Usrc Colonial Heights Dialysis

“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: 42725 Based on review of medical records and review of facility documents, it was determined that staff failed to follow the facility’s policy and procedures for disruptive patients for two patients (MR2, MR3). Findings: Review of facility document titled “Disruptive or Non-Adherent Patient or Family Member” last revised April 2023 reads in part: “Purpose: To provide guidance for disruptive or non-adherent patients and/or family members. Policy: Disruptive or non-adherent patients, family members and/or caregivers will be given guidance and assistance to improve the problematic behavior. Procedure: 1. Staff witnessing the disruptive or non-adherent behavior will inform the charge nurse immediately and if it involves a patient, will document behavior in EMR (electronic medical record). 2. The charge nurse will: a. Attempt to de-escalation and if it involves a patient, document patient’s actions in EMR. b. Document in an occurrence/incident report. c. Notify the facility administrator (FA), Medical Director, patient’s nephrologist and social worker (SW) of disruptive or non-adherent behavior. 3. FA will notify Senior Management, VP of Clinical Services and Clinical Specialist of the situation to provide assistance/support with intervention(s). 4. The patient or family member(s)/caregiver will be counseled by the charge nurse, FA and/or SW regarding his/her problematic behavior. This counseling will be documented in the EMR and in an incident report if applicable. 5. If the behavior continues, a conference will be scheduled. The patient, family member(s)/caregiver and/or any concerned persons that the patient requests to attend will be invited to the conference. 6. Monthly unstable IDT assessment and plan of care will be initiated. Documentation will include but is not limited to: a. Education provided; b. Communication to resources (e.g. Clinical Specialist, ESRD Network, etc.); c. Actions taken to modify behavior; d. Agreement of expectations; e. Patient/family/caregiver response and whether the actions have been successful/unsuccessful; f. Resolved/unresolved. 7. The problematic behavior and focused intervention(s) will be discussed. A plan will be: a. Initiated and agreed upon by all in attendance including the patient/family member(s)/caregiver, nephrologist, FA, nurse, dietitian and SW. b. An agreement of expectations signed by the patient and documented in the EMR and unstable assessment/plan of care. c. Focused interventions may include but are not limited to: i. Referral to a mental health specialist for psychiatric evaluation and treatment; ii. Moving the patient to another treatment day or shift; iii. Requesting a family member/caregiver remain with patient during treatments. 8. Notify the ESRD Network for guidance/support with the patient’s disruptive or non-adherent behavior. 9. If the decision by the IDT and patient is to transfer to another facility, all referrals and responses will be documented... Prevention: 1. Treat all patients with respect and dignity. Avoid speaking to patient in a condescending manner or using authoritative tone. 2. Avoid a confrontational and/or argumentative response to patients exhibiting disruptive/agitated behavior. 3. Be professional at all times...”. MR2 On March 8, 2025, a nursing note documented that MR2 needed redirection throughout the treatment day for “aggressive behaviors”. The behaviors documented were arguing with staff, refusing medications, and yelling at another patient. On March 11, 2025, EMP9 documented there is a “concern for the patient’s health perception” and noted that the patient is not compliant with fluid restrictions and medications. On March 12, 2025, EMP2 and EMP5 had a telephone conversation with MR2. MR2’s behaviors on March 8, 2025 were discussed and MR2 explained (MR2’s) version of what occurred. EMP2 encouraged MR2 to contact the FA or SW with any concerns. MR2 verbalized understanding. MR2 was advised that “verbally yelling at staff or other patients will not be tolerated at all, and if this happens again, further action will be taken”. The documentation indicates MR2 apologized for the behavior. On April 3, 2025, EMP10 documented an interaction with MR2 that indicated MR2 said (MR2) did not have to have their blood returned as per a conversation with the FA. There was no documentation to support this conversation and MR2 was informed that all blood would be returned at the end of treatment. On April 14, 2025, EMP10 documented a “late entry” from an event that occurred on April 12, 2025. The note indicates that MR2 called the facility stating MR2 received medications that (MR2) did not agree to. The note indicates MR2 was continuing to yell and EMP10 informed MR2 that if the yelling continued the call would be disconnected. EMP10 documented MR2 continued to yell and EMP10 did disconnect the call. On April 17, 2025, EMP10 documented the following incident: “Patient was speaking to another after (patient’s) treatment was complete. The patient next to them asked if they could hold their voices down as (patient) was on an important phone call. (MR2) looked over at (patient) and raised (MR2’s) voice even louder. The patient on the phone became angry and informed (MR2) that (MR2) was being rude. (MR2) loudly began cussing at the other patient... and then began saying ‘what do you want to do, whatcha going to do’, in a loud threatening voice towards the patient who was on the phone. Charge RN tried to diffuse the situation between the two patients. Patient appeared very angry and when the charge RN went up to (MR2) and asked (MR2) to leave, (MR2) refused... met with more profanity from (MR2)... Patient was asked to leave 3 more times. After patient left the building, 3 patients informed the charge nurse that they felt unsafe regarding the situation and (MR2’s) behavior today. FA notified immediately following the incident”. On April 18, 2025, a provider’s weekly progress note documented, in part, the following: “Patient’s behavior was noted to be disruptive and abusive to staff and other patients after treatment on 4/17/25, causing some patients and a few staff members to feel unsafe. Despite prior warnings, patient continues to do so, hence we will have to do involuntary discharge from our facility. Patient was informed of this telephonically, after the incidence {sp} was invested {sp} by the FA, and patient was found to be at fault”. There was no evidence to support that the facility followed the document titled “Disruptive or Non-Adherent Patient or Family Member” regarding the steps or actions to take to include, but not limited to, holding or attempted to hold a conference with MR2 and any family member(s)/caregiver regarding MR2’s behaviors, monthly IDT assessments and monthly unstable POC after the identification of the behaviors, and considering a move to another treatment day or shift. MR3 MR3 admitted to the facility in October 2021. Beginning in December 2021 until the IVD on August 9, 2024, staff documentation indicated MR3 exhibited disruptive behavior while in the facility. The behaviors consisted of, but not limited to, threatening comments, argumentative with staff, inappropriate language, and non-compliance. MR3’s plan of care (POC) was updated to reflect the behaviors. The updated POCs were March 27, 2023, July 27, 2023, August 31, 2023, and February 22, 2024. In July 2023, the facility drafted a behavior agreement. On July 10, 2023, a note indicated the lead social worker met with the patient in the conference room while EMP1 participated by telephone. The note indicates MR3’s behavior was discussed and a review of the behavior agreement was conducted. It indicates MR3 agreed to the behavior plan and was aware that if the behavior occurs again, staff may consider a referral for involuntary discharge. Following an incident in February 2024, MR3 requested to make a formal complaint. On February 13, 2024, a note indicated the clinical manager had been given MR3’s grievance form. In July 2024, staff documentation indicates MR3 continued to display disruptive behavior. On August 7, 2024, a nursing note documented the following: “Patient refused standing bp. Patient informed that since [patient] was walking out and driving home this was not optional. Writer went to put blood pressure cuff back on patient and patient shoved writer and told writer to get off of [patient]. Patient reminded [patient] was under a behavior contract and stated ‘I don’t f****** care’. Patient began to walk to the scale and lost balance and almost fell, but was able to catch [self] before falling. [EMP2] and [EMP6] made aware”. EMP2 entered a note on August 8, 2024 indicating their awareness of the incident and that EMP6 was no longer allowing the patient to treat at the clinic and would need to go to the hospital. There was no evidence to support that the facility followed the document titled “Disruptive or Non-Adherent Patient or Family Member” regarding the steps or actions to take to include, but not limited to, holding or attempted to hold a conference with MR3 and any family member(s)/caregiver regarding MR3’s behaviors, monthly IDT assessments after the identification of the behaviors, and considering a move to another treatment day or shift. The documentation indicates that a behavioral agreement was developed, reviewed, and signed by MR3; however, there was no evidence of a signed behavioral agreement by any parties. Additionally, there was no documentation that an investigation was completed regarding the incident on August 7, 2024 prior to the decision to immediately IVD MR3.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 42725 Based on review of a medical record, review of facility documents, and interviews, it was determined the facility failed to followed its internal grievance process. Findings: Review of facility document, Complaint/Grievance, last revised September 2020 reads, in part: “Purpose: [Name of facility] has an established process to receive and investigate patient and/or family member’s complaints. Background: ... Grievances are escalated complaints and generally require an investigation. All complaints and grievances will be documented... Policy: ... 3. The grievance procedure will be followed for all patient complaints... Procedure: 1. The receipt of a complaint is acknowledged verbally or in writing. All complaints or grievances received by the staff will be reported to the facility administrator. a. Patient will be updated at least every 3 days during the resolution process. b. Every effort will be made to resolve the complaint or grievance within 10 days. 2. All verbal complaints will be accurately and fully documented... 3. Within 48 hours, the facility administrator will speak directly with the individual to obtain an accurate account of the complaint or grievance. Based on the nature of the issue, the facility administrator will conduct an investigation in a non-threatening, non-retaliatory manner... 4. Information received during the investigation, the response and resolution will be documented on the... 5. The facility administrator will follow up with the individual who submitted the complaint or grievance and determine whether the issue is resolved... 6. If the complaint cannot be resolved, ... a meeting with the facility governing body will be scheduled to review the grievance... 7. If the governing body is not successful in satisfactorily resolving the grievance, the individual will be referred to the [Name of facility] Corporate Office... 8. All complaints/grievances will be recorded on the Complaint/Grievance Log and reviewed monthly during the QAPI meeting...”. MR3’s review revealed on February 13, 2024, documentation indicated the clinical manager was given MR3’s grievance form. A review of the complaint/grievance log in 2024 did not reveal an entry for MR3’s grievance. The SA requested all documentation related to MR3’s grievance. EMP8 indicated that there had been a change in FA’s since February 2024; therefore, the facility had limited ability to obtain further context. Interview on July 17, 2025 at 3:05 PM, MR1 indicated that (MR1) has voiced several concerns regarding a technician who is “on the phone, with the ear piece in [technician’s] ear while hooking us up to the machine” and concerns about the technician’s pace. MR1 indicated the technician’s pace is “very, very slow” compared to other staff, which can delay patient’s treatment time and effect their departure time. MR1 indicated there have been complaints from “other patients” about the same concerns, but “nothing has been done”. Interview on July 18, 2025 at 1:10 PM, EMP5 indicated there are concerns with the staff’s behavior related to patient care and staffing on the treatment floor; however, EMP5 indicated the concerns do not get addressed. EMP5 shared that the follow-up on grievances is inconsistent and does not always occur. The SA requested the complaint/grievance log for 2025. EMP5 informed the SA that there have been no complaints and/or grievances for 2025 (as of the date of the survey).”

“GOV-INVOL DISCHARGE PROCESS REQUIREMENTS CFR(s): 494.180(f)(4) The medical director ensures that no patient is discharged or transferred from the facility unless - (4) The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team- (i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record; (ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge; (iii) Obtains a written physician’s order that must be signed by both the medical director and the patient’s attending physician concurring with the patient’s discharge or transfer from the facility; (iv) Contacts another facility, attempts to place the patient there, and documents that effort; and (v) Notifies the State survey agency of the involuntary transfer or discharge. (5) In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure. This Standard is not met as evidenced by: 42725 Based on medical record reviews, document review, and interview, it was determined that the facility failed to follow the regulatory requirements for an involuntary discharge for one patient (MR2). Findings: Review of facility document, Involuntary Discharge or Transfer of a Patient and Checklist, last revised April 2023 reads, in part: “Purpose: To provide guidelines for patient involuntary discharge (IVD) or transfer. Policy: ... d. Patient’s behavior is disruptive, threatening or violent to the degree that delivery of care and/or facility operations is seriously impaired. i. Our first priority is the safety and security of our patients, staff and visitors. No threats or acts of aggression/violence will be tolerated against any patient, staff or visitor. ii. Any violation of this policy will result in assessment by the Facility Administrator (FA), Social Worker (SW) and Medical Director to determine the extent of the threatening situation and the actions to address the behavior... Procedure: 1. Immediate involuntary discharge (IVD) for threats/violent behavior: a. An immediate discharge procedure may be initiated if any person makes a threat(s), engages in threatening behavior or commits a violent act towards staff, patient(s) or visitor(s) on facility premises. b. The person will be removed from the premises by any authority deemed necessary. c. To ensure the safety of staff, patients and visitors, the violator will not be allowed to return to the facility until an assessment is made to determine further action...”. Review of MR2 indicated that MR2 was immediately discharged on April 17, 2025. The documented incident leading to MR2’s immediate IVD did not indicate that MR2 made a threat, engaged in threatening behavior, or committed a violent act towards staff, visitors, or other patients. There was no indication that an assessment by the FA, SW, and Medical Director was conducted to determine the extent of the situation or to determine further action. Interview on July 18, 2025 at 1:10 PM, EMP5 indicated there have been multiple versions of what happened on April 17, 2025. EMP5 shared, “the bottom line is [MR2] finished [MR2’s] treatment that day and should have left but didn’t, instead [MR2] argued with a patient.” Interview on July 18, 2025 at approximately 4:30 PM, EMP1 indicated that the decision was made “in the moment” and was based off the staff’s concern of “feeling unsafe and threatened”. EMP1 indicated that (EMP1) “did not want to lose staff because they felt unsafe”. EMP1 indicated there was no investigation conducted prior to making the decision. EMP1 was not aware of any policy and/or procedure related to an abbreviated involuntary discharge of a patient. EMP1 confirmed that after receiving notification by staff, EMP1 notified the medical director, obtained a verbal order, and completed the IVD packet. After the IVD packet was submitted and reviewed, EMP1 sent MR2 a letter notifying (MR2) that they had been discharged. EMP1 confirmed that a list area facilities and a list of area hospitals who may be able to provide care was not included in the letter.”

“GOV-RESPONDS TO NW REQUEST/WORKS TOWARD GOALS CFR(s): 494.180(i) The governing body receives and acts upon recommendations from the ESRD network. The dialysis facility must cooperate with the ESRD network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in ESRD network activities and pursue network goals. This Standard is not met as evidenced by: 42725 Based on a review of facility documents and interviews, it was determined that the facility failed to follow-up and respond to ESRD network requests following an involuntary discharge. Findings: EMP1 indicated during an interview that the facility submitted an IVD packet to the ESRD Network. Following the submission, EMP1 said that a conversation occurred (in April 2025) between EMP1 and the network in which (EMP1) agreed that the facility staff take training related to descalation and dealing with difficult patients. In May 2025, a follow-up revealed that there were no logs to indicate any training had occurred. In early June 2025, another follow-up occurred that revealed there had been no staff training conducted for descalation and dealing with difficult patients. By June 20, 2025, there had been no follow-up on behalf of the facility to indicate that any staff training had occurred. EMP1 indicated that the facility uses an outside company to provide training and that the company was “in the process of developing a training” following the April incident which is why the training had not occurred. The SA inquired about the status of the company developing a training course for descalation and/or dealing with difficult patients. EMP2 said that the company “has not indicated that they would be developing training on the topic of dealing with difficult patients.” EMP2 said that as of July 18, 2025, (EMP2) had enrolled the staff in training surrounding the topic of effective communication.”

“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: 49355 Based on observations and document review, it was determined the facility staff failed to ensure that dialysis treatment chairs were appropriately disinfected between patients in six (6) out of six (6) observations. The findings include: On 05/28/2024: At 11:35 a.m., this surveyor observed Staff Member #9 cleaning a vacated chair at station #4. The Staff Member did not wipe down either side of the outside of the chair, under the chair side tables. At 11:42 a.m., Staff Member #10 was observed cleaning the treatment chair at station #11. The Staff Member did not wipe down either side of the outside of the chair, under the chair side tables. At 3:20 p.m., this surveyor observed Staff Member #11 cleaning the vacated chair at station #4. The Staff Member did not wipe down either side of the outside of the chair, under the chair side tables. On 05/29/2024: At 9:44 a.m, this surveyor observed Staff Member #12 cleaning a vacated chair at station #4. The Staff Member did not wipe down either side of the outside of the chair, under the chair side tables. At 9:46 a.m., Staff Member #10 was observed cleaning the treatment chair at station #12. The Staff Member did not wipe down either side of the outside of the chair, under the chair side tables. At 10:55 a.m., this surveyor observed Staff Member #13 cleaning the vacated chair at station #7. The Staff Member did not wipe down either side of the outside of the chair, under the chair side tables. A review of the facility’s policy entitled, “Disinfection and Cleaning of Dialysis Machine Equipment,” policy # C-IC-0080, revision date 07/2023, reads, in part: ... “Disinfection Procedure: ... ... 11. Clean chair...sides.... The above observations were discussed at the exit conference on 05/29/2024 at 2:22 p.m. with Staff Members #1, 2, 14 and 15.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 49355 Based on observations, interview, and document review, it was determined the facility staff failed to maintain a safe environment for the dialysis patients by allowing expired medications and supplies to remain in the usable stock. The findings include: On 05/28/2024, this surveyor, along with Staff Member #1, were reviewing medication and supply storage areas on the treatment floor for expiration dates. Out-of-date medications and supplies discovered include: Blood Leak test strips - an opened container with an expiration date in 2023 Residual Chlorine test strips - an opened container with an expiration date in 2023 Parsabiv 2.5 mg/0.5 ml - #6 vials with an expiration of 4/24 Parsabiv 5 mg/ml - #2 vials with an expiration of 2/24 Prevnar 13 - #2 syringes with an expiration of 4/24. A review of the facility’s policy entitles, “Guidelines for Administration of Medication,” policy # C-MA-0010, revision date 04/2024, reads, in part: ... “Procedure: ... 16. Medication Storage: ... c. Ensure all supplies, medications and testing strips are checked at least monthly for expiration. Ensure expired items are discarded appropriately.” The above observations were discussed at the exit interview on 05/29/2024 at 2:22 p.m. with Staff Members #1, 2, 14 and 15.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 49355 Based on observations and document review, it was determined the facility staff failed to maintain aseptic technique when providing care to a central venous catheter (CVC) exit site for two (2) out of three (3) observations. The findings include: On 05/29/2024 at 11:07 a.m., Staff Member #13 started cleaning the Central Venous Catheter (CVC) exit site of Patient #16. The Staff Member used an antiseptic swab to clean the area while holding the patient’s shirt collar out of the way. Once the area was cleansed, Staff Member #13 released the collar, which then returned to the area over the cleansed exit site, touching it. While cleaning the hubs of the CVC tubing, the Staff Member allowed the hubs to touch a non-sterile field. At 3:25 p.m., this surveyor observed Staff Member #11 providing care to the CVC exit site on Patient #15. Once the staff member finished swabbing the site with antiseptic, the neck of the patient’s sweater was allowed to cover and touch the newly cleansed site. While allowing the exit site to dry, the staff member allowed the syringe packaging they held in their hand, to touch the site as well. A review of the facility’s policies entitled, “Dialysis Catheter Dressing Change Procedure,” policy #C-TI-0070, revision date 02/2023 reads, in part: ... “Procedure ... 3. Secure clothing away from dressing/exit site.” “Accessing and De-Accessing the Dialysis Catheter,” policy #C-TI-0090, revision date 02/2023 reads, in part: ... “Procedure: ... 6. Hub disinfection: ... do not drop the hub or allow hub to touch non-sterile surfaces to prevent contamination. ... Once disinfected, do not allow the catheter hubs to touch non-sterile surfaces.” The above observations were discussed at the exit interview on 05/29/2024 at 2:22 p.m. with Staff Members #1, 2, 14 and 15.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 49355 Based on observations and document review, it was determined the facility staff failed to ensure they maintained a safe environment by failing to dispose of contaminated sharps at the point of use in four (4) out of six (6) observations when deaccessing patients with a fistula or graft. The findings include: On 05/28/2024: At 12:25 p.m., this surveyor observed Staff Member #9 discontinue dialysis on Patient #13 at station #3 with an AV (Arteriovenous) fistula. The staff member removed the cannulation needles from the patient’s fistula, placed the needles on the chairside table, and then later discarded them into the sharps container. On 05/29/2024: At 9:33 a.m., this surveyor observed Staff Member #10 discontinue dialysis on Patient #23 at station #12 with an AV fistula. The staff member removed the cannulation needles from the patient’s fistula, placed the needles on the chairside table, and then later discarded them into the sharps container. At 9:55 a.m., this surveyor observed Staff Member #13 discontinue dialysis on Patient #21 at station #1 with an AV fistula. The staff member removed the cannulation needles from the patient’s fistula, placed the needles on the chairside table, and then later discarded them into the sharps container At 10:25 a.m., this surveyor observed Staff Member #13 discontinue dialysis on Patient #22 at station #9 with an AV fistula. The staff member removed the cannulation needles from the patient’s fistula, placed the needles on the chairside table, and then later discarded them into the sharps container A review of the facility’s policy entitled, “Termination of Dialysis Treatment,” policy #C-TP-0010, revision date 04/2023, reads, in part: “Purpose To provide guidelines for safe treatment termination and prevent AVF/AVG complications. ... Procedure: ... 13. ... b. Engage safety device on the fistula needles as needle is removed and discard in the sharps container at point of use.” The above observations were discussed at the exit interview on 05/29/2024 at 2:22 p.m. with Staff Members #1, 2, 14 and 15.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 49355 Based on observations and facility policy review, it was determined the staff failed to ensure the access sites for seven (7) patients were visible during the dialysis treatment. Findings: On 05/29/2024 at 9:02 a.m., this surveyor observed seven (7), out of a total of eleven (11), patients receiving dialysis treatments with their access sites covered with a blanket or clothing. A review of the facility’s policy entitled, “Intradialytic Monitoring of Patient,” policy #C-ID-0010, revision date 09/2020 reads, in part: ... “Monitoring: ... ENSURE PATIENT’S ACCESS, BLOOD LINES AND FACE ARE VISIBLE AT ALL TIMES.” (sic) The above observations were discussed at the exit interview on 05/29/2024 at 2:22 p.m. with Staff Members #1, 2, 14 and 15.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 49355 Based on medical record reviews, interviews and document review, it was determined the facility staff failed to: monitor patients intradialytic vitals per policy in two (2) out of six (6) in-center hemodialysis patients, conduct pre-treatment assessments by the charge nurse per policy in four (4) out of six (6) in-center hemodialysis patients. document deviations in dry weight (DW) versus post-treatment weight (PTW)(+/- 1kg) in one (1) out of one (1) home hemodialysis patient’s record reviewed, and document pulse readings outside of this facility’s guidelines in one (1) out of six (6) in-center hemodialysis patients. The findings include: The six (6) most recent flow sheets for six (6) in-center hemodialysis patients, one (1) home hemodialysis patient and one (1) home peritoneal dialysis patient were reviewed on 05/28/2024 by this surveyor. 1 - There were two (2) patients that did not have their vitals monitored every 30 minutes while receiving treatment: Patient #3: Duration of treatment - 3.5 hours Treatment date 05/13/2024, between 5:00 p.m. and 6:31 p.m., no vitals were recorded as per the flow sheet and no documentation from the technician or the charge nurse that the omission was noticed. Treatment date 05/24/2024, between 2:40 p.m. and 4:09 p.m., there were no vitals taken, per the flow sheet, and again between 5:08 p.m. and 6:41 p.m. There was no documentation from the technician or the charge nurse that the omission was noticed. Patient #5: Duration of treatment - 3 hours Treatment date 04/17/2024, between 4:34 p.m. and 5:32 p.m., no vitals recorded as per the flow sheet and no documentation from the technician or the charge nurse that the omission was noticed. 2 - There were four (4) patients that did not have a pre-assessment performed by the charge nurse within one (1) hour of the initiation of treatment: Patient #3: Treatment date 05/15/2024, initiated at 2:36 p.m., pre-assessment entered on the flow sheet at 4:12 p.m. Treatment date 05/24/2024, initiated at 2:38 p.m., pre-assessment entered on the flow sheet at 4:21 p.m. Patient #5: Treatment date 04/24/2024, initiated at 2:56 p.m., pre-assessment entered on flow sheet at 4:24 p.m. Patient #6: Treatment date 05/17/2024, initiated at 10:23 a.m., pre-assessment entered on flow sheet at 11:33 a.m. Treatment date 05/22/2024, initiated at 10:35 a.m., pre-assessment entered on flow sheet at 11:57 a.m. Treatment date 05/24/2024, initiated at 10:30 a.m., pre-assessment entered on flow sheet at 11:46 a.m. Patient #7: Treatment date 04/22/2024, initiated at 1:45 p.m., pre-assessment entered on flow sheet at 3:12 p.m. Treatment date 04/24/2024, initiated at 1:40 p.m., pre-assessment entered on flow sheet at 4:20 p.m. 3 - There was one (1) patient, the home hemodialysis patient, that did not have any documentation in the electronic medical record (EMR), addressing the deviations in dry weight (DW) versus post-treatment weight (PTW): Patient #4: Treatment date 05/20/2024, the patient’s DW was 91 kg, the PTW was 92.9 kg, a discrepancy of 1.9 kg. There was no documentation in the EMR by the nurse, acknowledging the disparity. Treatment date 05/22/2024, the patient’s DW was 91 kg, the PTW was 93.1 kg, a discrepancy of 2.1 kg. There was no documentation in the EMR by the nurse, acknowledging the disparity. Treatment date 05/24/2024, the patient’s DW was 91 kg, the PTW was 93.4 kg, a discrepancy of 2.4 kg. There was no documentation in the EMR by the nurse, acknowledging the disparity. Treatment date 05/27/2024, the patient’s DW was 91 kg, the PTW was 93.0 kg, a discrepancy of 2.0 kg. There was no documentation in the EMR by the nurse, acknowledging the disparity. 4 - There was one (1) in-center hemodialysis patient that did not have any documentation from the technician or the charge nurse concerning pulse readings outside of this facility’s guidelines: Patient #4: Treatment date 05/22/2024, during the 3.5 hour treatment cycle, the patient’s pulse was less than 60 throughout the entire treatment. There is no comment on the flow sheet from the technician or the charge nurse addressing this issue. Treatment date 05/24/2024, during the 3.5 hour treatment cycle, the patient’s pulse was less than 60 throughout the entire treatment. There is no comment on the flow sheet from the technician or the charge nurse addressing this issue. Staff Member #5 assisted this surveyor with accessing the EMR for Patient #9. The Staff Member agreed that there should be documentation in the medical record, acknowledging the discrepancy in the DW versus the PTW. In an interview on 05/28/2024, Staff Member #10 stated that technicians should notify the charge nurse of any deviations from the dialysis prescription or vital signs [i.e. changes to the blood flow rate (BFR) or pulse rate, etc outside of facility parameters] and should make a notation on the flow sheet if these events occur. A review of the facility’s policies, including: “Intradialytic Monitoring of Patient,” policy #C-ID-0010, revision date 09/2020 reads, in part: ... “Monitoring: ... 2. Vital Signs: Obtained and documented at least every 30 minutes and reported to charge nurse if outside of ... reportable parameters, refer to C-FORMS-0081 Reportable Parameters to CN. ... 3. Volume status: indicated by changes in BP (blood pressure) and HR (heart rate = pulse) parameters.... ... 10. Comment regarding patient status and staff observation at least every 30 minutes.” Policy entitled, “Pre-Treatment Assessment of Patient,” policy #C-PT-0010, revision date 01/2020, reads, in part: ... “Policy: ... Pre dialysis nursing assessment will occur within the first hour of patient contact....” Policy entitled, “Post Dialysis Assessment of Patient,” policy #C-TP-0060, revision date 01/2020, reads, in part: ... “Assessment: ... f. Weight/volume status ... i. Evaluate post weight variance from EDW. If post weight +/- 1 kg EDW (estimated dry weight) ... document.” Policy entitled, “Reportable Parameters to CN,” policy #C-FORMS-0081, revision date 01/2020, reads, in part: ... “PCT/CCHT, LVN: Report to Charge Nurse ... Intra-Dialysis ... Pulse <60 beats per minute” The above observations were discussed at the exit interview on 05/29/2024 at 2:22 p.m. with Staff Members #1, 2, 14 and 15.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 49355 Based on medical record review, interview and facility document review, it was determined the facility staff failed to follow physician’s orders for the prescribed dosage of dialysis blood flow rate (BFR) and document the reason for the discrepancy for five (5) out of six (6) in-center dialysis patients included in the sample. The findings include: On 05/28/2024, this surveyor conducted a review of flowsheets for six (6) in-center hemodialysis patients selected in the sample. Six (6) flow sheets were reviewed for each patient Patient #4: 05/24/2024 - BFR was run at 200 ml/min for the first 30 minutes (with a technician note on the flow sheet stating “increased blood flow rate to ordered rate without difficulty”) and then increased to 250 ml/min for 2 hours of the 3.5 hour treatment. The prescribed BFR was 400 ml/min. No documentation was noted on the flow sheet as to the reason for the discrepancy. Patient #5: 04/22/2024 - BFR was run at 350 ml/min for 1.5 hours and then decreased to 300 ml/min for the final 0.5 hour of the 3.0 hour treatment. The prescribed BFR was 400 ml/min. No documentation was noted on the flow sheet as to the reason for the discrepancy. Patient #6: 05/22/2024 - BFR was initiated at 450 ml/min for the first 1.0 hour and then decreased to 350 ml/min for the remaining 2.5 hours of the 3.5 hour treatment. The prescribed BFR was 400 ml/min. No documentation was noted on the flow sheet as to the reason for the discrepancy. Patient #7: 04/22/2024 - BFR was run at 400 ml/min for approximately 2.0 hours of the 4.25 hour treatment. The prescribed BFR was 450 ml/min. No documentation was noted on the flow sheet as to the reason for the discrepancy. 04/24/2024 - BFR was initiated at 200 ml/min for 30 minutes and then increased to 400 ml/min for the remainder of the 4.25 hour treatment. The prescribed BFR was 450 ml/min. No documentation was noted on the flow sheet as to the reason for the discrepancy. 05/27/2024 - BFR was initiated at 200 ml/min for 30 minutes (with a technician note on the flow sheet stating “increased blood flow rate to ordered rate without difficulty”), then increased to 450 ml/min for 30 minutes, then decreased to 400 ml/min for 1.5 hours and then decreased to 350 ml/min for the remainder of the 4.25 hour treatment. The prescribed BFR was 450 ml/min. No documentation was noted on the flow sheet as to the reason for the discrepancy. Patient #8: 05/14/2024 - BFR was run at 350 ml/min for the final 2.0 hours of the 3 hour treatment. The prescribed BFR was 400 ml/min. No documentation was noted on the flow sheet as to the reason for the discrepancy. 05/16/2024 - - BFR was initiated at 350 ml/min for 30 minutes, increased to 515 ml/min for 30 minutes and then decreased to 450 ml/min for approximately 2 hours of the 3.0 hour treatment. The prescribed BFR was 400 ml/min. No documentation was noted on the flow sheet as to the reason for the discrepancy. 05/23/2024 - BFR was initiated at 350 ml/min for the first 2.5 hours and then decreased to 200 ml/min for the final 0.5 hours of the 3 hour treatment. The prescribed BFR was 400 ml/min. No documentation was noted on the flow sheet as to the reason for the discrepancy. In an interview on 05/28/2024, Staff Member #10 stated that technicians should notify the charge nurse of any deviations from the dialysis prescription [i.e. changes to the blood flow rate (BFR)] and should make a notation on the flow sheet if these events occur. A review of the facility’s policy entitled, “Intradialytic Monitoring of Patient,” policy #C-ID-0010, revision date 09/2020, reads, in part: ... “Monitoring: ... 8. Delivery of dialysis prescription ... Delivery System: ... 3. Blood flow rate ... Intervention: ... 2. Modify the treatment plan based on the patient’s response, which must be documented by the charge nurse.” The above concerns were discussed at the exit conference on 05/29/2024 at 2:22 p.m. with Staff Members #1, 2, 14 and 15.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49355 Based on observations and document review, it was determined the facility staff failed to maintain an aseptic technique when accessing an arteriovenous (AV) graft/fistula site during two (2) out of two (2) observations. The findings include: On 05/28/2024 at 11:20 a.m., Staff Member #10 was at station #9 with Patient #11. The staff member cleansed the fistula site with antiseptic. Staff Member #10 then palpated the site for location and accessed the fistula without re-cleansing the area again with an antiseptic. At 11:33 a.m., Staff Member #11 was at station #1 with Patient #12. The staff member cleansed the fistula site with antiseptic. Staff Member #11 then palpated the site for location and accessed the fistula without re-cleansing the area again with an antiseptic. A review of the facility’s policy entitled, “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation,” policy #C-TI-0030, revision date 10/2023, states, in part: ... “Procedure: ... 3. Access preparation: ... b. Locate and palpate the needle cannulation sites prior to skin disinfection ... 4. Locate Arterial site ... DO NOT re-palpate vessel ... 5. Locate the venous site... DO NOT re-palpate vessel.” The above observations were discussed at the exit conference on 05/29/2024 at 2:22 p.m. with Staff Members #1, 2, 14 and 15.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 40084 Based on observation, interview and document review, it was determined the facility’s Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues identified during the previous recertification survey. The findings include: Current Recertification Survey Based on medical record reviews, interviews and document review, it was determined the facility staff failed to: monitor patients intradialytic vitals per policy in two (2) out of six (6) in-center hemodialysis patients, conduct pre-treatment assessments by the charge nurse per policy in four (4) out of six (6) in-center hemodialysis patients. document deviations in dry weight (DW) versus post-treatment weight (PTW)(+/- 1kg) in one (1) out of one (1) home hemodialysis patient’s record reviewed, and document pulse readings outside of this facility’s guidelines in one (1) out of six (6) in-center hemodialysis patients. Previous Recertification Survey Ending June 16, 2021 Based on observations, interview and Clinical Record review, it was determined that the facility failed to: ensure Staff obtain weights pre treatment for two (2) of four (4) Patients (Patients # 10 and # 11); ensure Staff obtain and document Patient Data to include blood pressure at least every thirty (30) minutes during the treatment for one (1) of nine (9) Patients (Patient # 3); ensure Staff obtain and document Patient Data to include access visualization at least every thirty (30) minutes during the treatment for six (6) of nine (9) Patients (Patients # 3, # 4, # 5, # 7, # 8 and # 9); ensure the Registered Nurse (RN) verified and documented the treatment prescription within one (1) hour of initiation of the treatment for five (5) of nine (9) Patients (Patients # 3, # 4, # 5, # 7, and # 9); ensure the RN documented and assessed the Patient within one (1) hour of initiation of the treatment for three (3) of nine (9) Patients (Patients # 7, # 8 and # 9).”