Davita Wickenburg Dialysis

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 49430 Based on document review and interview, it was determined that the facility failed to ensure compliance with the Life Safety Code (LSC) of the National Fire Protection Association (NFPA) by not keeping a current, yearly city fire inspection which has the potential risk of harm to patients if identifiable fire sources are not removed/repaired, increasing the risk of a fire in the facility. Findings include: Yearly city fire inspections are required for outpatient treatment centers per the Fire Code of the City of Wickenburg. Employee #1 confirmed on 03/06/2024 absence of a current city fire inspection.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 49430 Based on review of policy and procedure, medical records, and interview, it was determined that the facility failed to ensure that the dietician complete an accurate evaluation of nutritional status within thirty (30) days of admit. Failure to complete an accurate evaluation of nutritional status poses the potential risk that the patient’s interdisciplinary plan of care will be inaccurate. Findings include: The policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” requires: “...The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for car .... Assessment criteria will include ...Nutritional status by a dietitian...” Patient #1’’s “RD Monthly Progress Note” dated 02/07/2024 “...Pt was not seen by covering RD during FEB rounds d/t pt not being present during rounds. Feb labs missing. No concerns noted from IDT team at this time. RD recommends assessment upon pt return to clinic ...”. Employee #1 confirmed 03/06/2024 that patient was admitted on 01/24/24 and had completed 13 treatments by 03/01/2024 and that there were no other RD notes or assessments of this patient until 03/04/2024 at time the IDT Plan of Care was initiated which was also 3 days past the 13 completed treatments.”

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 49430 Based on review of policy and procedure, medical records, and interview, it was determined that the facility failed to ensure that the Social Worker (SW) complete an accurate evaluation of psychosocial needs within thirty (30) days of admit. Failure to complete an accurate evaluation of psychosocial needs, which are outlined in V509 interpretive guidance, poses the potential risk that the patient’s interdisciplinary plan of care will be inaccurate. Findings include: The policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” requires: “...The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for car .... Assessment criteria will include ...Psychosocial needs by a social worker ...Patient’s abilities, interests, preferences, and goals, including the desired level of participation in the dialysis care process ...Interest in transplant ...Family and other support ...Referral to vocational and rehabilitation services...” Patient #1’’s “MSW Monthly Progress Note” dated 02/28/2024 “...SW met with patient at chairside. ...” short discussion about code status and home situation. Employee #1 confirmed 03/06/2024 that patient was admitted on 01/24/24 and had completed 13 treatments by 03/01/2024 and that there were no other SW assessments of this patient until 03/04/2024 at time the IDT Plan of Care was initiated which was also 3 days past the 13 completed treatments”