Davita Walton County Dialysis

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 50523 Based on facility record review, a review of facility Policy and Procedure (P&), and patient and staff interviews, 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 39 in-center hemodialysis (ICHD) who were under the care of this facility. Findings include: Cross Reference: V757 - Failure of the Governing Body to ensure that the facility had adequate number of qualified staff to meet the needs of all patients and provide safe patient care; and to be in compliance with the minimum State required staffing ratios of one licensed and qualified nurse for every 12 patients who were receiving dialysis care and one qualified patient care giver for every four patients. Also, the Governing Body failed to identify and address the root cause of inadequate staffing.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 50523 Based on a review of facility records, patient and staff interviews, a review of the facility’s Policy and Procedures (P&P), and a review of the minimum state-required staffing ratios, it was determined that the Governing Body failed to ensure that the Facility Administrator employed adequate number of qualified staff to meet the needs of all patients as evidenced by a lack of at least one licensed and qualified nurse (who was not counted as a dialysis care giver in the staff-to-patient ratio of one dialysis care giver to four patients) who was readily available to provide nursing care, take charge and deal with unexpected complications of dialysis, other medical issues and emergencies, for every 12 patients receiving dialysis care; and that each care giver was not assigned more than four patients at any given time. The facility also failed to identify and address the root cause of inadequate staffing, which resulted in the ongoing rescheduling of patients’ hemodialysis treatments. This deficient practice had the potential to negatively affect the health and safety of 39 ICHD patients who dialyzed at this facility. Findings include: - A review of the facility’s “Governing Body Meeting” minutes dated 8/22/25, 9/17/25 and 11/28/25 revealed that the facility was closed due to the inability to secure licensed nursing coverage. The facility offered rescheduling of treatment options for all patients. - A review of “Patient and Teammate Schedule” (schedule of the number of patients dialyzing each shift and the number of three Patient Care Technicians (PCT’s) and 1 Registered Nurse (RN) providing patient care services), from November 2025 to December 2025 revealed the following: - The Patient Treatment Room had three Pods (sections) with four patient Stations (S) in each Pod. The total number of patients for hemodialysis treatment on the Mondays-Wednesdays-Fridays (MWF) schedule was 22 patients, specifically: 12 patients on first shift, nine patients on second shift, and one patient on third shift. The total number of patients for hemodialysis treatment on the Tuesdays-Thursdays-Saturdays (TTS) schedule was 17 patients, specifically: 10 patients on the first shift, and seven patients on second shift. TTS had two shifts only. - A review of the “Staffing Profile in Anaplan” (an application used for various things/labor reporting which showed staff clocking in and out, including the number of patients that were in dialysis treatment at specific times), revealed the following: On 11/10/25 - one PCT and one RN were present, which allowed for a maximum of four patients to receive hemodialysis at one time. Yet six patients were treated on first shift. On 11/14/25, 11/21/25 and 11/24/25 - two PCTs and one RN were present, which allowed for a maximum of eight patients to receive hemodialysis at one time. Eight patients didn’t receive hemodialysis treatment and were offered to be rescheduled. On 11//19/25 - two PCTs and one RN were present, which allowed for a maximum of eight patients to receive hemodialysis at one time. Yet 11 patients were treated on first shift. On 11/26/25 - two PCTs and one RN were present, which allowed for a maximum of eight patients to receive hemodialysis at one time. Yet nine patients were treated on first shift. On 12/1/25- two PCTs and one RN were present, which allowed for a maximum of eight patients to receive hemodialysis at one time. Yet 11 patients were treated on first shift. On 12/3/25- one PCT and one RN were present, which allowed for a maximum of four patients to receive hemodialysis at one time. Yet seven patients were treated on first shift. before the second PCT arrived at 9:36 a.m. - A review of the facility’s “Hospitalization and Treatment Behavior Log” for October 2025 through November 2025 revealed the following: On 8/22/25, 20 patients received their hemodialysis treatment, and three patients were in the hospital. All 20 patients were offered rescheduled treatment. On 9/17/25 22, patients didn’t receive their hemodialysis treatment, and one patient was in the hospital. All 22 patients were offered rescheduled treatment. On 10/22/25 21, patients didn’t receive their hemodialysis treatment, and two patients were in the hospital. All 21 patients were offered rescheduled treatment. On 11/10/25, a total of eight patients received hemodialysis treatment, one patient was in the hospital. 13 patients didn’t receive hemodialysis treatment and were offered to be rescheduled. On 11/14/25, a total of 13 patients received hemodialysis treatment, one patient was in the hospital. Eight patients didn’t receive hemodialysis treatment and were offered to be rescheduled. On 11/24/25, a total of 10 patients received hemodialysis treatment, two patients were in the hospital. 10 patients didn’t receive hemodialysis treatment and were offered to be rescheduled. On 11/26/25, a total of 13 patients received hemodialysis treatment, four patients were in the hospital. Five patients didn’t receive hemodialysis treatment and were offered to be rescheduled. On 11/28/25, 20 patients didn’t receive their hemodialysis treatment, and three patients were in the hospital. All 20 patients were offered to be rescheduled for treatment. There was no documented evidence of the total number of patients who actually came back for their rescheduled treatments. The above-mentioned dates showed a consistent pattern of patients being unable to receive their scheduled hemodialysis treatments due to inadequate staffing, resulting in repeated rescheduling of hemodialysis treatments. Additionally, the facility often operated with a patient load that exceeded the staff - patient ratio required to ensure safe and appropriate patient care. - A review of the facility’s last three months (August 2025 - October 2025), of QAPI Meeting minutes, revealed the missed treatment goal for August 2025 was to designate a teammate to lead the facility’s no-show efforts. For September and October 2025, the goal was to reduce rescheduling rates and improve treatment adherence. Although data was collected monthly, there was no documentary evidence showing the facility took any action to address or resolve inadequate staffing. - On 12/3/25 at 11:05 a.m., P#1 stated that the frequent rescheduling of her hemodialysis treatments had caused significant inconvenience for her, as she still needed to maintain her work schedule. P#1 stated that her employer had raised concerns about the ongoing issues related to her dialysis appointments because she was constantly late to work. P#1 stated that both her job and her hemodialysis treatments were important to her. P#1 also stated that there had been times when she arrived at the facility at 6:15 a.m. for her scheduled treatment, only to be sent home due to insufficient staffing. During a telephonic interview on 12/3/25 at 12:36 p.m., a member of the transportation crew stated that over the past couple of weeks, the facility has not had enough staff to treat all scheduled patients at their scheduled times. She added that on several mornings she transported a patient to the facility, only to have to take the patient back home because there were not enough staff available. During a telephonic interview on 12/3/25 at 2:06 p.m., P#2 stated that the facility had recently been offering to reschedule her hemodialysis treatments due to inadequate staffing. P#2 stated that she is immobile and depends on transportation, making rescheduled appointments difficult for her to manage. During a telephonic interview on 12/3/25 at 2:11 p.m., P#3 stated that it was difficult for him to reschedule his hemodialysis treatments outside his regular days because he already had a set routine for handling his personal matters on the days he does not receive dialysis. During a telephonic interview on 12/3/25 at 2:17 p.m., P#4 stated that when the facility lacked enough staff to treat him on time, he cannot wait because he relied on transportation. He said that occasional rescheduling is manageable, but it has been happening frequently at the facility lately. P#4 also stated that he had missed some of his rescheduled treatments due to transportation issues. During a telephonic interview on 12/3/25 at 3:55 p.m., the Medial Director (MD) stated that the facility has been searching for Registered Nurses in the surrounding area, but it has been challenging. A review of Policy #8-02-01, titled, “Teammate Qualifications, Licensure and Adequate Teammate Staffing”, last revised October 2017, stated: POLICY: 4. An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care giving and meets the need of the patients.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 50523 Based on facility record review, and staff interviews, 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 46 in-center hemodialysis (ICHD) patients and 14 peritoneal dialysis (PD) patients who were under the care of this facility. Findings include: Cross-Reference: V541 - Failure of the Interdisciplinary Team (IDT) to implement the plans of care relative to patients’ dialysis prescriptions for 18 of 22 Patients (P) (P#1, P#2, P#3, P#4, P#11, P#12, P#13, P#15, P#16, P#17, P#18, P#19, P#20, P#21, P#22, P#23, P#24, and P#25), who did not receive dialysis treatment on 8/8/25 due to facility closure, and were not rescheduled according to their individualized dialysis prescription.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 50523 Based on observation, staff interview, a review of facility Policy and Procedures (P & P) and a review of the Centers for Disease Control and Prevention (CDC) recommendations, it was determined that the Infection Control Committee failed to ensure that three of three Patient Care Technicians (PCT AA, PCT BB, and PCT CC) and one of one Registered Nurse (RN AA) observed during preparation of access sites (needle insertion sites) and cannulation (insertion of fistula needles), utilized appropriate infection control techniques to prevent cross contamination during the initiation of hemodialysis treatment of four of four patients (P), (P#7, P#8, P#9 and P#10). Failure to practice aseptic techniques increased the risks of cross contamination which could negatively affect the health and safety of P#7, P#8, P#9 and P#10. The facility also failed to ensure that one of four clean-labeled sinks was properly separated from dirty equipment. This deficient practice increased the risk for cross contamination with the potential to expose all 46 in-center hemodialysis patients who were receiving hemodialysis services at this facility and all Direct Patient Care staff (nurses and PCTs), to bloodborne pathogens in the dialysis environment. Findings include: During observation in the Patient Treatment Room on 8/19/25 from 9:57 a.m. to 11:30 a.m., the following was revealed: - PCT AA was observed during initiation of hemodialysis treatment to P#7 at Station (S), (S5). After disinfecting P#1’s access sites, PCT AA palpated (examined by touch) P#7’s access sites again (after the sites had been disinfected), wearing the same contaminated gloves, thus re-contaminating the access sites. - PCT CC, PCT BB, and RN AA observed at S11, S7, and S12 (respectively), repeated the same breach in infection control techniques (touching the disinfected access sites with the same contaminated gloves), thus re-contaminating the patients’ access sites before cannulation. These breaches in infection control techniques had the potential for cross contamination. - There was a labeled clean sink (designated for hand washing) yet staff were using the labeled clean sink as a dirty sink (designated for draining used saline bags, draining prime buckets, contaminated clamps, etcetera - etc.). During an interview with PCT AA on 8/19/25 at approximately 10:46 a.m., PCT AA stated that he was aware that once the access had been disinfected, it should not be palpated again before cannulation without re-disinfecting the access prior to cannulation. PCT AA also stated the labeled clean sink was used as a dirty sink. On 8/19/25 at 11:09 a.m., PCT BB confirmed what PCT AA stated above regarding disinfecting the access prior to cannulation. PCT BB also stated the labeled clean sink was being used as a dirty sink. On 8/20/25 at 11:15 a.m. The Facility Administrator acknowledged the above findings and stated that the clean labeled sink would be immediately relabeled as dirty. - A review of the facility’s Procedure: 1-04-01E titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SNF) and Administration of Heparin Loading Dose” with latest revision date of April 2025, stated: 13. Do not palpate insertion site once area has been prepped. RATIONALE: Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation. 19. Without contaminating the fistula needle, pull skin taut with non-dominant thumb below anticipated insertion site in opposite direction of needle insertion. RATIONALE: Pulling the skin taut anchors the vessels and eases the cannulation process. - The CDC specifies that palpation of a fistula or a graft must not be performed after the application of skin antiseptic, unless aseptic technique is maintained. This is to prevent reintroducing microbes to the access site, which could lead to a bloodstream infection. Also, the CDC states, a dirty sink labeled “clean” is a serious infection control breach that creates a false sense of security and promotes the spread of pathogens.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 50523 Based on a review of medical records and patient and staff interviews, it was determined that the Interdisciplinary Team (IDT) failed to implement the plans of care relative to patients’ dialysis prescriptions for 18 of 22 patients (P), (P#1, P#2, P#3, P#4, P#11, P#12, P#13, P#15, P#16, P#17, P#18, P#19, P#20, P#21, P#22, P#23, P#24, and P#25), who did not receive dialysis treatment on 8/8/25 due to facility closure, and were not rescheduled according to their individualized dialysis prescription. Failure to receive hemodialysis treatment for four consecutive days can lead to serious health risks, including fluid overload, electrolyte imbalances, increased toxin levels in the blood, and potentially life-threatening complications such as cardiac arrest. This deficient practice had the potential to negatively affect the health and safety of all 18 patients mentioned above. The facility census was 46 in-center hemodialysis (ICHD) patients. Findings include: - A review of the facility’s “Governing Body Meeting” minutes dated 8/8/25 revealed that the facility was closed due to the inability to secure licensed nursing coverage. The facility action plan stated that all patients who missed the 8/8/25 hemodialysis treatment schedule were offered rescheduled options for the weekend or earliest next available date to receive their makeup hemodialysis treatment. - A review of “Patient and Teammate Schedule” (schedule of the number of patients dialyzing each shift and the number of Patient Care Technicians (PCT AA, PCT BB, and PCT CC) and Registered Nurse (RN BB) providing patient care services), on August 8, 2025 and August 9, 2025 revealed the following: - The Patient Treatment Room had three Pods (sections) with four patient Stations (S) in each Pod. The total number of patients for hemodialysis treatment on the Mondays-Wednesdays-Fridays (MWF) schedule was 22 patients, specifically; 11 patients on first shift, 10 patients on second shift, and one patient on third shift. The total number of patients for hemodialysis treatment on the Tuesdays-Thursdays-Saturdays (TTS) schedule was 18 patients, specifically; 11 patients on the first shift, and seven patients on second shift. TTS had two shifts only. - On 8/8/25 (Friday), the facility was closed, so none of the 22 patients scheduled to dialyze on this date received their hemodialysis treatment. - On 8/9/25 (Saturday), four of the 22 patients who did not receive their hemodialysis treatment on 8/8/25 (Friday), were added to the 8/9/25 (Saturday) schedule (one patient added on first shift =12 patients instead of the regular 11 patients and three patients were added to the second shift = 10 patients instead of the seven regular patients on the TTS schedule). - Pod 1: PCT AA (Dialysis Care Giver) to four patients on first shift and three patients on second shift. - Pod 2: PCT BB (Dialysis Care Giver) to four patients on first shift and one patient on second shift. - Pod 3: PCT CC (Dialysis Care Giver) to four patients on first shift and two patients on second shift. -The facility operated two shifts (TTS) across 12 stations, allowing for a total of 24 patients to receive hemodialysis treatment. However, six available stations were not used, nor additional shift(s) to accomodate patients who were unable to dialyze on 8/8/25. - A review of the facility’s “Hospitalization and Treatment Behavior Log” for August 2025 revealed that on 8/9/25, a total of 18 patients received hemodialysis treatment (which confirmed the above documentary evidence). - A review of three of three sampled “Patients Notes” on August 8, 2025 revealed the following: P#11 was called and informed that the facility was closed yet there was no documentary evidence that P#11 was rescheduled for hemodialysis treatment. P#12 was called and informed that the facility was closed yet no documentary evidence that P#12 was rescheduled for hemodialysis treatment. P#13 was called and informed that the facility was closed and that someone will call about rescheduled hemodialysis. No evidence was found that P#13 was called pertaining to rescheduled hemodialysis treatment. - During an interview on 8/19/25 with the Group Facility Administrator at approximately 2:09 p.m., she stated that if the facility had an open hemodialysis chair(s), then the patient(s) should have been treated. On 8/19/25 at approximately 3:10 p.m. the Facility Administrator confirmed what the Group Facility Administrator stated above. The Facility Administrator stated that all patients were contacted on 8/8/25 and offered rescheduling options. The Facility Administrator also stated that four patients were rescheduled for 8/9/25; however, only two of them came and received their hemodialysis treatment. During a telephonic interview on 8/19/25 at approximately 2:48 p.m., P#11 stated that he was not contacted on 8/8/25 to reschedule his hemodialysis treatment. As a result, he called the facility on 8/9/25 to inquire about receiving treatment and was instructed to arrive by 11:00 a.m. Upon arrival, P#11 stated that RN BB informed him there were no available chairs for his hemodialysis treatment therefore he could not treat. On 8/20/25 at approximately 11:17 a.m., P#14 stated that he had to call the facility on 8/9/25 to be rescheduled from 8/8/25. He also stated that he received only half the time of his prescribed hemodialysis treatment on 8/9/25. On 8/20/25 at approximately 11:23 a.m., P#15 stated that no one had called to inform him that the facility was closed on 8/8/25, and he was not offered any options to reschedule his hemodialysis treatment. On 8/20/25 at approximately 11:27 a.m., P#3 stated that the facility did call to inform her the facility was closed on 8/8/25; however, no one offered her a rescheduling option. As a result, she waited until 8/11/25 (Monday, her regular schedule), to receive her next scheduled hemodialysis treatment. On 8/20/25 at approximately 11:30 a.m., P#16 was notified that the facility was closed on 8/8/25. P#16 stated he was told that he would be rescheduled for 8/9/25 and the facility would call him back with a chair time. P#16 stated he was never called with a chair time and had to go to the hospital to be dialyzed on 8/9/25. During a telephonic interview on 8/20/25 at approximately 4:12 p.m., the Medical Director acknowledged the above findings.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 50523 Based on record review, staff interviews, and a review of the facility Policy and Procedures (P&P), it was determined that the facility failed to ensure that the Interdisciplinary Team (IDT) developed an annual individualized Plan of Care (POC) on three of six patients (P#4, P#5, and P#6) sampled. Failure to develop an annual POC may result in a lack of achieved patient’s clinical outcomes and goals, such as improved lab values, managed symptoms, identifying new patient concerns, and improved ways to enhance quality of life. This deficient practice had the potential to negatively affect the health and safety of P#4, P#5, and P#6. The facility had 46 in-center hemodialysis (ICHD) patients, and 14 Peritoneal Dialysis (PD) patients. Findings include: A review of the medical records revealed the following: - P#4 was admitted to this facility on 2/1/22. The latest Annual Care Plan was dated 8/23/23. - P#5 was admitted to this facility on 9/27/22. The latest Annual Care Plan was dated 5/29/24. - P#6 was admitted to this facility on 11/10/23. The latest Annual Care Plan was dated 4/24/24. - There was no documentary evidence that the IDT conducted annual POC’s on P#4, P#5 and P#6. The Facility Manager stated on 8/19/25 at 1:33 p.m. that he was unable to locate any additional documented evidence of individualized POCs for the patients mentioned above. - A review of the facility’s policy and procedure # 1-14-01, titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care”, stated: 7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: - At least annually for stable patients”

“QAPI-INDICATOR-NUTRITIONAL STATUS CFR(s): 494.110(a)(2)(ii) The program must include, but not be limited to, the following: (ii) Nutritional status. This Standard is not met as evidenced by: 50523 Based on a review of Fiscal Year 2025 Quarterly Dialysis Facility Report (QDFR: A report prepared by Centers for Medicare and Medicaid Services (CMS) to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients of this facility, as compared to other facilities in the U.S.), facility records, and staff interviews, it was determined that the facility failed to effectively manage albumin (protein produced by the liver found in the blood) levels, and to evaluate the effectiveness of the facility’s albumin plan of intervention in six of six months of Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed (January 2025 - June 2025). This deficient practice had the potential to negatively affect the health and safety of 46 in-center hemodialysis (ICHD) patients, and 14 Peritoneal Dialysis (PD) patients who were under the care of this facility. Findings include: A review of Fiscal Year 2025 QDFR revealed that 61.5 % of ICHD patients and 53.3% of PD patients at this facility had albumin levels of less than (<) 4 g/dL (grams per deciliter). The U.S. average was 51.8%. A review of the facility’s last six months (January 2025 - June 2025), of QAPI Meeting minutes, revealed that the average albumin <4 g/dL was 70.7% for ICHD and was 78.0% for PD. Specifically; ICHD % of patients with Albumin <4.0 g/dL: - In January 2025, 51.3% - In February 2025, 75% - In March 2025, 73.5% - In April 2025, 67.5% - In May 2025, 77.1% - In June 2025, 80% PD % of patients with Albumin <4.0 g/dL: - In January 2025, 77.8% - In February 2025, 75% - In March 2025, 87.5% - In April 2025, 72.7% - In May 2025, 76.9% - In June 2025, 78.6% In June 2025, the facility initiated a plan to identify two patients with a three-month downward albumin trend and developed a care activity plan that focused on addressing the identified root causes. Although data was collected monthly, there was no documented analysis for the months of January 2025 to May 2025. QAPI minutes showed plans and root cause analyses, but the same improvement plan was reused without reassessing its effectiveness for the months of January 2025 to May 2025. - During the exit interview on 8/20/25 at 12:35 p.m., the Facility Administrator acknowledged the above findings.”

“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: 33921 Based on a review of facility records including facility Policy and Procedures (P&P) and patient’s family and staff interviews, it was determined that the Medical Director failed to ensure that Registered Nurse/Charge Nurse (RN/CN) and Facility Administrator adhered to facility P&P relative to notifying patient’s (P#1’s) emergency contact/family, Skilled Nursing Facility (SNF, where P#1 resided), P#1’s nephrologist and/or Medical Director, regarding P#1’s unexpected transfer to the hospital. This deficient practice negatively impacted P#1 and family. The facility census was 54. Findings include: During a telephonic interview with the complainant on 5/8/25 at 11:00 a.m., the complainant stated that P#1 was transported to this facility from the SNF, for her regular dialysis treatment, on Monday, 4/14/25. However, P#1 was not able to be dialyzed on that day because of issues with her dialysis access. The facility sent P#1 to the hospital, but did not notify the family nor the SNF personnel. The complainant added that she was wondering why P#1 did not call her and she could not reach P#1. The complainant also stated that the SNF did not notify P#1’s family either. According to the complainant, one of the personnel from the Transportation company knocked on P#1’s door at the SNF on 4/15/25 (Tuesday), and found out that P#1 was not in her room. So, it was the Transport personnel who notified the family on 4/15/25, that P#1 was not in the SNF. The complainant also stated that the SNF did not realize that P#1 was not in her room. The complainant also added that she and P#1’s son only found out on 4/15/25 that P#1 was sent to a nearby hospital (Hospital A) on 4/14/25, then was transferred to another hospital (Hospital B) for further intervention. The complainant also stated that she called the dialysis facility about P#1, and why they failed to notify the family about P#1’s transfer to the hospital. The complainant also stated that she was told by dialysis personnel that they had no way of calling P#1’s family because their “phones were down”. The complainant also added that she questioned this response, especially since everyone has cell phones these days. - During a telephonic interview with P#1’s son (P#1’s emergency contact), on 5/8/25 at approximately 11:30 a.m., he confirmed the above information. A review of facility records revealed the following: 1. A review of P#1’s “Treatment Details Report”, dated 4/9/25, stated: - P#1’s hemodialysis access was an arterio-venous graft (AVG), which was placed on 11/16/23 at her right upper arm. - P#1 received a loading dose of Heparin (anticoagulant) 2,000 units via intravenous push and 800 units per hour infusion for maintenance, per order. - P#1 was transported by a Transport company via stretcher from the SNF to the dialysis facility and vise versa, due to P#1’s history of Below the Knee Leg Amputation (BKA), dated 7/20/23, related to a history of diabetes (high blood sugar). - P#1’s prescribed hemodialysis treatment duration was 255 minutes (four hours and 15 minutes). - P#1 started treatment on 4/9/25 at 11:51 a.m. and ended at 15:30 (3:30 p.m.), which was 21 minutes short of prescribed treatment duration. - Close treatment reason, stated: “Patient choice (against medical advise [AMA], feels unwell/cramping, patient behavioral issue”. - Discharge Status: Discharged/Transferred to ER (Emergency Room) / Hospital. - Post Vitals included, “bleeding time equal or less than 10”. (Hemostasis - stopping of blood flow after dialysis). 2. A review of P#1’s hospital admission and discharge dated 4/9/25, stated: - P#1 was admitted to the Emergency Department (ED) on 4/9/25 with a Chief Complaint of... “Coming in from dialysis. Patient finished treatment and staff was unable to get the bleeding controlled. Controlled upon EMS (Emergency Medical Services) arrival with pressure bandage...’ 3. A review of P#1’s “Treatment Details Report”, dated 4/11/25, stated: - Post-Treatment Vitals included, “bleeding stop time greater than 30”. 4. A review of “Late Entry Note” regarding P#1, by the Administrative Assistant (AA), dated 4/15/25 for Event Date, 4/14/25, stated: “Patient sent out to hospital via Walton EMS due to possible infection at access site”. There was no other documentary evidence regarding P#1’s arrival to the facility on 4/14/25 for hemodialysis treatment and subsequent tranfer to the hospital from the dialysis facility and no documentary evidence of notifying P#1’s emergency contact/family, SNF, P#1’s nephrologist or Medical Director. 5. A review of “Patient Note” by Master Social Worker (MSW) dated 4/16/25, stated: MSW contacted patient emergency contact (P#1’s son). P#1’s son reported that P#1 was hospitalized on 4/14/25. P#1 was transferred to another hospital, (Hospital B) due to infection in her access. MSW will continue to provide support and monitor. 6. On 4/18/25, Registered Nurse (RN AA) documented in “Patient Note”: NP (Nurse Practitioner) called to give orders for new antibiotics on pt (P#1)... There was no documentary evidence that RN/CN nor Facility Administrator or designee notified P#1’s family nor the SNF personnel regarding P#1’s unexpected transfer to the hospital on 4/14/25. There was no documentary evidence that P#1’s nephrologist and Medical Director were notified of the unexpected tranfer of P#1 to the hospital. 7. A review of hospital admission and discharge summary revealed the following: - P#1 was admitted to the hospital (Hospital A), on 4/14/25 at 12:38 p.m., with a Chief Complaint of... “Patient brought in by EMS from dialysis. Patient was not dialyzed. Patient has abscess on fistula (right arm). It is swollen, warm to the touch and red. No fever with EMS. VSS... There is concern for infected AV fistula”. Diagnosis: Infection of arteriovenous fistula... Disposition: Transfer to another hospital (Hospital B)... - P#1 was admitted to Hospital B on 4/14/25 at 9:13 p.m. and discharged from Hospital B on 4/18/25 back to the SNF. While at Hospital B, P#1 underwent Peritoneal Dialysis (PD) catheter placement on 4/15/25 and PermCath (hemodialysis catheter) on 4/18/25, and was treated with antibiotics for infection. 8. A review of the facility’s Complaint and Grievance Logs between January 2025 - May 8, 2025, did not show any complaint or grievances pertaining to failure of the facility to notify P#1’s emergency contact or family, regarding P#1’s unexpected hospital transfer on 4/14/25. - During an interview with the Facility Administrator on 5/8/25 at 1:40 p.m., he stated that the facility (as well as the whole company) went through a Cyberattack and the “phones were down” on 4/9/25 and 4/10/25. They used their hard copy “Evacuation Kit” to notify family per protocol. NOTE: The unexpected transfer of P#1 to the hospital was on 4/14/24. - During an interview with the MSW on 5/8/25 at 2:15 p.m., the MSW stated that P#1’s son told him (MSW), that no one notified him (P#1’s son/emergency contact), where P#1 was. When this surveyor asked MSW if this failure to notify family of P#1’s transfer to the hospital was logged in the Complaint and Grievance Logs, MSW stated, no, because by the time he (MSW), found out, P#1 was already in the hospital. The MSW also added that usually, the Administrative Assistant or the Nurse will notify the family. This surveyor asked the MSW that if a patient or family member voiced their complaint or notified him (MSW), that the family was not informed that P#1 was sent to the hospital, was it not supposed to be logged in the Complaint and Grievance Logs? The MSW answered, I guess I dropped the ball on that one but will do better next time. - This surveyor asked the Facility Administrator if P#1’s unexpected transfer to the hospital on 4/14/25 was documented in the facility’s REM (Risk Event Management) log, or any hard copy documentation regarding the unexpected transfer. The Facility Administrator stated, no. The Facility Administrator showed this surveyor a “Systems Outage Guide as of 4/22/2025”, which stated: ... Key steps to submit a REM: - Complete the Manual REM Form One Pager - Store completed forms in a secure, locked location... - A review of the facility Policy: 1-10-01, titled, “Medical Emergency”, with latest revision date of October 2022, stated: POLICY: 7. Based on nurse’s assessment a reasonable attempt will be made to notify the patient’s designated contact/personal representative (as reflected in the patient’s medical record) of the patient’s change in condition or transfer to a hospital. This notification may include any follow up instructions for the patient related to patient’s change in condition. 8. Nurse in charge is to notify Facility Administrator (FA)/ Program Manager/designee. The FA/Program Manager/designee is to notify the patient’s nephrologist, Medical Director, Manager of Clinical Services (MCS), Regional Operations Director, and DaVita Risk Manager. 9. Document events in the patient’s medical record. 10. If a patient is transferred to the hospital via EMS, complete the Facility-Hospital Ambulance Transfer Trends form... - A review of RN’s Job Description ICHD (in-center hemodialysis), experienced, stated: 3. Analyzes patient assessments, laboratory data and, when concerns are noted, brings issues to the attention of the physician... Communicates all emergencies, patient life-threatening complications and related incidents to supervisor, Medical Director, Regional Operations Director, Facility or Group Facility Administrator.”