Usrc Chula Vista Dialysis

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 38542 Based on interview and record review, the facility failed to ensure the staff followed policy and procedure after an allegation of threat to a patient’s safety. As a result, there was a potential Patient 1 was at risk for further incidence of threatening behavior. Findings: Patient 1 was admitted to the facility on 11/24/16 with diagnoses which included End Stage Renal Disease (ESRD) per the patient’s problem list. Patient 2 was Patient 1 was admitted to the facility on 12/12/19 with diagnoses which included End Stage Renal Disease (ESRD) per the patient’s problem list. On 7/25/24 at 1:52 P.M., an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated Patient 1 and Patient 2 had an altercation and exchanged profanities. RN 1 stated Patient 2 verbally “threatened to shoot” Patient 1. On 7/25/24 at 1:59 P.M., an interview with the Clinical Specialist (CS) was conducted. The CS stated she was only “vaguely” aware and did not know the details of the incident. On 7/25/24 at 2 P.M., an interview with Patient Care Technician (PCT) 1 was conducted. PCT 1 stated on 7/13/24, Patient 1 has already completed his dialysis (cleaning of blood) treatment when he had an outburst after finding out his transportation would be late in picking him up. PCT 1 stated Patient 2 reacted to Patient 1’s outburst by yelling at Patient 1 to “shut up” and using racial slurs against Patient 1. PCT 1 stated Patient 1 yelled profanities to Patient 2. PCT 1 stated Patient 2 told Patient 1 “I am going to shoot you. I am going to f*****g kill you!” PCT 1 stated Patient 3 informed him she felt “scared” and “never wanted to sit next to Patient 2 again” after witnessing the altercation. PCT 1 stated the main concern was Patient 2 should not be on the same treatment schedule as Patient 1. On 7/25/24 at 2:30 P.M., an interview with the Facility Administrator (FA) was conducted. The FA stated on 7/13/24, he received a message from RN 3 stating there was a “verbal argument” between two patients. The FA stated he called RN 3 but was not informed that Patient 2 threatened to shoot Patient 1. The FA stated on 7/15/24, Patient 3 informed him she did not feel safe after hearing Patient 2 threatened to shoot Patient 1 and did not want to go to dialysis on 7/16/24 because of it. The FA stated the staff should have called the police because of the threat. The FA stated Patient 2 informed him she yelled profanities to Patient 1 and vice versa. The FA stated both Patient 1 and Patient 2 still dialyzed on the same shift on 7/16/24. On 7/25/24 at 3 P.M., an interview with Patient 3 was conducted. Patient 3 stated Patient 2 went on a “racist rant” and yelled profanities to Patient 1. Patient 3 stated Patient 1 also yelled profanities to Patient 2. Patient 3 stated Patient 2 threatened to “shoot” Patient 1. Patient 3 stated she did not want to put herself in an environment with a “vile” person and she was “hurt” because of what happened. Patient 3 stated Patient 2 had “bragged” to her before that she had more than one gun. On 7/25/24 at 3:20 P.M., an interview with Patient 4 via a Spanish-speaking interpreter/was conducted. Patient 4 stated she felt “scared” after witnessing the altercation between the two patients. On 7/29/24 at 1:45 P.M., an interview with Social Worker (SW) 1 was conducted. SW 1 stated she was not informed of the incident until 7/16/24. SW 1 stated she was initially told there was an “altercation” only between the two patients. SW 1 stated Patient 1 and Patient 2 still dialyzed on the same schedule on 7/16/24. SW 1 stated the staff informed her that Patient 2 was still saying “something” bad to Patient 1. SW 1 stated there was a lot of “missteps” on the way the facility handled the incident. SW 1 stated the situation should have been escalated to leadership. SW 1 stated the staff should have reached out to both patients’ doctors on the day of the incident to inform them of the incident. SW 1 stated the staff should have called the police due to the threat. SW 1 stated Patient 1 and Patient 2 should not have been still on the same treatment schedule on 7/16/24. On 7/31/24 at 9:39 A.M., an interview with RN 3 was conducted. RN 3 stated on 7/13/24, she witness Patient 1 and Patient 2 exchanged profanities. RN 3 stated Patient 2 yelled racist comments to Patient 1. RN 3 stated she sent a message to the FA that there was a verbal argument between two patients. RN 3 stated on 7/16/24, which was the next treatment session for both patients, Patient 2 came to the clinic and while Patient 1 was getting weighed on the scale close to where Patient 2’s treatment station, RN 3 stated she heard Patient 2 say “something racist” to Patient 1. RN 3 stated Patient 2 was trying to “get a reaction” from Patient 1. RN 3 stated the two patients should have not dialyzed at the same time after the incident. Per the facility’s policy and procedure titled Patient Rights and Responsibilities dated 1/2020, “...PATIENT RIGHTS:..2. The right to- receive care in a safe...environment...” Per the facility’s policy and procedure titled Involuntary Discharge or Transfer of a Patient and Checklist dated 1/2020, “...POLICY: ...d ...iii. Staff are required...to report any witnessed threat...to the FA, charge nurse or SW...PROCEDURE: 1...C. To ensure the safety of staff, patients and visitors, the violator will not be allowed to return to the facility until an assessment is made to determine further action...””