Fmc - Dialysis Services Des Moines South

“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: 36083 Based on documents review, and interviews, the facility did not ensure behavioral incidents of 2 of 3 patients (Patient #1 and Patient #2) in the sample reviewed, were reported, investigated, and addressed. The facility reported a census of 47 in-center hemodialysis patients at the time of the survey. Findings include: 1. The policy titled, Patient Rights and Responsibilities, dated 4/4/12, indicates that in order to comply with federal regulations, dialysis facilities are required to respect and protect patients’ rights. The policy provides that all staff members are responsible for ensuring that patients’ rights are respected and protected. The policy enumerates patients’ rights including the right to respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs. 2. The policy and procedure titled, Patient Safety and Event Reporting and Documentation, dated 2/6/23, provide the facility guidelines for identifying, reporting and documenting patient related safety and serious safety events to promote a culture of safety. The policy defines patient safety to include prevention of injury or preventable harm to a patient during the process of health care. The policy indicates the facility will create best practice guidelines by identifying factors that impact patient safety. The policy directs staff to report patient events with the understanding that event review is focused on opportunities for learning and improving quality and safety of patient care. The policy also directs staff to monitor by observation and recording of physiological and psychological signs, symptoms, and/or patient condition. The procedure indicates documentation of all patient events to be factual, complete, timely, and concise. The procedure also indicates documentation of patient assessment and represent an accurate recording of the events, times, interventions, and result of interventions and any conversations with the patient that are relevant to the patient event should be documented and actual language used by the patient should be quoted exactly where relevant to the patient event. The procedure further indicates documentation to include physician notification. The policy lists categories, event descriptions and definitions of events including behavior, described and defined as abusive/violent behavior indicating verbal threats, or threat of harm to the individual patient and/or to others that impact the safety of their wellbeing. 3. The facility’s grievance log from 9/1/23 through 4/3/24, indicated Patient #1’s concern regarding “incident that happened on 9/13 was still troubling him and he wanted to speak to a manager regarding the problem.” The grievance log noted a meeting with Patient #1, where Patient #1 indicated dislike that facility management did not address the incident when it happened on 9/13/24, and that he had to ask for a meeting. The grievance log also noted, “Met with [Patient #1 after treatment with CM [Clinic Manager] to address 9/13 incident that was previously dealt with by charge RN [Registered Nurse].” However, there was lack of evidence to show any information about Patient #1’s incident on 9/13/23, and how it was resolved. 4. The patients’ medical records showed the following: A) Patient #1 The interdisciplinary (IDT) notes dated 11/6/23, indicated a meeting with Patient #1 to address “9/13 incident that was previously dealt with by charge RN.” However, the IDT notes did not show any prior entries or documentation related to information details of Patient #1’s involvement in an incident dated 9/13/23 and how the “charge RN” has dealt with the said incident. The treatment flowsheets dated 9/13/23, showed that Patient #1 completed 3 hours and 33 minutes of treatment, from 5:33 AM to 9:06 AM. The flowsheets lacked indication of complaints, observations, or concerns related to any incident before, during, and after Patient #1’s treatment. The IDT notes dated 2/9/24, indicated Patient #1 was transferring to another clinic. B) Patient #2 The IDT notes dated 9/13/23, showed Patient #2 “refused to attend treatment” without indication of any behavioral incident. The IDT notes dated 12/11/23, showed Patient #2 was “verbally aggressive and refused to stay for tx [treatment]” as a reaction towards Patient Care Technician (PCT) A’s attempt at educating Patient #2 regarding BP medications. The treatment flowsheets dated 9/13/23, showed that Patient #2 did not receive treatment. The flowsheets did show any indication of any behavioral incident involving Patient #2 on 9/13/23. 5. The facility’s adverse events log from 9/1/23 through 4/3/24 (7 months), did not show any incident that transpired between Patient #1 and Patient #2 on 9/13/23, or any incident between Patient #2 and Patient Care Technician (PCT) A on 12/11/23. 6. Interviews with patients indicated they have witnessed and/or have been threatened by other patients’ behavioral aggression while at the facility, including the following: A) On 4/3/24 at 9:05 AM, Patient #5 stated being a witness to a “scuffle” between 2 patients before, naming Patient #1 but could not remember the “other” patient’s name and the date of the incident. Patient #5 expressed being “glad” that Patient #1 already left the facility because Patient #1 always talked negatively about everything and instigated the verbal altercation with the other patient. B) On 4/3/224 at 11:11 AM, Patient #3 stated that about “3-4 months ago” there was an issue between Patient #2 and PCT A, where there were loud voices in the treatment room and everybody heard the ongoing argument. C) On 4/3/24 at 1:28 PM, Patient #4 indicated having witnessed an uncomfortable incident that led another patient to transfer to another facility. Patient #4 also indicated that the aggressor was still a patient at the facility. Patient #4 reported that he/she did not think the facility addressed the incident. D) On 4/3/24 at 8:55 AM, Patient #1 indicated being at the lobby with 4 other patients waiting for treatments on 9/13/24, including Patient #2 who threatened Patient #1. Patient #1 stated the staff members were aware of the incident but did not do anything about it. Patient #1 indicated the threat remained as Patient #2 continued to give “dirty looks” and so Patient #1 moved to another facility. 7. Interviews with staff members indicated concerns regarding behavioral incidents involving Patient #1 and Patient #2, as follows: A) On 4/3/24 at 11:39 AM, the Social Worker (SW) verified grievance filed on 11/3/23, regarding an incident that happened between Patient #1 and Patient #2 on 9/13/23. The SW stated Patient #1 and Patient #2 had an argument in the lobby, where Patient #2 yelled at Patient #1, “you ruined my day.” The SW stated Patient #2 left and did not receive treatment that day. The SW indicated a meeting was held with Patient #1, the former Facility Administrator, and the SW on 11/6/23 to address the issue and where they reviewed the policy on patients’ rights with Patient #1. The SW acknowledged there was never a meeting with both present (Patient #1 and Patient #2). The SW indicated that Patient #1 stated in passing “the whole thing with [Patient #2]” as one of the reasons for Patient #1’s transfer to a different facility. The SW also acknowledged the lack of any documentation regarding threat to Patient #1’s during the incident on 9/13/23, and thereafter, the lack of documentation about her conversations with Patient #1 regarding the reasons for transfer, including follow-up investigation, and development and/or implementation of interventions or action plans as needed. B) On 4/3/24 at 2:54 PM, PCT B stated she worked on 9/13/23 when an incident occurred between Patient #1 and Patient #2 at the lobby. PCT B indicated Patient #2 left the facility and did not receive treatment that day. PCT B stated she “only heard bits and pieces” about it and she never talked to anyone about it. PCT B further stated an incident when Patient #2 threatened PCT A about meeting in the parking lot and Patient #2 would “take care of things.” PCT B indicated she did not report the incident as an occurrence and lacked knowledge if the incident was addressed. C) On 4/3/24 at 3:14 PM, PCT C stated she heard about the behavioral incident between Patient #1 and Patient #2 but acknowledged she did not report nor follow-up on it. PCT C also acknowledged facility protocol that staff members should follow, however, PCT C stated she “heard about it way after the fact and thought everything was taken care of” so she did not report it to anyone. D) On 4/3/24 at 3:41 PM, PCT D reported Patient #5 informed her about a confrontation out in the lobby, where Patient #2 threatened Patient #1 with profanity and threats of waiting outside the clinic for a confrontation. PCT D indicated Patient #2 did not do a treatment that day because of being so upset. PCT D stated that somebody walked out with Patient #1 after treatment to make sure Patient #2 was not there. PCT D also indicated Patient #2 recently berated another patient (Patient #6) with foul language from across the treatment floor during a dialysis a treatment. PCT D did not indicate reporting these incidents and there was lack of evidence in the records to show these were reported and addressed. E) On 4/3/24 at 4:14 PM, Registered Nurse (RN) F indicated she heard about the incident involving Patient #1 and Patient #2 but did not know the details of the incident. RN F stated behavioral incidents, such as verbal outbursts, would definitely be reported as an occurrence. F) On 4/4/24 at 9:31 AM, PCT A stated that on 9/13/23 when they “opened the doors to the clinic, [Patient #1 and Patient #2] were arguing with each other. PCT A stated Patient #2 ended up leaving that day and Patient #1 had a treatment. PCT A stated he was not sure if he documented the incident but indicated reporting about it to the CM (Clinic Manager) and to the Facility Administrator at the time. When asked if the incident should be documented as an adverse event or occurrence, PCT A answered, “I don’t believe it is considered as an adverse event. I don’t believe a patient argument is considered an adverse event.” PCT A also stated the incident would not count and be reviewed as an occurrence because “it diffused pretty quickly” with Patient #2 leaving and Patient #1 completing a treatment. PCT A also verified an incident documented on 12/11/23, when Patient #2 was verbally aggressive, telling PCT A to fight outside as a reaction to PCT A’s attempts at educating Patient #2 about blood pressure medications. PCT A stated the CM intervened and PCT A walked away but Patient #2 also left and did not receive treatment that day. PCT A stated the incident was not reported as an adverse occurrence and acknowledged the importance of reporting, investigating, and addressing adverse occurrences. G) On 4/4/24 at 9:58 AM, the CM (Clinic Manager) indicated awareness of the incident between Patient #1 and Patient #2 on 9/13/23, and stated that the facility administrator, the SW and the CM talked about the incident and “because [Patient #2] had calmed down and [Patient #1] hadn’t spoken about it, we didn’t bring it up... we thought it had just kind of dissipated.” The CM acknowledged that these behavioral incidents of Patient #1 and Patient #2 should have been reported according to policy. The CM stated expectations for all staff members to follow facility guidelines about reporting incidents and the CM further reported regret for not following up on behavioral incident. The CM also acknowledged the need for all staff education with regard to reporting, investigating, addressing, and following-up on behavioral occurrences in order to ensure a safe environment for patients.”