Fmc of Dekalb Gwinnett Inc.

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 50523 Based on facility record review, patient and staff interviews and a review of facility Policy and Procedures (P&P), it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This deficient practice had the potential to negatively affect the health and safety of 54 in-center hemodialysis patients who received hemodialysis services at this facility. Findings include: Cross-Reference: V 452 - Failure of the facility to ensure there was a culture of safety for patients and to ensure patients were treated with respect and dignity.”

“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: 50523 Based on observation, a review of facility records, patients and staff interviews, and a review of the facility’s Policies and Procedures (P&P), it was determined that the Clinical Manager (who was the Facility Administrator), failed to ensure all patients were treated with respect and dignity and were provided support and resolution regarding patients’ voiced concerns, grievances and complaints. Failure of direct patient care staff (nurses and patient care technicians-PCTs), to follow facility Policy regarding patients’ voiced concerns, complaints and grievances, staff behavior expectations of treating others with respect, dignity and ethical manner, deprived all patients of a culture of safety to be able to freely voice their concerns, complaints and grievances without fear of retaliation. This deficient practice had the potential to negatively affect the emotional health and safety of all 54 patients who were dialyzing at the facility. Findings include: During observation in the Patient Treatment Room on 6/25/25 between 11:01 a.m. and 12:50 p.m., it was observed that all staff were respectful to all patients during initiation and termination of dialysis treatments (shift change from first to second shift). During patient (P) interviews on 6/25/25 between 11:15 a.m. and 11:47 a.m., the following was revealed: - P#5 stated at 11:15 a.m., that she did not feel comfortable sharing her concerns with the nurses and PCTs, because she had voiced her concerns/complaints in the past but she felt that they were never addressed. P#5 also added that she chose to simply come to her hemodialysis treatments and kept any concerns to herself. - P#6 stated at 11:47 a.m., that she was afraid to speak up because she felt that the facility was not interested in addressing her concerns regarding the way certain staff members treated her and other patients. During Staff (nurses, PCTs, Clinical Manager and Social Worker - SW) interviews on 6/25/25 between 11:29 a.m. and 2:20 p.m., the following was revealed: - Licensed Practical Nurse (LPN AA), stated at 11:29 a.m., that the patients frequently made verbal complaints to her regarding the care received at the facility. LPN AA stated that whenever the patients voiced their concerns to her, she consistently referred them to the SW or to the Clinic Manager so that they (SW and Clinical Manager), could file a grievance on behalf of the patients. - PCT BB stated at 11:41 a.m., that when patients shared their complaints to her regarding the nurses’ and PCTs’ delivery of care to patients, PCT BB stated that she directed the patients to file a complaint with the SW or the Clinical Manager, rather than filing a grievance for the patients herself. - PCT CC stated at 12:32 p.m., that patients’ grievances were not addressed appropriately. PCT CC reported that many patients had discussed their concerns with her regarding issues at the facility. PCT CC added that most patients did not report their grievances to the SW or the Clinical Manager, because they felt their concerns would not be taken seriously. PCT CC also stated that she had never submitted a patient’s grievance. - The Administrative Assistant (AA) stated at 1:02 p.m., that there were times when patients expressed their concerns and dissatisfaction to her regarding their care, and she advised them to report their complaints to the SW or the Clinical Manager. The AA also added that she didn’t have access to the patients’ Grievance Log. - The SW, during a telephonic interview at 1:32 p.m., stated that any staff member could file a verbal or written grievance on behalf of patients. The SW also added that if patients’ grievances were not documented, they could not be properly addressed or resolved. - Registered Nurse (RN AA) at 12:49 p.m., stated that she had not received any complaints from patients. - The Clinical Manager stated at 2:20 p.m., that there were times when patients made verbal complaints to her, and she addressed their concerns immediately; however, those complaints were not recorded in the Patients’ Grievance Report. The Clinic Manager also stated that if patients’ grievances that were reported to the staff, were not filed or documented, they were not addressed because she was not made aware of these patients’ grievances. - A review of the facility’s “Patient Grievance Report” from December 2024 through June 2025 showed four complaints related to patient care. - P #1, on 12/16/24, requested to speak with the facility’s SW regarding a nurse’s sarcastic response to his inquiry and did not directly respond to him about his questions regarding his hemodialysis treatment. On 2/12/25 (58 calendar days later), the SW stated in her Initial Service Recovery: ... P#1 shared with the SW that he was having a lot of anxiety “around his care/health and expects that if he has questions/concerns they will be answered respectfully and professionally”. (sic) P#1 also added that he had concerns about his iron (for the treatment of anemia) and was not addressed until three weeks later. - P#2 on 12/17/24, expressed concerns about his safety and felt dismissed once he attempted to express his concerns with the PCTs. The SW’s Initial Service Recovery was dated 1/24/25 (38 calendar days later). - P#3’s daughter expressed her concerns about P#3’s care on 2/17/25, by PCT AA. P#3’s daughter did not want PCT AA to provide care to her father (P#3), because PCT AA was very rough with P#3 on 2/14/25. Corrective action was taken, and a documented counseling was given to PCT AA on 3/20/25 (31 calendar days later), after another patient (P#4), voiced a complaint regarding PCT AA’s behavior on 3/18/25. - P#4 on 3/18/25, complained that PCT AA threw her gloves at him in the past and was very rude in tone towards him. P#4 reported feeling unsafe and worried this behavior would happen again intentionally. The SW’s “Initial Service Recovery” note, dated 4/3/25 (16 calendar days later), stated: SW met with the patient today after the patient expressed wanting to transfer from the clinic. The patient reports he feels as if he has been label as a “problem patient’ and it has impacted his treatment from the staff. The patient identified how in the past (PCT AA) has thrown gloves at him. Patient reported he inquired with her (PCT AA) about why she was so rude to him and he (P#4), reported she (PCT AA) replied “Because of how you are, everyone knows how you are”. The patient reports due to this response he feels unsafe about his treatment and worries if things will be done to him intentionally. (sic) - P#5 on 2/12/25, expressed concerns about PCT EE that when PCT EE was working the patients including himself, were forced to wait a long time for start of treatment and waiting a long time coming off when treatment was completed. The SW’s Initial Service Recovery, dated 2/17/25, stated: ... “Patient also shared there are times when he asks her questions and is ignored”. (sic) Although the Patient Grievance Report showed that the above patients’ complaints were resolved, there was no documented evidence of additional actions or staff audits to ensure the facility’s Policy regarding Patient Grievance and providing respect and dignity were implemented and followed by the staff, and there was no documented evidence that the facility ensured there was a culture of safety for patients established, for freedom of communication and to prevent fear of retaliation. A review of facility Policy: Version 4, titled, “Patient Grievance” with latest revision date of May 5, 2025, stated: A patient or designated representative may register a verbal or written complaint at any time directly or anonymously through the following channels, identified on the “Important Numbers” document: “ Any facility staff member, Clinical Manager, or Director of Operations It is expected that all staff members will attempt to address and resolve patient complaints immediately, within the timeframe of the patient/ representative encounter. A review of the facility’s Human Resources, “Behavior in the Workplace”, version 1 with an effective date of 12/15/2020, stated: Guidelines: Expectations for behavior in the workplace includes: * Treat others with dignity and respect * Act in an ethical manner...”