Davita Town Park Dialysis

“CFC-PERSONNEL QUALIFICATIONS CFR(s): 494.140 This Condition is not met as evidenced by: 49321 Based on a review of personnel records and staff interviews, it was determined that the facility failed to ensure that one of one non-experienced Patient Care Technician (PCT BB) and one of two preceptors (Facility Administrator) were competent to perform assigned duties and to fulfill their roles in providing safe and effective patient care. This deficient practice had the potential to negatively impact the health and safety of 55 in-center hemodialysis patients who were under the care of this facility. Findings were: Cross Reference: V 693 - Failure of the facility to maintain current documentation to demonstrate that staff were competent to perform assigned duties.”

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 49321 Based on a review of personnel records and staff interviews, it was determined that the medical director failed to demonstrate responsibility for the operations of the facility. The facility failed to provide documentary evidences that one of one new non-experienced Patient Care Technician (PCT BB), received the appropriate education and training to competently perform her assigned duties. This deficient practice had the potential to negatively impact the health and safety of 55 in-center hemodialysis patients who were under the care of this facility. Findings were: Cross Reference: V 713 - Failure of the facility to maintain current documentation to demonstrate that staff were competent to perform assigned duties.”

“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: 49321 Based on a review of records and patient and staff interviews, it was determined that the facility failed to ensure that one of one new Patient Care Technician (PCT BB), treated one of one sampled Patient (P#1), with respect and dignity. This deficient practice had caused P#1 emotional discomfort. Findings were: A review of patient and staff schedule dated 12/26/23 revealed the following: - P#1 was assigned to Pod A2, Station 8. - PCT BB was assigned to care for patients in Pod A2. During a telephonic interview with P#1 on 3/26/24 at 3:06 p.m., she stated “PCT BB put my needles in on 12/14/23, and my arm was hurting and swelling. I was not able to run (continue dialysis treatment), so they stopped my treatment. No one said anything about me going back to the surgeon until the doctor saw my arm on 12/26/24. She (PCT BB) wanted to fight me. I just wanted her to apologize for messing up my arm. I have a new fistula (arteriovenous fistula - a surgical connection between an artery and a vein used as dialysis access) and I need it to live”. On 3/27/24 during separate interviews with the staff between 10:45 a.m. and 12:15 p.m., it was confirmed that on 12/26/23, a verbal altercation took place between PCT BB and P#1. During an interview with the Administrative Assistant on 3/27/24 at 10:45 a.m., she stated, “P#1’s Nephrologist came to the clinic and saw the hematoma (localized bleeding outside of blood vessels due to needle infiltration) on P#1’s arm. The Nephrologist asked P#1 how long the hematoma had been there and asked me to make an appointment for P#1 to see the surgeon. PCT BB went over to P#1. I heard P#1 cursing. I asked PCT BB to leave the floor and go to my office. I asked her again, and the third time, I walked over to her and told her to leave the treatment floor. The nurse told P#1 that if she did not calm down, he would take her off the machine.” During an interview with PCT CC on 3/27/24 at 11:20 a.m., she stated, “I spoke to P#1. She was not happy with PCT BB because she stuck her new access and infiltrated (the needle was dislodged from inside the AV fistula during needle insertion or during dialysis treatment. When infiltration occured, blood leaked outside of the fistula or into the surrounding tissues) it on 12/14/23. P#1 missed dialysis treatments because of the hematoma on her arm. I went to PCT BB and told her I would insert P#1’s needles and PCT BB agreed. But then, PCT BB rolled her chair next to P#1 and inserted her needles after she agreed to allow me to insert them. P#1’s venous pressure was high (elevated venous pressure during hemodialysis is associated with abnormal narrowing of a blood vessel) when her doctor came in and asked the nurse to make P#1 an appointment to see the surgeon. PCT BB walked back to P#1’s treatment chair and asked P#1 if she knows what a hematoma is. P#1 stated you did this to my arm. PCT BB stated you are not going to talk to me like I am somebody on the streets. I repeatedly asked PCT BB to walk away”. During an interview on 3/27/24 at 11:38 a.m., the Social Worker stated that she was not present at the facility on 12/26/23. When asked about P#1’s mental/emotional status prior to the incident, she stated “I knew P#1 had a fear of dialysis but I did not get an opportunity to talk to the staff about P#1’s anxiety. When asked about staff training after the incident, she stated “I did not talk to the staff about professionalism, and I never had a discussion with the staff on de-Escalation”. During an interview with the Facility Administrator (FA) on 3/27/24 at 12:03 p.m., it was revealed that the FA covered two facilities and was not present at this clinic when the incident happened on 12/26/23. When asked why PCT BB, being so new to dialysis, was allowed to cannulate (insert fistula needle) new or maturing accesses, the FA stated “PCT BB was a phlebotomist (primarily draws blood) before her employment with us, so we go to her a lot because of her phlebotomy skills.” The FA stated the RN charge nurse on 12/26/23 was a visiting nurse. When asked if there was any communication to the nurse regarding the emotional/mental status of P#1 and/or orientation to the facility, the FA stated that the nurse had worked at the facility prior to 12/26/23. The FA stated he conducted a Homeroom Meeting (A brief and informal meeting held in the Patient Treatment Room) on 12/27/23 to address the staff. The FA also provided documentation of corrective action for PCT BB after his follow-up with Human Resources and Risk Management about the incident. PCT BB was not available for an interview during the survey. A review of Policy: 1-04-04 titled, “Needle Infiltation/Hematoma and PX Management Tool- CANNULATION policy stated: Best Practice Take responsibility for what happened and apologize... Ensure the patient is aware that their Nephologist was notified, and appropriate care rendered. Identify expert cannulator/s within your facility and optimize schedules to ensure experts are cannulating new fistulas and other accesses with the highest risk of infiltration.”

“PQ-PCT-COMPLETE TRAINING PROGRAM CFR(s): 494.140(e)(3) Patient care dialysis technicians must- (3) Have completed a training program that is approved by the medical director and governing body, under the direction of a registered nurse, focused on the operation of kidney dialysis equipment and machines, providing direct patient care, and communication and interpersonal skills, including patient sensitivity training and care of difficult patients. This Standard is not met as evidenced by: 49321 Based on a review of personnel records and staff interviews, it was determined that the facility failed to provide documentary evidences that one of one new non-experienced Patient Care Technician (PCT BB), completed a training program under the direction of a registered nurse (RN); and that one of two preceptors (Facility Administrator) was competent to train new employees. This deficient practice had the potential to negatively impact the health and safety of 55 in-center hemodialysis patients who were under the care of this facility. Findings were: A review of personnel records revealed the following: - PCT BB was hired on 7/31/23. - PCT BB did not have any experience in dialysis. - This facility offered a required training program called “RISE ICHD (Incenter Hemo Dialysis) New PCT Patient Care Techician (PCT) Teammate Training Binder” to all new non-experienced teammates. A review of the RISE Training Binder showed the following: - Upon completion of initial training, review the Rise In-Center Hemodialysis Training Program Manual and obtain the following documents to print: ICHD Verification of Competency - Document is to be completed showing the completion of training with a passing final exam score of at least 80% and signed by the RN Trainer, Medical Director, and the FA. There was a lack of documented evidence that PCT BB participated, completed, and demonstrated training of all modules in the RISE Training Program Binder (documentation of week-to-week training for eight weeks). Although PCT BB had a verification of Competency form (without any supporting documentation of the completion of training/modules), it was only signed by the Medical Director, Facility Administrator, and PCT BB. The competency form was not signed by an RN Trainer. - Training Hour Tracking Form - Document is to be completed, tracking total time spent in clinical and didactic hours and signed by the RN Trainer and new teammate. The Verification of Competency for New Non-Experience In-center Teammates Skills Checklist (page 30) showed PCT BB has successfully completed the didactic phase and the clinical practicum phase of the Clinical Training for New Teammates for ICHD RISE program and has demonstrated competency in the following areas: Documentation Social Worker De-Escalation Risk Event Management Vascular Access Care and Proper Canulation The first Procedural Skills Verification Checklist was completed on 10/5/23 by LPN AA. The second Procedural Skills Verification Checklist was completed on 2/15/24 by RN Trainer. A review of records revealed that PCT had been cannulating (inserting needle) new fistula (arteriovenous fistula - a surgical connection between an artery and a vein used as dialysis access) prior to 2/15/24 and had documented access event on 12/14/23. Cross reference: V 452 for details. There was a lack of documented evidence that PCT BB completed all of the required training and modules such as PCT Professional Behavior; PCT Critical Policies; Infection Control; Principles of Dialysis and Hemodialysis Devices; Lab; Hemodialysis Treatment; Water and Dialysate; PCT Weekly Evaluation Tool; and PCT Skills Checklist. During an interview on 3/27/24 at 12:05 p.m., the FA stated “we do not keep training records in the clinic” and did not produce the missing documents. When asked why PCT BB, being so new to dialysis, was allowed to cannulate new or maturing accesses, the FA stated “PCT BB was a phlebotomist (primarily draws blood) before her employment with us, so we go to her a lot because of her phlebotomy skills.” Moreover, the FA was one of the two preceptors for PCT BB. When asked for a copy of his Procedural Skills Verification Checklist, the FA stated “I have not done a checklist in a while”.”

“MD RESP-STAFF ED, TRAINING & PERFORM CFR(s): 494.150(b) Medical director responsibilities include, but are not limited to, the following: (b) Staff education, training, and performance. This Standard is not met as evidenced by: 49321 Based on a review of personnel records and staff interviews, it was determined that the facility failed to provide documentary evidences that one of one new non-experienced Patient Care Technician (PCT BB) and one of two preceptors (Facility Administrator) received the appropriate education and training to competently perform their assigned duties. This deficient practice had the potential to negatively impact the health and safety of 55 in-center hemodialysis patients who were under the care of this facility. Findings were: Cross Reference: V 693 - Failure of the facility to maintain current documentation to demonstrate that personnel were competent to perform assigned duties.”