after each patient treatment session”. Review of the facility policy titled, “Infection Control for Dialysis Facilities”, revised April 2023, page 3, item 13 read, “At the end of each treatment, the dialysis station will be cleaned and disinfected”, item 13a read, “Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient...(e.g., dialysis chair, tray tables, blood pressure cuffs)...” and page 4, item 14 read, “Non-disposable items are to be disinfected after each patient use...”.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 34452 Based on observations, document review and interview, it was determined that the facility failed to ensure staff aseptic technique for site care and access of the CVC (central venous catheter) for one (1) of one (1) Staff Member, SM # 9. The findings include: On October 2, 2024 between 8:30 AM and 10:30 AM, the following was observed during initiation and termination of treatments in the dialysis treatment area: At 9:00 AM, SM # 9 was observation at Station # 6 during CVC care and access. SM # 9 was wearing the face mask below the nose. SM # 9 performed cleaning of the catheter site and immediately applied a dressing. The catheter tubing was not cleaned. Dirty supplies as removed from the catheter site were placed on the clean field with clean supplies. SM # 9 picked up trash from the floor and placed in the trash can and continued patient care. At 12:00 PM on October 2, 2024, an interview with SM # 5 indicated CVC care should be done according to the facility policy. At 2:00 PM, a review of the facility policy titled “Central Venous Catheter (CVC)” reads in part “Use dialysis precautions and aseptic technique throughout procedure. Set up clean field with all appropriate supplies on a clean, moisture proof barrier. Device disinfectant and skin antiseptic: 2% cholorhexidine Gluconate/70% Isopropyl Alcohol - CVC access exit site and skin - air dry time 60 seconds. 70% alcohol pad - CVC limbs - 1 large pad per CVC limb. Teammate and patient will wear masks covering the nose and mouth during this procedure.””

“PR-PTS INFORMED OF RIGHTS WHEN BEGIN TX CFR(s): 494.70 The dialysis facility must inform patients (or their representatives) of their rights (including their privacy rights) and responsibilities when they begin their treatment and must protect and provide for the exercise of those rights. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure informed consent was obtained from Patients or Responsible Party for dialysis treatment prior to treatment for three (3) of twelve (12) Patients (P), P # 4, # 5 and # 6. The findings include: On October 2, 2024 between 1:00 PM and 3:00 PM, clinical Record review revealed the following: P # 4- A clinical record review revealed the consent for hemodialysis treatment documented “Patient unable to sign”. There was no documented signature by the responsible party. There was no documented date or witness signature. The face sheet lists “Responsible Party/Healthcare Decision Maker - [Family Member]”. The comprehensive assessment dated July 22, 2024 reads in part “cognitive impairment”. A review of P # 4’s admitting diagnosis reads in part “anoxic brain damage”. P # 5- A clinical record review revealed the consent for hemodialysis treatment was not signed by the Patient or Responsible Party. There was no documented date or witness signature. P # 6- A clinical record review revealed the consent for hemodialysis treatment was not signed by the Patient or Responsible Party. There was no documented date or witness signature. On October 2, 2024 at approximately 1:30 PM, SM # 5 confirmed the findings and stated, “It is my expectation that all patients receiving dialysis will be properly informed of their dialysis treatments and have a signed consent in their medical record, that is our facility’s policy, there is no informed consent on record for these patients [P #4, P #5, P #6], this is a serious oversight which I cannot explain”. At 2:00 PM, a review of the facility policy titled “Pre-Intra-Post treatment data” reads in part “If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.””

“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: 34452 Based on document review and interview, it was determined that the facility failed to ensure the patient or patient representative participated in the plan of care for one (1) of two (2) patients (P), P # 4. The findings include: On October 2, 2024 between 1:00 PM and 3:00 PM, clinical Record review revealed the following: P # 4- The plan of care (90 day) dated July 27, 2024 had no signature by the Patient to indicate participation. “Reviewed with patient. Patient not present at meeting” was documented on the plan of care. The face sheet lists “Responsible Party/Healthcare Decision Maker - [Family Member]”. The comprehensive assessment dated July 22, 2024 reads in part “cognitive impairment”. A review of P # 4’s admitting diagnosis reads in part “anoxic brain damage”. There was no documentation that the patient representative and/or responsible party was notified and invited to the plan of care meeting. There was no documentation that the patient representative and/or responsible party was given the opportunity to participate in the plan of care for P # 4. At 2:00 PM, a review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” reads in part “The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.” On October 3, 2024, at 12:00 PM, SM # 5 indicated staff should following the facility policy concerning plan of care documentation.”

“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: 34452 Based on document review and interview, it was determined that the facility failed to ensure the Blood Flow Rate (BFR) was achieved as ordered by the Physician for two (2) of two (2) Patients (P), P # 3 and # 4. The findings include: On October 2, 2024 between 1:00 PM and 3:00 PM, clinical Record review revealed the following: P # 3- The flowsheet dated September 27, 2024 revealed the BFR ordered by the Physician was 400. The BFR from 1:00 PM to 1:58 PM was documented as 350 and 200. There was no documentation that the licensed nurse or Physician was notified of the decreased BFR. P # 4- The flowsheet dated September 25, 2024 revealed the BFR ordered by the Physician was 400. The BFR from 5:42 AM to 10:11 AM was documented as 300 and 200. There was no documentation that the licensed nurse or Physician was notified of the decreased BFR. The flowsheet dated September 27, 2024 revealed the BFR ordered by the Physician was 400. The BFR from 7:00 AM to 9:31 AM was documented as 350 and 200. There was no documentation that the licensed nurse or Physician was notified of the decreased BFR. At 2:00 PM on October 2, 2024, a review of the facility policy titled “Pre-Intra-Post treatment data” reads in part “If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” On October 3, 2024, at 12:00 PM, Staff Member # 5 indicated staff should following the facility policy concerning BFRs.”

“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: 34452 Based on document review and interview, it was determined that the facility failed to ensure the prescription was verified by the Registered Nurse (RN) for two (2) of two (2) Patients (P), P # 3 and # 4; the RN assessment was completed with one (1) hour of the initiation of the treatment for one (1) of two (2) Patients, P # 4; and the treatment data to include blood pressure was documented at least every 30 minutes for one (1) of two (2) Patients, P # 4. The findings include: On October 2, 2024 between 1:00 PM and 3:00 PM, clinical Record review revealed the following: P # 3- The flowsheet dated September 27, 2024 revealed the RN verified the treatment prescription at 12:35 PM. Documentation revealed the treatment was initiated at 10:49 AM. P # 4 The flowsheet dated September 19, 2024 revealed there was no treatment data to include blood pressure between 6:34 AM and 7:14 AM, and 7:14 AM and 7:50 AM. The flowsheet dated September 27, 2024 revealed the treatment was initiated at 5:42 AM. The RN assessment was documented at 7:00 AM. The RN verified the treatment prescription at 7:55 AM. The flowsheet dated September 27, 2024 revealed the BFR ordered by the Physician was 400. The BFR from 7:00 AM to 9:31 AM was documented as 350 and 200. There was no documentation that the licensed nurse or Physician was notified of the decreased BFR. At 2:00 PM on October 2, 2024, a review of the facility policy titled “Pre-Intra-Post treatment data” reads in part “The licensed nurse will round on those patients without reported abnormal findings and compete the nursing assessment within one (1) hour of dialysis treatment initiation. The nursing assessment will be performed and documented by a licensed nurse. The assessment includes.. verification of prescription.” On October 3, 2024 at 12:00 PM, Staff Member # 5 indicated staff should following the facility policy concerning treatment data documentation.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure the plan of care was completed and signed by the interdisciplinary team for one (1) of two (2) patients (P), P # 4. The findings include: On October 2, 2024 between 1:00 PM and 3:00 PM, clinical Record review revealed the following: P # 4- The plan of care (90 day) dated July 27, 2024 was signed by the Registered Dietitian (RD) and Social Worker (SW) on July 27, 2024. There was no signature by the Physician, RN or Patient to indicate participation. “Reviewed with patient. Patient not present at meeting” was documented on the plan of care. The face sheet lists “Responsible Party/Healthcare Decision Maker - [Family Member]”. The comprehensive assessment dated July 22, 2024 reads in part “cognitive impairment”. A review of P # 4’s admitting diagnosis reads in part “anoxic brain damage”. At 2:00 PM on October 2, 2024, a review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” reads in part “The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.” On October 3, 2024, at 12:00 PM, Staff Member # 5 indicated staff should follow the facility policy concerning plan of care documentation.”

“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: 41450 Based on medical record review, staff interview and facility documentation review, the medical director failed to ensure that facility staff adhered to the facility’s informed consent policy for dialysis treatment for three (3) of twelve (12) patients (P) currently receiving dialysis treatments, P #4, P #5, and P #6 . The findings include: On 10/2/24 at approximately 11:00 AM, an interview was conducted with Staff Member (SM) #5 who confirmed the facility census of twelve (12) patients currently receiving scheduled dialysis treatments. On 10/2/24 at approximately 1:00 PM, medical record reviews were conducted and revealed Patient (P) #4, P #5, and P #6 had no signed documentation of an informed consent for dialysis treatment. On 10/2/24 at approximately 1:30 PM, SM #5 confirmed the findings and stated, “It is my expectation that all patients receiving dialysis will be properly informed of their dialysis treatments and have a signed consent in their medical record, that is our facility’s policy, there is no informed consent on record for these patients [P #4, P #5, P #6], this is a serious oversight which I cannot explain”. Review of the facility’s policy titled, “Informed Consent for Dialysis Treatment”, revision date October 2024, page 1, item 3 read, “To guarantee that every patient is fully informed regarding dialysis treatment, prior to the first dialysis treatment in the facility they must have the following: a. Explanation of ESRD diagnosis, risks, benefits, complications, and alternatives to treatment explained to them by the patient’s physician, b. An opportunity to ask questions of the dialysis facility teammates relating to the facility operation, c. An informed consent (Authorization for and Verification of Consent to Hemodialysis Procedure...) signed by the patient or personal representative and witnessed by the Registered Nurse...”.”