Davita Classic City 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: 50523 Based on a review of patient records, staff interviews and a review of facility Policy and Procedures (P&P), it was determined that the facility failed to ensure that one of one patient (P) (P#1) sampled, was treated with respect and dignity and provided with clear communication of information about assistance in personal needs during dialysis treatment based on a current comprehensive assessment by the Interdisciplinary Team (IDT), relative to P#1’s mobility level. This deficient practice had caused P#1 emotional discomfort and uncompleted hemodialysis treatments. This facility had 92 in-center hemodialysis (ICHD) patients under their care. Findings include: A review of P#1’s records revealed the following: - P#1 was admitted to this facility on 7/1/24 and was discharged on 3/19/25. - A review of P#1’s last six “Treatment Detail Report” flowsheets showed that P#1’s prescribed hemodialysis treatment time (duration), was three hours and 30 minutes, three times a week. - On 2/27/25, P#1’s hemodialysis treatment duration was two hours and 44 minutes and on 3/8/25 P#1’s hemodialysis treatment duration was two hours and 28 minutes. P#1’s hemodialysis treatment was ended early due to “Patient Choice”. There were no documentary evidences to explain why P#1 didn’t complete his hemodialysis treatment on 2/27/25 and 3/8/25. A review of P#1’s Comprehensive Interdisciplinary Assessment dated 8/22/24, revealed: - P#1 required “Limited Assist” (patient can bear some weight but requires the use of an assistive device to ambulate such as a cane, wheelchair or walker). There was no further follow up assessment by the Interdisciplinary Team (IDT) nor any documentary evidence to indicate that there had been a change in P#1’s mobility status to require him to be a “Full Assist” (total dependence). A review of P#1’s “Dialysis Emergency Procedure” dated 7/1/24, revealed that P#1 can exit the facility with an assistive device (walker) with teammate assistance. - During a telephonic interview with P#1 on 3/26/25 at 11:34 a.m., P#1 stated that two weeks before he discharged himself from the facility, he had trouble finding a dialysis caregiver (licensed nurses or Patient Care Techinicians -PCTs), who were willing to take him off from his dialysis machine and assist him to the restroom, which made him soil himself during hemodialysis treatment on two separate occasions. P#1 added that the facility staff told him that since he was transported by stretcher, he would have to receive assistance in the same manner he came in to this facility for hemodialysis treatment. P#1 explained that he only needed assistance with transferring him in and out of a wheelchair (after unhooking him from the dialysis machine), since the facility didn’t have any walkers. P#1 further explained that he did not need assistance toileting. P#1 also revealed that on 3/8/25, he had a bowel movement on himself while receiving hemodialysis treatment at this facility because no dialysis care staff was willing to assist him to transfer to a wheelchair and take him to the restroom, and he felt extremely embarrassed to accidentally soil himself. P#1stated that he continuously asked staff for assistance to the restroom, but the Charge Nurse/Registered Nurse (CN/RN AA) informed him that the facility could not personally assist him to the restroom due to safety concerns. P#1 stated that at both times (2/27/25 and 3/8/25), he soiled himself while undergoing hemodialysis treatment, so he had to end his hemodialysis treatment early, and requested for the transportation company to transport him back home. - On 3/26/25 at 12:22 p.m., PCT AA stated that if patients cannot stand on their own, the facility staff cannot transport them to the restroom. PCT AA stated that if the patients came in the treatment room by stretcher they must be assisted and transported the same way to avoid any falls or incidents in the treatment room and while at the facility. - On 3/26/25 at 12:37 p.m., CN/RN AA stated that she was told by upper management that if patients came into the facility by a stretcher, it is the transport company’s responsibility to transfer that patient. CN/RN AA revealed that on 3/8/25 she was the RN to inform P#1 that the facility could not assist him to the restroom because he came in by stretcher and that the facility wanted to avoid any safety hazards. CN/RN AA stated that P#1 was very upset because apparently certain staff had assisted him to the restroom in the past. - On 3/26/25 at 1:02 p.m., RN BB stated that staff were not supposed to assist with transferring a patient that came into the facility with a transportation company by stretcher. RN BB stated that it would be a liability for the facility if a patient sustained harm while in the facility’s care trying to assist with transferring a transported patient. - On 3/26/25 at 1:15 p.m., PCT BB stated that stretcher patients were treated as stretcher bound patients because there was no guarantee that the patient will or will not fall with assistance by facility staff. - On 3/26/25 at 1:24 p.m., the Social Worker (SW) stated that prior to 3/8/25, P#1 had spoken and complained to her about this facility’s rule (regarding assisting patients who were transported via stretcher). The SW stated that she did not file a complaint or grievance for P#1, but instead the SW asked the Facility Administrator (FA) to further explain the policy to P#1. - On 3/26/25 at 1:42 p.m., the FA stated that he spoke with P#1 regarding the facility’s safety procedure explaining that the transportation company would be needed for P#1’s assistance with transferring. The FA also added that he asked P#1 if he wanted to file a grievance report, but P#1 refused. The FA also confirmed that a complaint or grievance report wasn’t filed or documented in P#1’s behalf. - During a telephonic interview with the Medical Director (MD) on 3/26/25 at 4:10 p.m., the MD stated that he was made aware by facility staff regarding P#1’s complaint but by the time the MD came to the facility to make his monthly rounds, P#1 had already discharged himself from this facility and transferred to another facility. - There was no documentary evidence that the MD was notified by facility staff of P#1’s complaint to corroborate the MD’s statement. - A review of facility Policy: 3-01-06A, titled, “Addressing Patient Grievances: Davita Teammates” with latest revision date of October 2024, stated: 1. Patient grievances may be verbal or written. They may be submitted directly to a facility teammate or submitted to the DaVita Guest Services department. 2. All complaints/grievances should be documented on the facility Patient Grievance Log. 3. All details of patient grievances and discussions will be documented ... 4. The DaVita teammate receiving the grievance should report the grievance to the charge nurse, Facility Administrator (FA), or Social Worker. A review of facility Policy: 4-08-19, titled, “Safe Patient Handling” with latest revision date of October 2024, stated: 5. DaVita may refuse care if the charge nurse determines that the transfer would potentially expose the teammate or patient to injury. If care is refused, the RN will notify the patient’s attending nephrologist/ Non Physician Practitioner (NPP) and document the event in the patient’s electronic health record. 8. Communication of the recommended patient transferring method, will be documented by the RN, and included in the patient plan of care. -A review of facility Policy: 1-01-10, titled, “Refusal of Care/ Treatment Against Medical Advice” with latest revision date of October 2022, stated: 2. If a patient refuses care/treatment, the RN will document the event in the patient’s medical record. Documentation will include, as appropriate, the following: - A description of the care/ treatment that was refused by the patient; - The patient’s stated reason for refusing care/ treatment ... - A description of all other interventions planned to address the patient’s refusal of care/ treatment, including recommendations to the patient; and - A copy of the refusal of care/ treatment Against Medical Advice form signed by the patient.”

“PA-EVAL CURRENT PHYS ACT LVL/VOC/PHYS REHAB CFR(s): 494.80(a)(12), (13) The patient’s comprehensive assessment must include, but is not limited to, the following: (12) Evaluation of current patient physical activity level. (13) Evaluation for referral to vocational and physical rehabilitation services. This Standard is not met as evidenced by: 50523 Based on a review of facility records, staff interviews and a review of facility Policy and Procedures (P&P), it was determined that the Interdisciplinary Team (IDT) failed to conduct a current comprehensive re-assessment of patient’s (P) (P#1’s ) mobility status such as ability to ambulate, transfer, and other physical activities pertinent to the dialysis environment, including but not limited to observation, to determine the current level of assistance needed by P#1 that was reflected in P#1’s current, individualized Plan of Care (POC); and failure of the IDT to clearly communicate to P#1 any changes in the assistance provided by the facility’s Direct Care Staff (licensed nurses and Patient Care Technicians - PCTs), before refusing P#1 of the assistance he needed. This failure resulted in P#1’s incidences of soiling himself during hemodialysis treatment that led to shortened treatments on two of two occasions. This facility had 92 in-center hemodialysis (ICHD) patients under their care. Finding include: A review of P#1’s Comprehensive Interdisciplinary Assessment dated 8/22/24, revealed: - P#1 required “Limited Assist” (patient can bear some weight but requires the use of an assistive device to ambulate such as a cane, wheelchair or walker). There was no further follow up assessment by the Interdisciplinary Team (IDT) nor any documentary evidence to indicate that there had been a change in P#1’s mobility status to require him to be a “Full Assist” (total dependence). - There was no documentary evidence that the IDT conducted a current comprehensive re-assessment and current Plan of Care relative to P#1’s change in mobility status and level of assistance needed as well as what the licensed nurses and PCTs can provide, prior to refusing P#1’s need for assistance. - The Facility Administrator was not able to provide a documentary evidence of P#1’s current POC when requested. - A review of facility Policy: 1-14-01, titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” with latest revision date of October 2020, stated: 7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: Marked deterioration in health status - For additional information, please Cross Reference: V 452 - Failure of the facility to ensure that one of one patient (P) (P#1) sampled, was treated with respect and dignity and provided with clear communication of information about assistance in personal needs during dialysis treatment. - On 3/26/25 at 4:55 p.m., the Facility Administrator acknowledged these findings.”