Davita Inverrary Dialysis

“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: 36734 Based on record review and interview, the facility failed to investigate and attempt a resolution without reprisal or denial of services for 1 sampled patient (Patient #1), as evidence by the facility initiated an involuntary discharge for the patient after the patient filed a grievance against the facility. The findings included: Record review revealed Patient #1 was admitted to the facility for treatment on 3/15/25. A telephone interview was conducted with Patient #1 on 07/11/25 at 11:00 AM. The patient stated he reported the head nurse for conduct and in response, he was told to leave the facility. The patient stated he was put in a room and threatened by a physician he had never seen before. Patient #1 stated he expected the facility to reprimand the nurse. He only wanted an apology. A review of a Grievance/Investigation Document, dated 05/16/25 for Patient #1, documented a verbal complaint as follows: Social Worker (SW) met with patient to discuss psychosocial concerns. The patient shared, “I was violated and I want to know if the facility is going to pay for my counseling. I have post traumatic stress disorder (PTSD) and this made it worse.” SW informed patient that she needed to obtain additional information. SW informed patient that the facility does not have a policy concerning payment for patient counseling. Patient shared that he felt his rights were violated, his information was shared and his machine malfunctioned. SW sought additional clarification for dates of the events the patient had mentioned. Patient shared, “I felt bullied, but it just wasn’t right.” SW informed patient that she would file a grievance on his behalf and would formalize in writing. SW asked patient if he would like a referral for counseling and patient declined. Patient shared, “I don’t want a referral I only want to know that the facility is going to pay for it.” SW informed patient that she could only provide a referral and could not assume or guarantee that the facility would pay for it as that is not in their policy. Patient shared, “I need somebody to lose their job, that’s what I need.” SW discussed formalizing patient’s grievance and indicated she will follow up with patient in the coming week. The investigation revealed: SW and facility administrator (FA) interviewed staff to obtain collateral information. Staff confirmed that the patients machine malfunctioned on 05/05/25. Staff confirmed that the patient had an accident and left feces in his chair on 05/09/25. Staff confirmed that the patient expressed that he felt he was disrespected and it triggered his PTSD. The plan documented was for the medical director, FA, and SW to conduct a meeting with the patient to discuss his grievance. The machine that malfunctioned was removed from the floor. An interview was conducted with the SW on 07/11/25 at 1:00 PM. The SW stated Patient #1 had defecated on himself while receiving treatment. The patient stated that staff had told everyone in the facility about the incident. The SW stated the facility medical director, FA and self had a meeting with Patient #1 on 05/23/25 to discuss the patient’s grievance. The SW stated that Patient #1 was adamant about a staff member being terminated because he felt his rights were violated. The SW stated Patient #1 was aggressive and threatened to call corporate and other agencies. The SW stated the medical director told Patient #1 that no one was going to be fired, and he had the right to contact whomever he chose. The SW stated after the meeting the medical director and the facility issued a 30 day discharge notice to Patient #1. Surveyor questioned the SW if Patient #1’s grievance was ever followed up on, and the SW replied yes, that was the meeting. An interview was conducted with the FA on 07/11/25. The FA acknowledged the above. Surveyor questioned if staff were educated on customer service and/or patient rights in response to Patient #1’s grievance. The FA stated “No.” No resolution was offered to Patient #1.”

“GOV-INVOL DISCHARGE PROCESS REQUIREMENTS CFR(s): 494.180(f)(4) The medical director ensures that no patient is discharged or transferred from the facility unless - (4) The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team- (i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record; (ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge; (iii) Obtains a written physician’s order that must be signed by both the medical director and the patient’s attending physician concurring with the patient’s discharge or transfer from the facility; (iv) Contacts another facility, attempts to place the patient there, and documents that effort; and (v) Notifies the State survey agency of the involuntary transfer or discharge. (5) In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to ensure a patient was appropriately involuntarily discharged from the facility for 1 sampled patient (Patient #1). The findings included: Record review revealed Patient #1 was admitted to the facility for treatment on 3/15/25. Patient #1’s last treatment at the facility was on 06/06/25. A telephone interview was conducted with Patient #1 on 07/11/25 at 11:00 AM. The patient stated he reported the head nurse for conduct and in response, he was told to leave the facility. The patient stated he was put in a room and threatened by a physician he had never seen before. The facility administrator (FA) and social worker (SW) were present. The patient stated he had an “accident” in April and the nurse started yelling and telling everyone. Patient #1 stated he was forced to leave the facility. The facility never told him that he could stay. The facility got a security guard to watch him while he was getting treatment. It made him feel uncomfortable, he did not have a choice but to leave. Patient #1 stated he went to his primary care physician that provided him a list of nephrologists. His new nephrologist has privileges at the facility, but suggested due to everything that was going on that he transfer to another facility. Patient #1 stated he expected the facility to reprimand the nurse. He only wanted an apology. An interview was conducted with Staff A, a registered nurse, on 07/11/25 at 12:00 PM. Staff A stated the Patient #1 was his patient. Staff A stated Patient #1 had no behaviors, and the patient was not a problem. The patient did have stomach issues and sometimes would cut his treatment short, but other than that he was very compliant. Staff A stated that Patient #1 was his patient the day of the incident (doesn’t remember date). Staff A went on break, and when he came back, the patient was not in the chair and the chair was messy with feces. Patient #1 came out the bathroom and stated he was embarrassed. Patient #1 was discreetly escorted out of the facility. Staff A stated the last time the patient wanted to be taken off due to an upset stomach, Staff A went to the charge nurse (CN) and told her that he wanted to come off treatment. The CN handed him an information pamphlet about risk of cutting treatment short and told him to give it to the patient. Staff A stated he gave it to the patient and the patient threw the pamphlet on the floor and told him to have the CN come give it to him. The CN went to the patient and gave him the pamphlet from the floor and told him that this is what could happen if you missed treatment. The two had words back and forth. The CN brought up the incident about the patient soiling himself and told the patient that she kept the incident discreet. The CN was passing medications while going back and forth with the patient. When questioned if he told anybody about the incident he stated he told the social worker the same thing. An interview was conducted with the CN on 07/11/25 at 12:30 PM. The CN stated she knew Patient #1. The CN further stated the patient did not have any behaviors. The CN stated she was upset the patient decided to leave the facility. The CN recalled the incident she had with Patient #1 where they had “words”. The CN stated she did not think it was a big deal. The patient was still cordial with her when he came in. The CN further stated she was told by management that the patient wanted her fired. When asked if the facility had a security guard present for Patient #1, she stated yes, when Patient #1 came in for treatment, there was a security guard present. When Patient #1 would leave, the security guard would leave. An interview was conducted with the SW on 07/11/25 at 1:00 PM. The SW stated Patient #1 had soiled himself while receiving treatment. The patient stated that staff had told everyone in the facility about the incident. The SW further stated Patient #1 was insistent hat his rights were violated and he wanted the CN to be fired. The SW stated she started a grievance for Patient #1. The SW further stated Patient #1 did not have any behaviors prior to this incident or after. The SW stated the facility medical director, FA and self had a meeting with Patient #1 on 05/23/25 to discuss the patient’s grievance. The SW stated that Patient #1 was adamant about a staff member being terminated because he felt his rights were violated. The SW stated Patient #1 was aggressive and threatened to call corporate and other agencies. The SW stated the medical director told Patient #1 that no one was going to be fired, and he had the right to contact whomever he chose. The SW stated after the meeting the medical director issued a 30 day discharge notice to Patient #1, and then the facility followed. A review of a copy of the certified mail dated 5/28/25 to the patient documented: “We are writing to inform you that effective Friday 6/27/25 Florida kidney physicians will no longer be able to provide professional medical services to you this decision comes after your continual negative interactions towards staff and refusal to communicate in an effective manner.” A review of a copy of the facility’s letter to Patient #1, dated 6/2/25 documented that the doctor has informed the facility that he will be discharging you from their care on 7/2/25 and no longer providing medical orders for your dialysis care. If you do not have a nephrologist who is credentialed in our facility and willing to take over your care by 7/2/25 we will need to discharge you from our facility effective 7/2/25. Therefore the doctor will no longer be providing orders for your dialysis care, we will have to discharge you from our facility 30 days from the date of this letter. The facility cannot dialyze you without orders from a nephrologist who is credentialed in our facility. A list of nephrologists who have privileges to practice at the facility is attached as well as area dialysis centers and area hospitals for emergency care. Please inform us of your new nephrologist as soon as possible so we can facilitate the transfer of your medical records for your ongoing dialysis care. An interview was conducted with the FA on 07/11/25. The FA acknowledged the above. The FA confirmed that they did have security to supervise the Patient #1 during dialysis treatments until the patient transferred out of the facility. The FA stated the patient made a comment that he had post-traumatic stress disorder (PTSD) and they thought it would be safer to have security available. Surveyor questioned the FA if she felt that having a security guard present during the patients treatment could be seen as intimidation and/or retaliation of the patients grievance. The FA had no response.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 40153 Based on observations, interviews and record review, the facility failed to perform disconnection of a central Venous Catheter (CVC) in a sanitary manner for 1 of 9 patients during dialysis observation (Patient #6). The facility failed to initiate an Arteriovenous (AV) fistula for dialysis treatment in a sanitary manner for Patient #7 and failed to perform disconnection of AV Fistula dialysis treatment in a sanitary manner for 2 of 9 patients reviewed (Patient #7 and Patient #8) The findings included: A review of the facility’s policy titled “Infection Control for Dialysis Facilities,” revised on April 2023, revealed the following: All teammates, Physicians, and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e.plugging/unplugging acid/bicarb lines from dialysis machine, changing acid types, when exchanging a dialysis machine), f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. In an observation conducted on 09/30/24 at 11:43 AM, Staff C, a Patient Care Technician (PCT), was performing the initiation of AV fistula dialysis for Patient #7. Staff C was observed washing her hands and putting on a clean pair of gloves. Halfway through the initiation, Staff C removed her left glove and reached for a drawer to pull out a new syringe. She then donned a new glove on her left hand without practicing hand hygiene and proceeded to touch the bloodlines. In an observation conducted on 09/30/24 at 1:20 PM, Staff C was performing disconnection of AF fistula dialysis on Patient #8. Staff C was observed washing her hands and donning a new pair of gloves before touching the Patient’s bloodlines. She then adjusted the dialysis chair with her gloved hands and touched the bloodlines without changing gloves or practicing hand hygiene. In an observation conducted on 09/30/24 at 1:45 PM, Staff I, a Licensed Practical Nurse, was observed disconnecting a central venous catheter for Patient #6. While touching the Patient’s bloodline, Staff I touched his face shield to adjust the straps and did not change gloves or practice hand washing before returning the bloodline connections. In an interview conducted on 10/02/24 at 11:50 AM with the facility’s Administrator she was made aware of the findings.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 40153 Based on observations, interview and record review, the facility failed to track immunization status regarding the Influenza vaccine and failed to obtain a refusal consent form for 1 of 4 patients reviewed (Patient #4). The findings included: A review of the facility ’ s policy, “Seasonal Influenza Management,” revised in April 2024, revealed the following: to prevent the spread of seasonal influenza infections in dialysis settings. A review of the facility ’ s policy, “Vaccinations for Adults Hemodialysis Patients,” revised in October 2024, revealed the following: Refusal will be documented on the consent form and in the electronic health record. The consent form must be completed and filed in the Patient ’ s medical record. A record review revealed that Patient #4 was admitted to the facility on 11/10/23 for in-center Hemodialysis. Further review did not reveal Patient #4 was offered or refused the yearly Influenza vaccine. Patient #4 was admitted during the season for Influenza management. In an interview conducted on 10/1/24 at 3:38 PM with the Facility ’ s Administrator, she stated Patient #4 refused the influenza vaccine, but she lacked the supporting documents the consent form was offered to the Patient and his refusal.”