Davita Mission Viejo Dialysis

“PR-INFORMED OF INTERNAL GRIEVANCE PROCESS CFR(s): 494.70(a)(14) The patient has the right to- (14) Be informed of the facility’s internal grievance process; This Standard is not met as evidenced by: 50003 Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the grievance process was followed for one of two sampled patients (Patient 1). This failure had the potential to affect the patient care, clinical outcomes, and patient rights. Findings: Review of the facility’s P&P titled Patient Grievance revised April 2025 showed the following: - Grievances may be reported to a facility teammate either verbally or in writing. Grievances should be submitted to a facility teammate within 30 days of the date of the incident or when the person filing the grievance on behalf of the patient became aware of the issue. - The facility teammate should report the grievance to the charge nurse. If a solution to the grievance is not reached through this discussion, the charge nurse is to notify the FA and the Regional Operations Director (ROD) within one business day to follow up. - The FA (or their designee is to discuss the grievance with the patient, investigate and take appropriate action toward a solution if possible. This discussion should occur within 10 days of receipt of the grievance. If the patient’s grievance cannot be resolved by the FA, the ROD and Medical Director will be notified and a formal grievance conference will be coordinated. This grievance should occur within 10 days of receipt of the grievance. - If the patient grievance cannot be resolved by the ROD and/or Medical Director, the Divisional Vice President will be notified. - The Divisional Vice President will discuss the grievance with the patient and take appropriate action towards a solution, if possible. The Divisional Vice President along with Group General Counsel will take the necessary steps to review and, if necessary, investigate the grievance. The Divisional Vice President will issue a written, final decision to the patient within 10 days of the grievance conference. Review of the facility’s P&P titled Adequacy Management Guidance revised April 2024 showed the prescribed single pool, kt/v should be greater than 1.2 for patients on dialysis treatment of three times a week. Factors effecting adequacy include treatment time, needle size, access function, and size of dialyzer. Medical record review for Patient 1 was initiated on 6/24/25. Patient 1 was admitted to the facility on 6/29/23, with End Stage Renal Disease with the order for hemodialysis treatment three times a week for a duration of three hours. Review of the complaint filed by Patient 1 dated 5/23/25, showed Patient 1 was informed a month ago for a change of her treatment days from Tuesday, Thursday, and Saturday to Monday, Wednesday, and Friday. Patient 1 informed the facility of the inability to change her schedule due to working full-time (40 hours a week). But with her treatment, she was on a modified work schedule and had been allowed to work from home on dialysis days. Patient 1 stated having asked the facility to reconsider since she was the only patient at 0430 hours, and was done before 0800 hours. Patient 1 added the facility had ignored her request and she had written the facility two letters. Patient 1 stated this had been very stressful and upsetting for her the last few weeks. Review of the facility’s Grievance log from January to June 2025 showed there was no complaint from month to month until May 2025 that two complaints were recorded; however, there was no documented evidence Patient 1’s grievance was documented in the facility’s log. There was no documented evidence the IDT had discussed regarding the patient’s grievance file, During an interview conducted with the facility’s Social Worker on 6/24/25 at 1425 hours, the Social Worker stated regarding the patient’s grievance process, upon receiving the concern, the staff would take the immediate action to help resolve the issue. If unable to resolve, the IDT would work together to further assist the patient. There was a grievance binder/log with the form for the patient to complete. When asked about Patient 1’s concern, the Social Worker stated she had been informed of Patient 1’s challenges with the work schedule since the facility offered the changed in treatment schedule. The Social Worker stated Patient 1 had provided the Facility Administrator with the letter and the Facility Administrator had been working with Patient 1 on it. The IDT also discussed about Patient 1’s concern during the weekly core team meeting as Patient 1 had been skipping the Friday treatments this month. When the Social Worker was asked for the documentation regarding Patient 1’ missed treatment and grievance, the Social Worker verified she did not have any documentation. On 6/24/25 at 1615 hours, an interview and concurrent facility document review was conducted with the Facility Administrator. When asked about Patient 1’s concerns with the facility initiated treatment schedule changes and missed treatments, the Facility Administrator stated the IDT had discussed the patient’s concern including in the weekly patient-centered core team meeting and documentation should be done in the progress notes. The Facility Administrator stated the reason for Patient 1’s change in treatment schedule was because the facility only had one RN at this time for the Tuesday, Thursday, and Saturday; and Patient 1 was assigned in the Isolation room had to be moved to the Monday, Wednesday, and Friday group to get treatment. When asked for documentation on Patient 1’s grievance and missed treatments concerns, the Facility Administrator stated she failed to document the process and conversations between Patient 1, herself, and the IDT. Review of the treatment log showed Patient 1 had missed two dialysis treatments days for May 2025 and three treatments days for June 2025. Furthermore, Patient 1 also requested to shorten the treatments hours from three hours to two hours on treatment dates of 5/28, 6/2, 6/4, 6/9, 6/11, 6/16, 6/18, and 6/23/25 (for eight days). Review of Patient 1’s three months dialysis adequacy (refers to whether a patient is receiving enough dialysis to effectively remove waste products from the blood) trend showed a decline in result as followed: 1.81 (April 2025); 1.77 (May 2025); and 1.30 (June 2025). On 6/24/25 at 1400 hours, an interview was conducted with RN 1. RN 1 stated Patient 1 was recently asked to switch to the Monday/Wednesday/Friday dialysis schedule which might have conflicted with the patient’s work schedule. As a result, Patient 1 was unable to complete her prescribed dialysis treatments and occasionally had missed treatments since the treatment schedule switched. RN 1 stated the Nephrologist was made aware, and Patient 1 was provided with education regarding the risks associated with missed or shorten treatments. On 6/24/25 at 1615 hours, a concurrent interview and medical record review as conducted with the Facility Administrator and Clinical Coordinator. The Facility Administrator and Clinical Coordinator acknowledged Patient 1’s frequency of missed and shortened treatments and monthly trend of adequacy results had shown a decline. The Facility Administrator further verified the facility failed to follow the grievance policy and procedure to document the grievance and hold a care conference to discuss for the resolution with the patient and IDT as it might had the potential to affect the pateint’s dialysis treatment and health outcomes.”