Fresenius Kidney Care Lilburn

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 03383 Based on document review and staff interviews, it was determined that the facility failed to ensure that the facility’s Emergency Preparedness Plan (EPP) included a risk assessment using an all hazards approach. The facility census was 52. Findings were: A review of the facility’s EPP with the Facility Administrator (FA) on 12/21/23 at 1:50 p.m. revealed the FA could not provide documentation to show that the EPP’s risk assessment was based on an all-hazards approach. During a telephonic interview with the Director of Operations on 12/21/23 at approximately 4:30 p.m., it was revealed that the facility’s EPP was available electronically. However, the FA was unable to provide surveyors with the missing documents during the survey.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 03383 Based on document review and staff interviews, it was determined that the facility failed to ensure that facility’s Emergency Preparedness Plan (EPP) included a policy and procedure (P&P) that included a system for medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records. The facility census was 52. Findings were: A review of the facility’s EPP with the Facility Administrator (FA) on 12/21/23 at 1:50 p.m. revealed a lack of system in place for medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records. During a telephonic interview with the Director of Operations on 12/21/23 at approximately 4:30 p.m., it was revealed that the facility’s EPP was available electronically. However, the FA was unable to provide surveyors with the missing documents during the survey.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 03383 Based on document review and staff interview, it was determined that the facility failed to develop policies and procedures (P&P) that addressed the use of volunteers in an emergency and other emergency staffing strategies during an emergency. The facility census was 52. Findings were: A review of the facility’s EPP with the Facility Administrator (FA) on 12/21/23 at 1:50 p.m. revealed a lack of P&P that addressed the use of volunteers in an emergency and other emergency staffing strategies during an emergency. During a telephonic interview with the Director of Operations on 12/21/23 at approximately 4:30 p.m., it was revealed that the facility’s EPP was available electronically. However, the FA was unable to provide surveyors with the missing documents during the survey.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 03383 Based on document review and staff interview, it was determined that the facility failed to develop emergency preparedness policies and procedures (P&P) that addressed provision of care and treatment at an alternate care site identified by emergency management officials under a waiver in accordance with section 1135 of the Act. The facility census was 52. Findings were: A review of the facility’s EPP with the Facility Administrator (FA) on 12/21/23 at 1:50 p.m. revealed a lack of P&P which outlined the facility’s role in the provision of care and treatment at an alternate care site identified by emergency management officials under a waiver in accordance with section 1135 of the Act. During a telephonic interview with the Director of Operations on 12/21/23 at approximately 4:30 p.m., it was revealed that the facility’s EPP was available electronically. However, the FA was unable to provide surveyors with the missing documents during the survey.”

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 03383 Based on document review and staff interview, it was determined that the facility failed to ensure that the facility’s Emergency Preparedness Plan (EPP) included primary and alternate means for communicating with facility staff, federal, state, tribal, regional, and local emergency management agencies. The facility census was 52. Findings were: A review of the facility’s EPP with the Facility Administrator (FA) on 12/21/23 at 1:50 p.m. revealed a lack of primary and alternate means for communicating with facility staff, federal, state, tribal, regional, and local emergency management agencies. During a telephonic interview with the Director of Operations on 12/21/23 at approximately 4:30 p.m., it was revealed that the facility’s EPP was available electronically. However, the FA was unable to provide surveyors with the missing document during the survey.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 03383 Based on document review and staff interview, it was determined that the facility failed to ensure the facility’s Emergency Preparedness Plan (EPP) maintained a communication plan that included a method for sharing information and medical documentation for patients under the care of this facility, and as necessary, with other health providers to maintain the continuity of care. The facility census was 52. Findings were: A review of the facility’s EPP with the Facility Administrator (FA) on 12/21/23 at 1:50 p.m. revealed a lack of documentation to confirm that the EPP included a method for sharing information and medical documentation for patients under the care of this facility, as necessary, with other health providers to maintain the continuity of care. During a telephonic interview with the Director of Operations on 12/21/23 at approximately 4:30 p.m., it was revealed that the facility’s EPP was available electronically. However, the FA was unable to provide surveyors with the missing documents during the survey.”

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 03383 Based on document review and staff interview, it was determined that the facility failed to ensure that the facility’s Emergency Preparedness Plan (EPP) included a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. The facility census was 52. Findings were: A review of the facility’s EPP with the Facility Administrator (FA) on 12/21/23 at 1:50 p.m. revealed that the FA could not provide documentation to confirm that the EPP included a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction. During a telephonic interview with the Director of Operations on 12/21/23 at approximately 4:30 p.m., it was revealed that the facility’s EPP was available electronically.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 25727 Based on observation, a review of CDC recommendations, and staff interview, it was determined that the Infection Control Committee failed to ensure that three of three patients (P#21, P#22, and P#23) observed who held pressure to their access sites for hemostasis (stopping of the flow of blood) after dialysis, performed hand hygiene (wash hands with soap and water or use an alcohol based hand sanitizer) after glove removal and prior to leaving the facility. This deficient practice had the potential for cross contamination and increased risk of infection and could affect 52 patients who were dialyzing at this facility. Findings were: During observation in the patient treatment area on 12/20/23 between 10:30 a.m. and 11:45 a.m., the following was observed: - P#21, P#22, and P#23 who were seated at Stations (S) 10, 11, and 13 respectively, held pressure to their dialysis access sites and left the facility without performing hand hygiene. - P#21, P#22, and P#23 were not reminded by the staff to wash their hands nor were offered to use hand sanitizer after glove removal. - According to CDC recommendations, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal. During an interview with PCT AA on 12/20/23 at 3:00 p.m., she stated that the patients wore gloves while holding pressure to sites but she was not sure if the patients washed their hands before they left the facility.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 03383 Based on observation and staff interview, it was determined that the facility failed to ensure pH (acidity) testing strips that were stored in the water treatment room were not expired. This failure could affect the health and safety of 52 patients who were dialyzing at this facility. Findings were: During a tour of the facility on 12/19/23 at 2:05 p.m. with the Technical Manager, eight containers of pH strips were found in a bin in the water treatment room. Dates of expired pH strips included: two expired on 09/14/22; one expired on 12/21/22; three expired on 05/10/23; and two expired on 12/13/23. The Technical Manager present during the tour confirmed the above findings on 12/19/23 at 2:05 p.m.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 25727 Based on a tour of the facility and staff interview, it was determined that the facility failed to ensure that one of one double doors at the back of the building, was maintained to prevent entry of insects and vermin; and to provide a safe environment for 52 patients who were dialyzing at this facility. Findings were: During a tour of the facility on 12/19/23 at 2:15 p.m., the following was observed: - The back double doors leading to the outside had approximately 1/4 inch - 1/2 inch gap between the double doors and the floor (24 inches width across the left door, 1/2 inch in the middle, and 12 inches across the right door) that could allow insects and vermin to enter the building. The Technical Manager confirmed the above findings on 12/19/23 at 2:15 p.m. and stated that they need to apply a weatherstrip to the door. A re-inspection of the back exit doors on 12/21/23 at 2:00 p.m. showed unrepaired gap between the double doors and the floor.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 25727 Based on observation and staff interview, it was determined that the facility failed to maintain a safe environment as evidenced by presence of rust colored substance and separation of caulk material from the sides and front of one of one sink in the lab (laboratory) area; and broken mechanisms and/or torn leather upholstery on 14 of 23 patient treatment chairs (at Stations (S) 2, 3, 4, 6, 7, 9, 10, 11, 12, 14, 15, 17, 18, and 20) in the patient treatment area. This deficient practice could hinder effective cleaning/disinfection and could have a negative effect on the health and safety of 52 patients who were receiving dialysis treatment at this facility. Findings were: During observation in the patient treatment area on 12/19/23 and 12/20/23 between 10:00 a.m. and 4:00 p.m., the following was revealed: - The dirty sink in the lab area had rust colored substance and caulk material breaking apart from the sides and around the front of the sink. - The dialysis chairs at S2, 3, 4, 6, 7, 9, 10, 11, 12, 14, 15, 17, 18, and 20 had multiple torn leather upholstery on the back rest and/or head rest approximately one to three inches long. - The dialysis chairs at S3, 14, and 20 had broken metal mechanisms. The Charge Nurse was notified on 12/20/23 at 4:00 p.m. and confirmed the above findings.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 03383 Based on observations and staff interviews, it was determined that the facility failed to ensure that four of nine patients (P#15, P#16, P#17, P#18) observed in the patient treatment area at Stations (S) 8, 12, 15, and Isolation Room respectively, had their vascular access sites uncovered/visible to the staff throughout dialysis treatment, to ensure patient safety. This deficient practice could provide an opportunity for accidental needle dislodgement or a line disconnection to go undetected and could result in exanguination (severe loss of blood). The facility census was 52. Findings were: An observation in the patient treatment area on 12/19/23 at 2:22 p.m. revealed P#15’s access was covered by a blanket. On 12/20/23 between 6:49 a.m. and 8:07 a.m., P#16, P#17, and P#18’s access sites were completely covered with a blanket. The patients’ dialysis access sites were not visible during their treatment. During observation in the Patient Treatment Area, the following was revealed: - On 12/19/23 at 2:22 p.m., P#15’s access was covered by a blanket. - On 12/20/23 between 6:49 a.m. and 8:07 a.m., P#16, P#17, and P#18’s access sites were completely covered with a blanket. During an interview with the Charge Nurse (CN) and Patient Care Technician (PCT) CC on 12/19/23 at 2:25 p.m., PCT CC stated that staff reminded P#15 to uncover his access site but was unable to find documented evidence. The CN stated it should have been documented. The Facility Administrator (FA) was informed of and shown the above findings on 12/20/23 at 8:07 a.m. The Facility Administrator was unable to provide documentary evidence that patients were reminded by staff to keep their dialysis access uncovered, to ensure their safety during dialysis.”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 25727 Based on patient and staff interviews, observation, and a review of policy, it was determined that the facility failed to provide opportunity for private communication of sensitive topic to one of one patient (P#20) who verbalized his wish to die. Findings were: During an interview with P#20 on 12/20/23 at 11:10 p.m., P#20 stated that he was scared and tired of dialysis. He verbalized his wish to die. At 11:15 a.m. on 12/20/23, the Social Worker (SW) was observed and heard while she talked to P#20 about his wish to die. This staff-patient interaction was conducted at chairside rather than in a private location. During an interview with the SW on 12/20/23 at approximately 2:00 p.m., she stated that the issue was urgent therefore, she talked to P#20 in the treatment room. A review of policy titled, “Patient Rights and Responsibilities” dated 4/4/12 showed the following: Policy: Privacy Rights Patients have the right to privately discuss their condition and treatment. There should be ready access to a room in the facility where patient and/or family meetings may be held in private.”

“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: 03383 Based on medical record review and employee interview, it was determined that the interdisciplinary team (IDT) failed to update the plan of care for one of one sampled patient (P#3), who had frequent hospital admissions from September 2023 to December 2023. Findings were: A review of the medical records for P#3 revealed that the patient was hospitalized one time in September 2023 and October 2023 with unspecified infectious disease, two times in November 2023 with circulatory overload and acute osteomyelitis (an infection in a bone), and one time in December 2023 with fluid overload. - There was no documentary evidence that the frequent hospitalizations were addressed in the patients’ assessment notes, nursing notes or plan of care, by the IDT. There was no documented evidence that the IDT attempted to develop action plans and goals to decrease P#3’s hospitalizations. A review of Physician visit notes dated 12/19/23 mentioned the patient’s non-compliance with dialysis diet, 4+ edema (swelling) and multiple ulcers, blood glucose (sugar) of 600 without hospital intervention, interdialytic weight gain (result of salt and water intake between two dialysis sessions) of 7.4 kg (kilograms), and potassium of 7.0. - The plan of care was not updated to address the patient’s non-compliance with treatments with interventions to improve compliance. - The plan of care did not address the patient’s fluid overload, hyperglycemia (high blood sugar level), or hyperkalemia (high potassium) or list interventions to improve these conditions. - The patient’s plan of care dated 11/16/22 listed treatment adherence as a focus area with a goal of improving treatment adherence by 02/29/24; interventions indicated “Identify small actions to achieve goals” and indicated interventions were “In progress”, “Provide education” and “Identify and address barriers to permanent access, meds, diet, fluids.” - There was no documented evidence of the effectiveness of interventions or changes that were made to interventions to meet the goal. The Facility Administrator was notified of the above findings on 12/21/23 at 7:45 a.m. and did not produce the missing documents.”

“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: 03383 Based on observation and staff interviews, it was determined that the Medical Director failed to ensure that two of two staff [Patient Care Technician (PCT) AA and Registered Nurse (RN) AA] who were assigned to care for Patient (P) #8 at Station (S) 9, adhered to facility policy and promptly responded to one of one dialysis machine alarm that showed a low blood pressure alarm. Findings were: During observation on 12/20/23 at 7:01 a.m., the dialysis machine at S9 began to alarm. PCT AA checked the alarm at 7:04 a.m. and at 7:05 a.m., informed RN AA, who was conducting an assessment on a patient at S12. When finished, RN AA checked the machine in S9 at 7:08 a.m. PCT AA confirmed to surveyor on 12/20/23 at 7:06 a.m., that it was a low blood pressure alarm. Surveyor confirmed with PCT AA that the patient’s blood pressure was 98/55. PCT AA also stated when asked how long it normally takes to check alarms, “It should take less than a minute unless staff is engaged.” A review of policy titled, “Managing Machine Alarms” dated 7/1/19 showed Staff must promptly respond to and address dialysis machine alarms. During an interview with the Facility Administrator (FA) on 12/20/23 at 8:42 a.m., the FA stated promptly means alarms should be answered within seconds, not minutes. RN AA stated during an interview on 12/20/23 at 4:26 p.m., she did not realize that it was Patient #8’s machine that was alarming; the UF (Ultrafiltration - the process of removing excess fluid from the blood through the dialysis membrane by means of pressure) was turned off and he was given 100 cc of saline. He was okay and went back to sleep.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 03383 Based on patient and staff interviews and document review, it was determined that the facility failed to ensure that one of two patient grievances was followed up on and resolved. Findings were: During entrance conference on 12/19/23 at approximately 2:30 p.m., the FA indicated there had been no patient grievances filed. A review of the grievance file located in the facility survey binder had one grievance and did not include the grievance filed by P#7. During an interview on 12/20/23 at 6:30 a.m., Patient (P) #10 mentioned that she has a concern about P#7 not being allowed to come into the building until the nurse arrives. Stated P#7 takes transportation services (transport) to dialysis and she was concerned that P#7 has to wait outside in the cold. An interview with P#7 on 12/20/23 at 7:15 a.m. revealed that P#7 takes transport to dialysis and could not enter the dialysis center until a Registered Nurse (RN) is present; RN gets to the facility late sometimes, up to 30 minutes late. P#7 also stated “I cannot get into the building; this is also the case when there are problems with the water and bicarb system. This happened several times last summer and several times recently, and they don’t have enough staff. I talked to someone on the floor about it and was told their policy says the nurse must be here before we can come in the building and sometimes it’s something wrong with the water or bicarb.” Surveyor asked P #7 if she was shown a policy that says this and P#7 stated, “No”. A review of the grievance file located in the facility survey binder had one grievance and did not include the grievance filed by P#7. On 12/20/23 at 7:40 a.m., the Facility Administrator (FA) was informed about P#10’s concern with patient arriving by transport and not being allowed to enter the building; having to wait outside until the nurse arrives. The FA stated, “she (P#7) is not happy; she would be the one to say something negative.” Surveyor requested a copy of the grievance policy and the policy that mandates a nurse must be in the building before patients are allowed in the building. On 12/20/23 at 9:57 a.m., the FA provided the grievance policy, a policy titled, “Guidelines for Ensuring All Patients Have Left the Facility Prior to Departure of the Registered Nurse” and an email sent on 12/20/23 at 9:21 a.m. with V759 that indicated “An RN must be on-duty whenever patients are present, including the beginning and end of the treatment day.” The FA did not provide a policy that mandated a nurse to be present before patients are allowed in the building. A review of the grievance policy showed the following: 1. FKC Staff promptly acknowledges and reports all patient grievances to the Nurse in Charge (or Team Leader) as soon as possible. 2. The Nurse in Charge (or Team Leader) meets with the patient to gather information and completes as many fields as possible on the Patient Grievance Status Report daily within 72 hours of being notified. 3. The CM reviews the Patient Grievance Status Report daily. For any new grievances, CM meets with the patient within 5 business days to acknowledge, investigate and address the grievance. Note: MSW or other staff may also assist in assessing and resolving patient grievances, as appropriate. 4. CM reports back to the patient when a resolution is attained or considered by the facility. The FA did not provide documentation to confirm that staff adhered to the facility’s grievance policy.”