Fkc Riverside Park

“CFC-PATIENTS- RIGHTS CFR(s): 494.70 This Condition is not met as evidenced by: 30177 Based on interview, document review, and review of facility policies, the facility failed to meet the Condition for Coverage (CfC) for Patients’ Rights when they 1) failed to protect patients from verbal abuse for two of two patients (Patient (P) P11 and P12 and 2) failed to ensure it implemented an internal grievance process that informed the patient/designee of the status of the investigation periodically, and when resolution is attained. The pervasive non-compliance with patients’ rights and staff-to-patient verbal abuse violated patients’ rights and created an unsafe and hostile environment for all 79 in-center hemodialysis patients. Findings include: 1. The facility failed to protect two of two patients from verbal abuse when 1.) Patient Care Technician (PCT)1 yelled, cursed, and physically threatened P11 and 2.) PCT2 subjected P12 to disrespectful and demeaning behavior on the treatment floor. (Refer to V452). 2. The facility failed to ensure it implemented an internal grievance process that informed the patient/designee of the status of the investigation periodically, and when resolution is attained (Refer to V765).”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 30177 Based on observation, staff interview, and policy review, the facility failed to ensure the salt level in the brine tank (a plastic container that holds salt pellets that produces a brine solution) was “at least “half full. The failed practice did not ensure sufficient concentrated sodium-rich salt solution for regeneration to prevent scaling to reverse osmosis membranes. This failed practice had the potential to negatively impact the safety and well-being of the 79 in-center hemodialysis patients receiving treatments at this facility. Findings include: Observation of the water treatment area on 01/03/24 at 3:22 PM with the Biomedical Technician (BMT) revealed the salt level in the brine tank was maintained at a minimum of half full. During an interview on 01/03/24 at 3:30 PM, the BMT confirmed that the brine tank’s salt level was not maintained at half full. The BMT was questioned about the expectations for the salt level in the brine tank and replied that the salt level should be half full. The BMT was then asked who was responsible for monitoring and maintaining the salt level in the brine tank. The BMT replied, “the Patient Care Technicians (PCTs). A review of the facility’s policy titled, “Water Softener,” with a published date of 05/03/23, revealed, “Check brine tank daily to be sure the tank is at least half filled with salt, adding salt pellets if necessary. . .Salt levels inside brine tanks will be maintained at a minimum of half full.””

“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: 30177 Based on interview, document review, and review of facility policies, the staff failed to ensure all patients were treated with respect and dignity, in that patients (Patient (P) P11 and P12) were the victims of staff-to-patient verbal abuse by Patient Care Technician (PCT) 1. PCT1 yelled, cursed, and physically threatened P11 by lunging at patient during his/her hemodialysis treatment where other patients and staff were present. P12 was subjected to disrespectful and demeaning behavior perpetrated by PCT2. This failed practice created an unsafe and hostile in-center hemodialysis treatment environment and did not protect and promote the patients’ right to respect and dignity for all 79 in-center hemodialysis patients dialyzing in this center. Findings include: 1.Review of an untitled document, which the Facility Administrator and Director of Operations described as the “Patient’s Grievance Log,” revealed on 09/22/22 PCT1 engaged in a verbal altercation with P11. Documentation revealed that “P11 was communicating with the nurse when PCT1 intervened and cursed, yelled, engaged in name-calling, and lunged [at him/her in the treatment area during a] heated argument creating an unsafe environment for patients and other staff.” Documentation noted that PCT1 engaged in a verbal altercation with the patient’s spouse on the parking lot post-dialysis treatment that same day. The grievance also revealed that P11 indicated that he/she feared reprisal. During an interview on 01/05/24 at 11:30 AM, the Director of Operations was asked what he/she recalled of an incident on 09/22/22 involving P11. The Director of Operations revealed that he/she was aware of the incident. When asked if PCT1’s yelling, cursing, and lunging at P11 was considered demeaning, disrespectful, and verbally abusive, he/she replied, “Yes.” The Director of Operations was asked if PCT1 was present in the facility and continues to care for patients, he/she replied, “Yes” and stated PCT1 was reassigned to not work with P11 at that time of the incident. There was no documentation to support how patients who were present and witnessed the abuse were protected from abuse by PCT1. In an interview with PCT1 on 01/05/24 at 1:30 PM, PCT1 was asked what he/she recalled of the incident on 09/22/22 involving P11. PCT1 confirmed that he/she yelled and cursed at P11 during a verbal altercation on 09/22/22. In an interview with the Social Worker on 01/05/24 at 1:45 PM, he/she was asked what he/she recalled of the incident on 09/22/22 involving P11. The Social Worker revealed that he/she was aware of the incident and that the patient was provided and asked to sign a “letter of behavior concern” related to the incident. The Social Worker stated that on 10/04/22, P11 requested to be transferred to another facility. Additional grievances from P11 revealed that on 10/11/22, 11/08/22, 12/01/22, 01/05/23, and 01/31/23, P11 again asked to transfer to another facility. P11 was transferred to another facility on 03/04/23. 2. Review of an untitled document, which the Facility Administrator and Director of Operations described as the “Patient’s Grievance Log,” revealed on 03/04/22, P12 submitted a grievance indicating he/she “feels uncomfortable being cared for by PCT2 due to comments made by PCT2” while caring for him/her. PCT2 yelled across the clinic, give him/her Benadryl; you know it’s 8:00 AM; he/she’s gonna [sic] be asking for it.” P12 stated the incident and yelling about his/her care across the treatment floor embarrassed him/her. P12 further stated that when he/she asked PCT2, “why he/she did that, PCT2 brushed him/her off.” The Clinic Manager met with PCT2 to explain to PCT2 that him/her behavior was inappropriate, and that the patient was very upset by this. PCT2 acknowledged that he/she was “not having a good day” and should not have taken it out on the patient. Per patient request, PCT 2 will not be assigned to the patient ...” During an interview with P12 on 01/05/24 at 3:50 PM, he/she was asked if he/she recalled an incident involving PCT2. P12 stated that he/she remembered the incident and revealed that he/she felt embarrassed when PCT2 yelled across the facility to the nurse regarding the patient’s medical care. P12 stated that he/she requested not to be cared for by PCT2. During an interview on 01/05/24 at 11:30 AM, the Director of Operations was asked what he/she recalled of an incident on 03/04/22 involving P12. The Director of Operations revealed that he/she was aware of the incident. When asked if yelling at a patient’s confidential medical care across the treatment floor while patients and other staff were present during treatment was considered disrespectful and demeaning, the Director of Operations replied yes. Review of the facility’s policy titled, “Patient Rights and Responsibilities,” revised on 04/04/12, revealed that “The patient has the right to respect, dignity, and recognition of his or her individual and personal needs, and sensitivity to his or her psychological needs and ability to cope with end-stage renal disease (ESRD) ... Patient rights and the ability to exercise these rights must be protected by the facility.””

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 30177 Based on interview, document review, and review of facility policies, the facility failed to ensure it implemented an internal grievance process that informed the patient/designee of the status of the investigation periodically, and when resolution is attained or considered attained by the facility. In addition, the facility failed to follow the facility policy and communicate with eight supplemental sample patients (Patient (P) P13, P14, P15, P16, P17, P18, P19, and P20) with periodic updates of the status of their grievance investigation when the grievance was not immediately resolved or when a resolution was attained. This failure had the potential for patients’ grievances to go unresolved and could potentially negatively impact all 79 patients receiving in-center hemodialysis treatments at this facility. Findings include: Review of an untitled document, which the Facility Administrator and Director of Operations described as the “Patient’s Grievance Log,” revealed the following: A grievance was received for P13 on 03/04/22 and documented as resolved on 09/12/2023. A grievance was received for P14 on 02/04/22 and 02/21/22 and documented as resolved on 09/12/2023. A grievance was received for P15 on 05/03/23 and documented as resolved on 09/12/2023. A grievance was received for P16 on 05/03/23 and documented as resolved on 09/12/2023. A grievance was received for P17 on 05/03/23 and documented as resolved on 06/08/2023. A grievance was received for P18 on 05/02/23 and documented as resolved on 09/12/2023. A grievance was received for P19 on 03/13/23 and documented as resolved on 09/12/2023. A grievance was received for P20 on 02/01/23 and documented as resolved on 04/03/2023. However, there was no documentation to indicate that the facility staff provided the patients or their representatives with periodic updates on the progress of the grievance during the unresolved period. Additionally, there was no documentation that the “Clinic Manager” reported back to the patient when a resolution was attained or considered attained by the facility. During an interview on 01/04/24 at 3:15 PM, the Director of Operations and the Facility Administrator were asked to provide information regarding the resolution of P13, P14, P15, P16, P17, P18, P19, and P20 grievances. In response, the Director of Operations stated that the grievance was not immediately resolved. Subsequently, the Director of Operations was requested to present documentation confirming the periodic updates provided to the patient or their representative on the grievance status and evidence indicating when the facility communicated the resolution to the patient. The Director of Operations confirmed that the facility failed to periodically update the patients or their representative on the grievance status and failed to communicate the resolution to the patients. Review of the facility’s policy titled, “Patient Grievance Procedure,” revised on 04/04/14, revealed, “The Clinical Manager reports back to the patient when a resolution is attained or considered attained by the facility. When the grievance cannot be immediately resolved, the Clinical Manager must provide the patient/representative with updates periodically on progress.””