**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to follow physician orders for the care and services of a dialysis fistula (a plastic device inserted into a vein or artery to deliver treatment for kidney failure), failed to provide documentation between the facility and the dialysis center, and failed to revise the care plan related to the care of a dialysis fistula for 1 of 1 (Resident #4) residents reviewed for dialysis. The findings include: 1.Review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with, dated October 2010, revealed .Staff caring for resident with ESRD (End Stage Renal Disease) including residents receiving dialysis care outside facility, shall be trained in the care and special needs of these residents .The care of grafts and fistula [plastic devices inserted into the an extremity to deliver treatment for kidney disease] .The resident's comprehensive care plan will reflect the resident ' s needs related to ESRD/dialysis care . Review of the facility policy titled, Hemodialysis Access Care, dated October 2010, revealed .Hemodialysis .Care involves the primary goal of preventing infection and maintaining patency of the catheter (preventing clots) .Keep site clean at all times .Check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals .Check the patency of the site at regular intervals. Palpate (touch) the site to feel the thrill, or use a stethoscope to hear the whoosh of bruit [whooshing sound produced by blood flow through the fistula] of blood flow through the access .The general medical nurse should document in the resident ' s medical record every shift as follows .location of catheter .condition of dressing (interventions as needed) .If dialysis was done during shift .any part of report from dialysis nurse post [after]-dialysis being given .observations post [after] dialysis . 2.Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including, End Stage Renal Disease, Dependance on Renal Dialysis, Chronic Kidney Disease, and Hypertension. Review of the admission Minimal Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #4 was cognitively intact. Resident #4 received Hemodialysis. Review of the Physician Order dated 5/1/2025 revealed .Dialysis on TThSat [Tuesday, Thursday, Saturday] @ [at] [named facility]- 3 Times per week on TThSat with pick-up @ 11[11:00] am For END STAGE RENAL DISEASE [ESRD] . Review of the Physician Order dated 5/6/2025 revealed .check LUE [left Upper Extremity] Fistula [a connection between an artery and a vein, surgically created for dialysis] for thrill [a palpable vibration or buzz felt when touching the fistula, indicating the flow of blood through it. A thrill is a key sign that the fistula is functioning correctly] qday [every day] . Review of the Physician Order dated 5/7/2025 revealed .dialysis on MWF [Monday, Wednesday, Friday] @ [named facility] .3 times per week on MWF @ 11[11:00] am w [with]/pick-up at 10:15am with [named facility] to transport. For (ESRD) . Review of the Care Plan dated 5/9/2025 revealed .chronic kidney disease and receives dialysis on Monday, Wednesday, and Friday .Monitor Fistula for Thrill and bruit every shift and PRN [as needed] .Notify MD [Medical Doctor] of problems . Review of Interdisciplinary Notes revealed the facility was able to provide documentation that the fistula was monitored for thrill on 5/10/2025, 5/16/2025, 5/19/2025, 5/26/2025, and 5/27/2025. No other documentation could be provided for 28 days out of 33 days since admission. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for May and June 2025, revealed no documentation that the thrill was monitored per physician order for Resident #4. 3.During an interview on 6/3/2025 at 9:35 AM, LPN A was asked how the facility communicated with the dialysis center. LPN A stated . We send a dialysis cover sheet with him which includes his vital signs, weight, and the address he ' s going to . LPN A was asked if she could provide the communication sheets. LPN A was unable to provide a record of the communication between the facility and the dialysis center. LPN A was asked if she checked the thrill as was stated in Resident #4 ' s care plan. LPN A stated, .no I don ' t check the thrill . During an interview on 6/3/25 at 5:16 PM, the Director of Nursing (DON) confirmed the care plan should be updated immediately and should reflect the Physician current order. The DON was unable to provide record of communication between facility and dialysis. The facility failed to provide communication between the dialysis center and the facility, the facility failed to follow physicians order related to dialysis, the facility failed to revise the care plan to reflect the Physician order and staff failed to monitor the thrill every day as ordered.

Based on policy review, review of the facility's Infection Control Program documents, and interview, the facility failed to establish and implement a program to identify, report, investigate and control infections and communicable diseases when the Infection Preventionist (IP)/Director of Nursing (DON) failed to track organisms being treated in the facility and monitor for outbreaks and cross contamination. This had the potential to affect 7 of 7 residents in the facility. The findings include: 1. Review of the facility policy titled, Surveillance for Infections, dated 9/2017, revealed, .The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions .The purpose of the surveillance of infections is to identify both individual case and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections .For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data .resident's name .room number .unit .date of onset of infection .Infection site .Pathogens . Review of the facility policy titled, Infection Control, dated 10/2018, revealed .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .The objectives of our infection control policies and practices are to .Prevent, detect, investigate, and control infections in the facility . Review of the facility policy titled, Infection Prevention and Control Program, dated 10/2018, revealed .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection .Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, detecting unusual pathogens with infection control implications .Culture reports, sensitivity date, and antibiotic usage reviews are included in surveillance activities . 2. Review of the INFECTION CONTROL PROGRAM, monitoring documents dated 1/2025, 2/2025, 3/2025, and 4/2025, revealed .Infections by Unit .UTI [urinary tract infection] by Unit .URI [upper respiratory infection] by Unit .Wounds/Skin by Unit .GI [gastrointestinal infection] by Unit .Other Categories .ANALYSIS OF ANTIBIOTIC USAGE BASED ON INFECTION TYPE . There was no documentation listed in the INFECTION CONTROL PROGRAM, that named the organism that was being tracked. 3.During an interview on 6/3/2025 at 3:03 PM, IP/DON confirmed that she does not track the organisms in the INFECTION CONTROL PROGRAM. IP/DON was unable to provide documentation that infection organisms were being tracked.