Fresenius Kidney Care of Halifax

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 19883 Based on observation, interview, and facility document review, it was determined that the facility failed to ensure items contained within the facility’s emergency evacuation box had not expired. The findings included: On May 28, 2025 during an inspection of the facility’s emergency evacuation box the following items were noted to be expired: A.V. Fistula needle set 16 g x 1” BE w/clamp, (manufactured date of 4/12/18 and expiration date of 4/12/23); a bag of multiple 18g x 1 1/2” needles with expiration dates of 01/31/23 and 1/31/23; and four, Procell D cell batteries with a “use before” date of 03/2024. Staff Member #1 reported during an interview on May 29, 2025 that they had placed new needles in the emergency evacuation box but had failed to remove the expired needles, and that it was an oversight. Staff Member #1 was unaware that the D cell batteries had expired. Review of the facility’s policy titled: “Emergency Equipment and Supplies” with a published date of July 6, 2020, reads in part: “... Items approaching expiration must be reordered and replaced prior to the actual expiration date.””

“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: 19883 Based on observation, interview, and facility document review, the facility failed to ensure that expired influenza vaccine was not available for use. The findings included: On May 28, 2025 multiple unopened vials of influenza vaccine were observed in the facility’s medication refrigerator with a manufacturer’s expiration date of 4/2025. The vials were not labeled/grouped as a package or otherwise marked as expired and not safe for patient use. Staff Member #1 reported during an interview on May 28, 2025 that they were aware of the expired influenza vaccine, and had planned to remove the vaccine from the refrigerator and send it back. Review of the facility’s policy titled: “Medication Preparation and Administration” with a published date of February 26, 2023, reads in part: “...Expiration dates for all stored medications are to be monitored on a monthly basis. Expired medications are to be discarded via (name of facility’s) off-site return program or in accordance with local and/or state law.” And “...CDC immunization program states vaccine are to be discarded per manufacturer’s expiration date.””

“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: 19883 Based on clinical record review, staff interview, and facility document review, the facility staff failed to monitor the blood pressure of two (2) of five (5) patients (Patient #2 and Patient #3), within 45 minutes, during their dialysis treatments. The findings include: Review of treatment records for five (5) patients included in the survey sample revealed the following: Patient #2 (Pt. #2): Six (6) treatment records were reviewed from 5/17/25 to 5/28/25. On 5/23/25 Patient #2’s blood pressure was recorded during their treatment at 1:03 PM, and was not recorded again until 2:03 PM. Patient #3 (Pt. #3): Six (6) treatment records were reviewed from 5/16/25 to 5/28/25. On 5/21/25 Patient #3’s blood pressure was recorded during their treatment at 10:37 AM, and was not recorded again until 11:35 AM. Staff Member #1 explained during an interview on May 29, 2025 that the patient’s blood pressures should have been obtained during dialysis treatments every 30 minutes, not to exceed 45 minutes. A review of the facility’s policy “Patient Assessment and Monitoring”, published 5/1/23, reads in part: “...During treatment: - Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations...””

“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: 19883 Based on medical record and facility document review, the facility staff failed to follow physician’s orders for the prescribed dose of dialysis BFR (blood flow rate) for two (2) of five (5) in-center dialysis patients included in the sample, (Patient #4 and Patient #5). The findings included: Patient #4: The surveyor reviewed six (6) dialysis treatment records from 5/15/25 through 5/27/25. The treatment sheets evidenced an order for a dialysis prescription with BFR of 450. On 5/17/25, the BFR was documented as 350, 400 and 435. On 5/20/25, the BFR was documented as 400. On 5/22/25, the BFR was documented as 400, 300, and 290 Pt. #4’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed. Patient #5: The surveyor reviewed six (6) dialysis treatment records from 5/15/25 through 5/27/25. The treatment sheets evidenced an order for a dialysis prescription with a BFR of 350. On 5/17/25, the BFR was documented as 400. Patient #5’s clinical record failed to contain evidence of documentation explaining why the BFR was not being administered as prescribed. A review of the facility’s policy “Patient Assessment and Monitoring”, published 5/1/23, reads in part: “...3. Machine Parameters and Extracorporeal Circuit - Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. Document any findings and interventions in the medical record...”.”