Davita Douglasville Dialysis

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 50523 Based on a review of facility records, staff interviews, and a review of the facility’s Policies and Procedures (P&P), it was determined that the Medical Director failed to ensure that one of one Registered Nurse (RN AA) and one of one Patient Care Technician (PCT AA), adhered to the facility’s established P&P relative to required presence of at least one RN and one PCT while one of one patient (P) #1, was still present inside the facility. Failure to have a Direct Patient Care (DPC) staff (at least one RN and one PCT) to be present while P#1 was still in the facility had the potential risk of negatively affecting the health and safety of P#1, which could include complications post dialysis treatment such as, but not limited to: hypotension (low blood pressure), loss of consciousness, shortness of breath, bleeding access, and electrolyte imbalance, while being unattended. The facility had 75 in-center hemodialysis patients and nine peritoneal dialysis (PD) patients who were under their care. Findings include: - A review of the facility’s “Patient Grievance Log”, from February 2025 to August 2025, revealed the following: - P#1’s wife presented a verbal complaint on 8/26/25 at 5:15 a.m., to PCT BB, and stated that on 8/22/25, P#1 was locked inside the facility after exiting the Patients’ Restroom. P#1’s wife stated that there were no staff members (nurses and patient care technicians) present at the time. A member of the cleaning crew (janitorial services) was eventually able to unlock the door for P#1 to exit the facility. - A review of the facility’s “Risk Event Management” (REM) records dated August 26, 2025 revealed that the facility had taken actions pertaining to P#1’s complaint stating that a grievance meeting was held and the primary nurse was notified. - A review of the facility Lobby Video Surveillance on August 22, 2025 revealed the following: P#1 exited the Patient Treatment Room and left the facility through the front doors at 6:48 p.m. P#1 returned inside the lobby at 6:53 p.m. and proceeded to enter the Patients’ Restroom. At 6:58 p.m., RN AA escorted P#2 and her daughter from the Patient Treatment Room to the front door. At 7:00 p.m., RN AA locked the front door, turned off the lobby lights and returned to the Patient Treatment Room. At 7:05 p.m., P#1 exited the Patients’ Restroom. - A review of the “Teammate Timecards” (used to track employee work hours) on August 22, 2025, revealed the following: - PCT AA clocked in at 4:28 a.m. and clocked out at 7:02 p.m. - PCT BB clocked in at 4:06 a.m. and clocked out at 3:23 p.m. - PCT CC clocked in at 4:19 a.m. and clocked out at 4:50 p.m. - RN AA clocked in at 4:27 a.m. and clocked out at 7:01 p.m. - RN BB clocked in at 4:12 a.m. and clocked out at 4:04 p.m. - A review of the facility’s “End of Day Dialysis Facility Guidance”, revealed the following: At the end of each treatment day all patient areas including treatment area(s), lobby, and rest room(s) are visually checked by teammate(s) to make sure no patient/ caregiver/ visitor is still in the facility. RN AA and PCT AA both clocked out and left the facility before P#1 exited the facility. Although the facility filed the grievance for P#1, there was no documented evidence that P#1 was contacted to discuss the complaint, there were documented findings of the investigation, nor a resolution plan. Additionally, there was no documentation indicating that RN AA was spoken to, nor was there any in-service training conducted to educate her and the other direct care staff regarding the “End of Day Dialysis Facility Guidance”. - During an interview with PCT BB on 9/2/25 at 12:10 p.m., she stated that the Patients’ Restroom and lobby had to be confirmed as empty, and staff were required to verify that no patients were standing outside waiting to be picked up before the closing RN and PCT could leave the facility. - During an interview with PCT AA on 9/2/25 at 12:20 p.m., she stated that she always checked the patients’ bathrooms, lobby, and outside of the facility to verify that all patients were gone. PCT AA stated that neither the RN nor the PCT could leave for the day until all patients had left. - During an interview with the RN BB on 9/2/25 at 12:32 p.m., she stated that if a patient was still present inside or outside the facility, the RN or closing PCT was not permitted to leave until the patient had left the facility. RN BB also stated that all patients’ restrooms and the lobby were required to be checked prior to locking the facility’s front doors and before leaving. - An attempt to call P#1 was conducted on 9/2/25 at 1:00 p.m., but was unsuccessful. A message for P#1 was left by this surveyor on P#1’s voicemail to call back, at P#1’s earliest convenience. - A telephonic interview was conducted on 9/2/25 at 1:13 p.m., with the Medical Director (MD). The MD stated that he had been made aware of the incident and wanted the staff to be immediately in-serviced and educated on the end-of-day dialysis facility guidelines, including visually checking to ensure no patients remained in or at the facility before staff left. - During the exit interview on 9/2/25 at approximately 3:00 p.m., the Facility Administrator and the Assistant Facility Administrator both acknowledged the above findings. - A review of the facility’s Policy: 3-01-06 titled, “Patient Grievance”, with latest revision date of April 2025, stated: Internal Grievance Process: C. The FA (or their designee) is to discus the grievance with the patient, investigate and take appropriate action towards a solution, if possible. This discussion should occur within 10 days of receipt of the grievance. - A review of the facility’s Policy: 8-02-01 titled, “Teammate Qualifications, Licensure and Adequate Teammate Staffing”, with latest revision date of October 2017, stated: 6. At the end of the day, a minimum of one (1) licensed nurse (RN) or Licensed Practical Nurse [LPN]/ Licensed Vocational Nurse [LVN] as required by state regulations) and another teammate must be present as long as any patient is on the DaVita premises.”