Fresenius Medical Care - Dodgeville

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 35561 Based on interviews, review of emergency drill records, and review of policies and procedures, the facility failed to provide sufficient education and training to ensure emergency preparedness of all staff members. Failure to provide the required emergency staff training had the potential to adversely affect in-center patient safety in the event of an emergency. This deficient practice had the potential to affect all 41 current patients receiving dialysis treatments. Findings include: During an interview on 06/26/24 at approximately 11:15 AM, Patient Care Technicians (PCT)1 was asked if periodic fire drills were conducted in the dialysis facility. PCT1 stated “I’m not sure, maybe, but not while I was here.” During an interview on 06/28/24 at approximately 11:40 AM, the Renal Dietitian when questioned about whether fire and emergency drills were conducted in the dialysis facility. The Renal Dietitian stated, “I think so, but I can’t remember exactly when. It has been a while.” Review of the facility emergency drill documentation revealed that the last documented fire drill for this facility was conducted in August of 2023. An interview with the Director of Operations on 06/28/24 at 3:00 PM verified that there was no additional documentation of facility emergency drills to review and confirmed that the quarterly disaster drills had not been conducted as required by facility policy. Review of the facility’s policy titled “Fire Drill,” dated 08/02/17, stated “Quarterly, all facilities shall perform a fire drill for each shift of patients and staff. In addition to the drill, activation of the fire alarm once per staff shift shall occur to: - Ensure the alarm system is working and simulation of emergency fire conditions. - Ensure each shift of staff working in the facility are familiar with the signals and emergency action required during a fire. Document fire drills, alarms and signal received by the monitoring services or fire department, and patient and staff participation on the QAI (Quality Assessment Indicators) checklists.””

“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: 35561 Based on observation, interview, and review of the facility’s policies and procedures, the facility failed to ensure two of four Patient Care Technicians (Patient Care Technician (PCT)2, PCT3) and Clinical Manager who were observed during care delivery, implemented proper infection control measures after discontinuation of dialysis by failing to encourage hand hygiene for patients holding pressure on access needle sites which presents a risk for blood exposure. Failure to use recommended infection control practices increases the risk for cross contamination and has the potential to expose patients, staff, and others to blood-borne pathogens. This deficient practice had the potential to affect all 41 patients receiving treatment in the hemodialysis unit. Findings include: On 06/26/24 at 10:45AM, PCT2 was observed discharging Patient (P)7 at Station 7. After the patient had finished holding pressure with a gloved hand on access needle sites, PCT2 removed the glove from the patient’s hand, applied pressure dressings and discharged the patient. The patient was unaccompanied during discharge and walked by hand sanitizer and a handwashing sink. The unidentified patient was observed touching multiple areas of the weigh scale. PCT2 failed to offer, remind, or encourage hand hygiene at the dialysis station upon discharge. On 06/27/24 at 10:35AM, the interim Clinical Manager was observed discharging P10 at Station 10. After the patient had finished holding pressure with a gloved hand on access needle sites, the Clinical Manger applied pressure dressings and discharged the patient. The Clinical Manager failed to assist P10 in removing the soiled glove. P10 was unaccompanied during discharge and was observed touching the weigh scale while still wearing the soiled glove. On 06/27/24 at 10:50AM, PCT2 was observed discharging P11 at Station 3. After the patient had finished holding pressure with a gloved hand on access needle sites, PCT2 removed the glove from the patient’s hand, applied pressure dressings and discharged the patient. The patient was unaccompanied during discharge and walked by hand sanitizer and a handwashing sink. The unidentified patient was observed touching multiple areas of the weigh scale. PCT2 failed to offer, remind, or encourage hand hygiene at the dialysis station upon discharge. When questioned about encouraging patients to wash hands post dialysis, PCT2 stated “We are supposed to.” During an interview on 06/28/24 at 3:40 PM, these findings were discussed with the Director of Operations who responded, “These observations do not meet the requirements of our infection control policy.” The Director of Operations acknowledged that this practice presented a risk for cross contamination and stated, “we all need to do better with that.” Review of the facility’s policy titled “Hand Hygiene,” dated 11/06/23, indicated “Patients should perform hand hygiene if able, prior to and after each dialysis treatment. As needed, direct patient care staff will demonstrate hand washing to patients and explain risk of contamination with regard to their vascular access and hands to all patients. To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed.””

“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: 35561 Based on observation, interview, and review of policies and procedures, the facility failed to ensure staff removed personal protective equipment (PPE) before leaving the treatment area, in two of two observations at the nursing station. Failure to remove PPE outside the treatment area presents a potential for cross contamination and has the potential to expose patients and staff to blood-borne pathogens. This deficient practice had the potential to affect all staff receiving treatment in the dialysis unit. Findings include: During observation on 06/28/24 at 10:40 AM, Registered Nurse (RN)2 left the treatment room area and entered the nursing station wearing the same PPE gown that was worn on the treatment floor. RN2 took a chair at the nursing station and proceeded to complete phone calls and computer work for the next 30 minutes. RN2 then returned to the treatment area wearing the same PPE gown. Immediately after RN2 left the nursing station, the facility Medical Director was observed using the same chair and computer while wearing street clothes. During an interview on 06/28/24 at 11:10 AM, the Director of Operations was questioned about wearing used PPE in the nursing station. The Director of Operations stated that the nursing station was deemed to be a “clean area,” and that staff were instructed to remove PPE prior to entering. During observation on 06/28/24 at 3:20 PM, Registered Nurse (RN)2 again left the treatment room area and entered the nursing station wearing the same PPE gown that was worn on the treatment floor. RN2 took the same chair at the nursing station and proceeded to complete phone calls and computer work for the next 15 minutes. At this time, RN2 was questioned about whether potentially contaminated PPE used on the treatment floor was allowed to be worn within the nursing station. RN2 responded “Yes, I do it all the time. I thought it was fine.” During an interview on 06/28/24 at approximately 3:40 PM, these findings were discussed with the Director of Operations, at which time the Director of Operations acknowledged that this practice presented a risk for cross contamination and stated, “we all know that we should remove PPE when entering the nursing station to keep those staff who are not wearing PPE safe.” Review of the facility’s policy titled “Personal Protective Equipment,” dated 11/06/23, stated “All personal protective equipment shall be removed prior to leaving the work area.””

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 35561 Based on personnel file review, staff interview and policy review and, the facility failed to implement accepted standards of practice to prevent the transmission of infections and communicable diseases with regard to Hepatitis B vaccination in one of three personnel files reviewed (Patient Care Technicians (PCT)1) who had direct patient care contact. This deficient practice had the potential to expose staff and all patients who were currently receiving in center dialysis services to pathogens. Findings include: Review of PCT1’s (date of hire 02/07/22) personnel file review revealed there was no evidence the Hepatitis B vaccine had ever been offered to this employee. On 02/01/22, a Hepatitis B surface antibody test was done and indicated a result of “< [less than]10,” which indicates susceptibility to Hepatitis B infection. There was no further documentation in the employee file of an offer of the Hepatitis B vaccination, or a statement attesting to whether the employee declined or had previously received the vaccine elsewhere. During an interview on 06/28/24 at 1:45 PM after the personnel file review was completed, the Director of Operations verified these findings and acknowledged that health screening had not been completed as required by the facility’s policy. The Director of Operations stated, “the Hepatitis B vaccine was missed during the PCT orientation period.” Review of the facility’s policy titled, “Employee Requirements for Testing and Vaccination for Hepatitis B,” dated 04/05/21, indicated, “If susceptible, offer vaccine. If the employee declines, a signed declaration must be maintained in the employee file. The hepatitis B vaccine shall be provided within 10 working days of initial assignment to all employees that have occupational exposure to blood or other potentially infectious materials.””

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 35561 Based on record review and interview, the facility failed to monitor the implementation of infection control policies and activities within the dialysis unit. The failure to observe each staff members adherence to infection control policies has the potential to allow the spread of infections among the 41 patients who were currently receiving dialysis services. Findings include: Review of the facility’s infection control monitoring and staff infection control audits for the last 12 months indicated a score of 100% for the months of July 2023 through April 2023. There were no results for May 2023. However, the 100% scores provided on the “Clinic Audit Checklists” provided failed to document what type of practices were observed to determine these scores. The checklists did not document which staff were observed. The checklists also failed to document the identity of the observer who was evaluating these practices. Interview on 06/28/24 at 3:05PM with the Director of Operations was asked to provide the worksheets which were used for the direct observations, the Director of Operations stated that he/she was unable to provide the worksheets. During an interview on 6/28/24 at 3:40 PM, the Director of Operations confirmed these findings and stated, “I was unable to retrieve any documentation of direct observations of infection control practice.” A policy reflecting the facility’s process for infection control audits, direct observation of infection control practices or infection control monitoring was requested on 06/28/24 of the Director of Operations, however, was not provided. The policy was requested again on 06/28/24 at 3:00 PM at which time the Director of Operations stated that there was no infection control monitoring policy available to review.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 35561 Based on observation, interview, personnel file review, and review of policies and procedures, the facility failed to ensure one of one staff (Patient Care Technician (PCT)1) responsible for water testing had documentation of successful completion of a colormetric test to ensure they had the ability to perform their duties correctly. The failure to conduct testing correctly had a potential for undetected chlorine/chloramine breakthrough, which could harm all 41 patients receiving in-center hemodialysis. Findings include: On 06/26/24 at 12:20 PM, PCT1 was observed completing the scheduled chlorine/chloramine testing for the dialysis facility which required PCT1 to distinguish between different shades of colors to determine an accurate result of the test. During review of the facility’s documentation of chlorine/chloramine testing for May 2024, it was noted that of the 105 chloramine tests conducted between the dates of 05/01/24 and 05/31/24, PCT1 had been responsible for completing and interpreting the results of these tests 52 times. Review of the personnel file for PCT1, with a hire date of 02/07/22, failed to have evidence that a colormetric test had been completed for this PCT. During an interview on 06/28/24 at 1:45 PM after the personnel file review was completed, the Director of Operations verified these findings and acknowledged the color blindness testing had not been completed as required by facility policy. The Director of Operations stated, “the Ishihara Test was missed during the PCT orientation period.” Review of the facility’s policy titled, “Color Blindness Testing,” dated 12/15/20 indicated, “Certain positions within the company require employees to distinguish or interpret color when performing various functions of the job including, but not limited to water and/or other quality tests ... Individuals in these positions are required to take the Ishihara Test for Color Blindness. The Ishihara Test for Color Blindness should be administered after an offer of employment is made and prior to starting the new position. The manager is responsible for confirming the test results are documented and place in the employee’s medical file.””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 35561 Based on interview, medical record review, and policy review, the facility failed to ensure a patient undergoing deterioration in health status, with excessive missed treatments and concurrent poor nutritional status was identified as unstable for one of six records reviewed (Patient (P)6). This failure had the potential to place the patient at risk for serious medical complications related to inadequate dialysis and could potentially affect all 41 in-center dialysis patients receiving treatment at the facility. Findings include: Record review revealed P6 was admitted to the dialysis facility on 06/30/22 with the diagnosis of hypertensive chronic kidney disease, resulting in End Stage Renal Disease. Review of the facility report titled, “Absence and Hospitalization,” dated 06/26/24, revealed that P6 had been absent, without hospitalization or reason, for 41 of the 75 (or 55%) scheduled dialysis treatments between the dates of 01/01/24 and 06/24/24. Review of the “Provider Rounding Note,” dated 02/15/24, revealed the physician documented, “Coming in with very elevated BP’s (blood pressure) for several weeks ...patient with dementia depends on son for transportation and decision making. He/She misses treatments frequently, when discussed with son he/she becomes agitated and states that is how things have to be.” Review of the “Nutrition Progress Note,” dated 06/15/24, the Dietitian (RD ) documented “Significant wt (weight) loss noted x [times] 3 months > [greater than] 7% {of body weight} ...He/She misses a lot of treatment and often reports nausea. It would be appropriate for him/her to have a palliative care consult at the very least given how much treatment he/she misses.” Review of the “Psychosocial Progress Note”” dated 06/27/24, the Medical Social Worker (MSW ) documented, “W asked how he/she has been feeling lately as he/she hasn’t been to tx [Treatment] since 6/18. He/She reports he/she has been having GI (gastrointestinal) issues and hasn’t been feeling well enough to come.” Review of P6’S Lab results indicated a decrease in P6’s serum Albumin (a protein that is found in blood plasma) which may indicate nutritional health from 3.6 on 04/18/24 to 3.3 on 05/21/24. A normal value for serum Albumin is 3.5 - 5 gm/dl (grams per deciliter) with a preferred value / goal of 3.8 or greater. Review of the “Comprehensive Interdisciplinary Assessment” was last documented on 09/09/23, with Plan of Care developed on 09/14/23. There was no evidence in the clinical record to indicate that the interdisciplinary team had identified P6 as needing a monthly reassessment and plan of care revision that addressed failure to meet outcome goals. During an interview on 06/28/24 at 3:40 PM the Director of Operations confirmed the above findings. The Director of Operations acknowledged that P6 had demonstrated indicators that would deem the patient unstable, requiring monthly reassessment and plan of care revision. Review of the facility’s policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated 07/03/23, revealed “Patient stability must be reviewed monthly. The interdisciplinary team will offer input to the attending physician who will determine whether the patient is stable or unstable on the criteria included in this policy. The following are unstable criteria: Change in mentation or psychosocial needs severe enough to interfere with the patient’s ability to follow aspects of the treatment plan and may include situations related to immediate family members.””