Davita Wichita Dialysis Center

“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: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure 4 (Certified Clinical Hemodialysis Technicians [CCHT] 7 and 9, Patient Care Technician (PCT) 11, and Registered Nurse [RN] 3) of 4 observed staff performed hand hygiene after removal of gloves, before patient contact, and before they touched patient care equipment (dialysis machine, dialysis chair, bloodlines, access lines). Failure to perform hand hygiene provided a mode of cross contamination with the potential spread of pathogens, which could negatively impact the health and well-being of the 141 patients who received dialysis treatments and/or home therapy oversight at the facility. Findings Include: A facility policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, indicated, “All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the treatment area, b. prior to gloving and immediately after glove removal, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse” Observations of the dialysis treatment area on 10/16/24 with the Facility Administrator and the Manager of Clinical Services revealed the following: At 10:01 AM, Registered Nurse (RN) 3 was observed in Station 15. RN 3 exited the station, removed the pair of gloves he had on, and typed on the computer keyboard near the station. At 10:06 AM, CCHT 7 was observed in Station 18. While wearing a pair of gloves, CCHT 7 touched her personal protective equipment (PPE) gown and then touched the dialysis machine. At 10:21 AM, Patient Care Technician (PCT) 11 was observed in Station 2. PCT 11 exited the station and removed the pair of gloves. PCT 11 entered Station 3 and touched Patient 12. At 10:39 AM, RN 3 was observed in Station 20. RN 3 exited the station, removed the pair of gloves, and obtained and applied a new pair of gloves. RN 3 entered Station 19 and touched Patient 13. RN 3 exited Station 19 removed the pair of gloves, and typed on the computer keyboard near the station. At 10:42 AM, PCT 11 was observed in Station 7. PCT 11 exited the station, removed the pair of gloves, and pushed a mechanical lift to a storage alcove. PCT 11 obtained and applied a new pair of gloves, entered Station 11, and touched the dialysis chair. At 10:44 AM, PCT 11 was observed in Station 2. PCT 11exited the station, removed the pair of gloves, and obtained and applied a new pair of gloves. PCT 11 re-entered Station 2 and touched the bloodlines attached to the dialysis machine. At 3:20 PM, CCHT 9 was observed obtaining and applying a previously used face shield and obtaining and applying a pair of gloves. CCHT 9 entered Station 17 and touched the access lines. At 3:27 PM, RN 3 was observed typing om the computer keyboard near Station 13. RN 3 obtained and applied a glove to his left hand and touched the dialysis machine. RN 3 removed the glove and typed on the computer keyboard again. Observation of the water purification and storage area on 10/16/24 with the Biomedical Technician and the Manager of Clinical Services revealed the following: At 11:25 AM, PCT 11 was observed performing a water test while wearing a pair of gloves. After performing the water test, PCT 11 removed the pair of gloves and prepared to leave the area. When interviewed immediately after performing the water test, PCT 11 confirmed there was no hand hygiene (sanitizer and/or hand washing sink) available for use in the water purification and storage area. During an interview on 10/16/24 at 10:09 AM, CCHT 7 confirmed she was trained and expected to perform hand hygiene before she touched patient care equipment. During an interview on 10/16/24 at 10:54 AM, PCT 11 stated she was trained and expected to perform hand hygiene after removal of gloves and before touching patient care equipment. During an interview on 10/16/24 at 3:20 PM, the Facility Administrator and the Manager of Clinical Services confirmed staff were trained and expected to perform hand hygiene after they removed their gloves and before they touched patient care equipment. During an interview on 10/16/24 at 3:26 PM, CCHT 9 confirmed he was trained and expected to perform hand hygiene before he touched patient care equipment. During an interview on 10/16/24 at 3:33 PM, RN 3 confirmed he was expected to perform hand hygiene after he removed his gloves and before he touched patient care equipment.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 35949 Based on observations, interviews, and policy review, the facility failed to ensure all environmental surfaces in the dialysis treatment stations were disinfected at the end of each dialysis treatment during 2 of 2 observations. Failure to thoroughly disinfect all environmental surfaces in the dialysis treatment stations had the potential to serve as a vehicle for transmission of infectious disease and negatively impact the safety and wellbeing of the 76 in-center patients who received dialysis treatments at the facility. Findings Include: A facility policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, indicated, “13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops).” Observation of the hemodialysis treatment area on 10/16/24, revealed the following: At 10:25 AM, Registered Nurse (RN) 3 disinfected Station 15. RN 3 failed to disinfect the intravenous (IV) pole prongs, and the emergency disconnection pack and hemostats hanging on the IV pole prongs. At 11:06 AM, Certified Clinical Hemodialysis Technician (CCHT) 8 disinfected Station 8. CCHT 8 failed to disinfect the IV pole prongs, and the emergency disconnection pack and hemostats hanging on the IV pole prongs. During an interview on 10/16/24 at 10:33 AM, RN 3 acknowledged the IV pole prongs, and the emergency disconnection pack and hemostats hanging on the IV pole prongs were not disinfected. RN 3 confirmed he was trained and expected to disinfect all surfaces in the treatment station after each treatment. During an interview on 10/16/24 at 11:10 AM, CCHT 8 stated she was not told when trained to disinfect the IV pole prongs, the emergency disconnection pack, and the hemostats that hung on the IV pole prongs. During an interview on 10/16/24 at 11: 15 AM, the Manager of Clinical Services confirmed staff were trained and expected to disinfect all environmental surfaces in the dialysis treatment stations after each dialysis treatment.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 35949 Based on observation, interview, and facility policy review, the facility failed to label and dedicate all equipment and supplies used to care for dialysis patients positive for bloodborne pathogens in 1 of 1 isolation room. Failure to label and dedicate equipment and supplies used when treating dialysis patients that required bloodborne pathogen isolation had the potential to provide a mode for cross-contamination and the potential spread of bloodborne pathogens and negatively impact the well-being of the 141 patients who received dialysis treatments and/or home therapy oversight at the facility. Findings Include: A facility policy titled “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance,” revised 04/2024, indicated, “19. Equipment/Supplies a. Dedicated ancillary supplies such as blood pressure cuffs, clamps, tourniquets, stethoscope, blood glucose meter, bicarb/dialysate jugs, bleach buckets, sharps container, thermometer, pens, centrifuge, and non-disposable items will be used. b. Such supplies will be labeled “isolation” and will remain in the isolation room/area or station and be disinfected after every patient use with 1:100 (one to one hundred) bleach solution.” During a concurrent interview and observation of the isolation room on 10/16/24 at 3:30 PM with the Manager of Clinical Services revealed the following unlabeled and undedicated items: one of two stethoscopes, one biohazard bin, one sharps container, one bottle of hand sanitizer, and one intravenous pole. The Manager of Clinical Services confirmed the listed items in the isolation room were unlabeled and undedicated. The Manager of Clinical Services stated the items “should be labeled.””

“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: 35949 Based on observation and interview, the facility failed to label machines 2 of 5 machines in the biomedical repair area in need of repair to prevent use. Failure to label machines in need of repair provided an opportunity for malfunctioning machines to be used and had the potential to negatively impact the 76 in-center patients who received dialysis treatments at the facility. Findings Include: During a concurrent interview and observation on 10/14/24 at 9:15 AM of the biomedical repair area, revealed two of five machines were not labeled as ready for use or in need of repair. The Facility Administrator stated he had “no idea” if the machines were ready for use or waiting for repair and would “assume” they were not ready for use since the machines were in active mode. During an interview on 10/17/24 at 9:28 AM, the Biomedical Technician confirmed the facility’s process was to label all machines in the biomedical repair area. During an interview on 10/18/24 at 7:19 AM, the Manager of Clinical Services confirmed the facility did not have a policy for labeling machines ready for use or for those machines in need of repair.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 35949 Based on interview, record review, and facility policy review, the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 5 (Patient 1, 2, 3, 4, and 11) of 6 sampled in-center patients. Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 76 patients who received dialysis treatments at the facility. Findings Include: A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, indicated, “10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” Patient 1 Patient 1’s treatment sheet, dated 09/28/24, revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient 1’s BFR was documented as 350 mL/min from 6:30 AM until the treatment was terminated at 9:29 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient 1’s treatment sheet, dated 10/10/24, revealed a prescribed BFR of 400 mL/min. Patient 1’s BFR was documented between 300 mL/min and 350 mL/min from 6:25 AM until the treatment was terminated at 9:35 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient 1’s treatment sheet, dated 10/12/24, revealed a prescribed BFR of 400 mL/min. Patient 1’s BFR was documented between 300 mL/min and 350 mL/min from 6:44 AM until the treatment was terminated at 9:22 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient 2 Patient 2’s treatment sheet, dated 09/24/24, revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient 2’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient 2’s treatment sheet, dated 09/26/24, revealed a prescribed BFR of 400 mL/min. Patient 2’s BFR was documented as 390 mL/min from 10:30 AM until the treatment was terminated at 1:16 PM. There was no rationale documented why the prescribed BFR was not achieved. Patient 2’s treatment sheet, dated 09/28/24, revealed a prescribed BFR of 400 mL/min. Patient 2’s BFR was documented as 350 mL/min from 7:27 AM until the treatment was terminated at 10:06 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient 2’s treatment sheet, dated 10/03/24, revealed a prescribed BFR of 400 mL/min and a prescribed dialysate flow rate (DFR) of 800 mL/min. Patient 2’s BFR was documented as 450 mL/min from 6:20 AM until the treatment was terminated at 8:21 AM and the DFR was documented between 590 mL/min and 610 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR and DFR were not achieved. Patient 3 Patient 3’s treatment sheet, dated 10/20/24, revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient 3’s BFR was documented between 300 mL/min and 350 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient 4 Patient 4’s treatment sheet, dated 09/24/24, revealed a prescribed blood flow rate (BFR) of 500 milliliters per minute (mL/min). Patient 4’s BFR was documented between 300 mL/min and 480 mL/min from 1:14 PM until the treatment was terminated at 2:14 PM. There was no rationale documented why the prescribed BFR was not achieved. Patient 4’s treatment sheet, dated 09/26/24, revealed a prescribed BFR of 500 mL/min. Patient 4’s BFR was documented between 300 mL/min and 350 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient 4’s treatment sheet, dated 09/28/24, revealed a prescribed BFR of 500 mL/min. Patient 4’s BFR was documented between 350 mL/min and 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient 4’s treatment sheet, dated 10/12/24, revealed a prescribed BFR of 500 mL/min. Patient 4’s BFR was documented between 350 mL/min and 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient 11 Patient 11’s treatment sheet, dated 09/24/24, revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient 11’s BFR was documented between 200 mL/min and 250 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient 11’s treatment sheet, dated 09/28/24, revealed a prescribed BFR of 350 mL/min. Patient 11’s BFR was documented as 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient 11’s treatment sheet, dated 10/01/24, revealed a prescribed BFR of 350 mL/min. Patient 11’s BFR was documented as 250 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient 11’s treatment sheet, dated 10/08/24, revealed a prescribed BFR of 350 mL/min. Patient 11’s BFR was documented between 300 mL/min and 350 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. During an interview on 10/16/24 at 3:33 PM, Registered Nurse 3 stated the staff were expected to follow the prescription and document reasons for any change. During an interview on 10/16/24 at 6:03 PM, Certified Clinical Hemodialysis Technician 10 stated additional documentation should include “saying why” the patients’ prescriptions were not achieved. During an interview on 10/16/24 at 6:53 PM, the Facility Administrator stated staff were expected to document rationales for changes to the patients’ prescriptions.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 35949 Based on interview, record review, and facility policy review, the facility failed to monitor patients’ vital signs and/or machine parameters according to their policy for 3 (Patients 2, 4, and 5) of 6 sampled in-center patients. Failure to monitor patients’ vitals and machine parameters according to the facility’s policy provided an opportunity for changes to the patients’ condition during dialysis treatments to be unrecognized and unaddressed and negatively impact the care provided to the 76 in-center patients who received dialysis treatments at the facility. Findings Include: A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, indicated, “iii. Non-nocturnal treatments are completed at least every 30 minutes.” Patient 2 Patient 2’s treatment sheet, dated 09/24/24, revealed monitoring was not documented for 46 minutes, from 7:15 AM until 8:01 AM and for 92 minutes, from 9:00 AM until 10:32 AM. Patient 4 Patient 4’s treatment sheet, dated 09/24/24, revealed monitoring was not documented for 60 minutes, from 1:14 PM until 2:14 PM. Patient 5 Patient 5’s treatment sheet, dated 10/02/24, revealed monitoring was not documented for 52 minutes, from 1:57 PM until 2:49 PM. During an interview on 10/16/24 at 3:33 PM, Registered Nurse 3 stated staff were trained and expected to monitor patients every 30 minutes. During an interview on 10/16/24 at 6:53 PM, the Facility Administrator stated staff were trained and should be monitoring patients every 30 minutes.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 46640 Based on document review, record review, and staff interview, the above-named End Stage Renal Disease (ESRD) facility’s Governing Body failed to ensure the interdisciplinary team (IDT) and Medical Director adhered to the regulatory requirements and facility policy and procedure for 3 of 11 patients (Patient 1, 10, and 11) who did not receive their Patient Rights and Responsibilities and Patient’s Standard of Conduct, Responsibilities and Facility Rules. This deficient practice violates the patients’ rights and responsibilities and could result in serious injury, serious harm, serious impairment, or death. The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) situation. On 04/16/24 at 3:02 PM, Surveyors notified facility administration (Staff C, Facility Administrator) that an immediate jeopardy (IJ) existed related to CfC 494.180, Governance. The facility submitted a Plan of Removal (POR) on 04/16/24 at 6:00 PM. On 04/17/24 at 8:45 AM, the facility was notified the written POR was accepted. The POR included the following: Wichita Dialysis takes the conditions of coverage very seriously; immediate steps were taken to verify facility provides quality dialysis treatments to patients in a healthy and safe environment. A Governing Body (GB) Meeting was held 4/16/2024 to discuss the immediate jeopardy status presented by CMS surveyor; immediate plan of correction developed, approved and initiated to verify Governing Body and Interdisciplinary Team adhered to the regulatory requirements and policies and procedures for all patients including the IVD (Involuntary Discharged) patient. The Facility Administrator or designee immediately began in-servicing 100% clinical teammates on: Policy 8-03-02 Patient Behavior Agreements, 30 Day Discharge, Involuntary Discharge or Involuntary Transfer emphasizing: PURPOSE: To provide guidance on Patient Behavior Agreements, 30 Day Discharge, Involuntary Discharge or Involuntary Transfer. These may become necessary when a patient does not conform to the Patient’s Standards of Conduct and/or Patient’s Rights, Responsibilities and Facility Rules. When a facility is considering involuntary discharge, the patient is automatically designated as “unstable” and therefore requires an assessment. The Interdisciplinary Team (IDT) must assess the patient with an intent to identify any potential action or plan that could prevent the need to discharge or transfer the patient involuntarily. If at any time teammates or other patients feel an immediate severe threat or safety is a concern, the pol ice should be notified immediately via 911. If a patient’s behavior in the dialysis facility is threatening, either verbally or physically, the treatment that day will be terminated and the patient will be asked to leave the facility. The facility will immediately notify the Medical Director, the patient’s physician, the Regional Operations Director (ROD), the ESRD Network and the Risk Manager. In collaboration with the ESRD Network, the facility and Risk Manager will make a determination of whether the patient should be immediately discharged from the facility due to the nature of the threatening behavior or placed on a Behavior Agreement. The collaboration with the ESRD Network will be documented in the electronic health record. Policy 3-01-03 Accepting End Stage Kidney Disease Patients For Treatment emphasizing: Prior to First Treatment at any DaVita dialysis facility, the treating facility must provide all patients, including Transfer, Visiting, and Permanent Patients, certain documents and forms to read and/or sign. These documents and forms are available to clinic teammates in Davita’s registration system and are updated from time to time. Executed versions of these documents should be stored in DaVita’s registration system. These documents and forms may include, but are not limited to: a. Patient Rights; b. Patient Acknowledgement, Authorization, Assignment and Financial Responsibility Form (PAFR); c. Patient Responsibilities and Standards of Conduct; d. Patient Grievance Procedure; e. Authorization for and Verification of Consent to Hemodialysis/Peritoneal Dialysis. Policy 3-01-07B Patients Standards of Conduct, Responsibilities and Facility Rules with emphasis on but not limited to: ........ 11. I am responsible for treating other patients, visitors and facility teammates with consideration and respect. I will not engage in any behavior that endangers, threatens or harms others, or use profanity. 12. No acts or threats of violence by anyone on DaVita premises is tolerated 13. No verbal, physical, or visual intimidation or harassment is tolerated. Potential consequences for failing to comply: I understand I must comply with all stated Patient’s Standards of Conduct, Responsibilities and Facility Rules. My failure to comply may have serious consequences, including, but not limited to: physical side effects, loss of privileges, and temporary or permanent dismissal from the facility. If I behave ~n a way that violates these Patient’s Standards of Conduct, Responsibilities and Facility Rules, the administrator, physician or regional director, as applicable, will discuss the behavior with me. Policy 3-02-01 Medical Records Custodian and Maintenance with the MR Custodian and designee, with emphasis on but not limited to: Verifies that the medical records are complete, documented accurately, and maintained in accordance with accepted professional standards and practices. Verifies that a monthly review is completed on 10% of the facility medical records. Documentation of deficiency trends are identified and action plans developed as defined in the DaVita policy: Quality Assurance Review and Medical Record Quality Assurance Policy. o Verifies that the medical records of all new patients are reviewed within 30 days of admission for completeness. Attendance of in-service evidenced by TMs signature on clinical in-service form. Any teammate not present for in services completed 4/16/24 and 4/17/24 will get in-service on their next scheduled workday before starting patient care. 100% of all current active Medical Records are being audited to verify they contain: Patient Rights, Responsibilities & Standards of Conduct and Facility Rules. Any missing documents will be immediately printed and signed by patient on their next scheduled dialysis treatment. As for all new patients starting 04/17/24, the Facility Administrator (FA) or designee will complete daily Medical Record audits on every new patient daily x 2 weeks, then weekly x 4 weeks to verify Patient Rights, Responsibilities & Standards of Conduct and Facility Rules were signed, then minimum of monthly as outlined in our Medical Record Policy. The Facility Administator or designee will review results of all audits with teammates during homerooms, with Medical Director during Governing Body and monthly FHM, minutes will reflect the completion, review and monitoring of the plan of correction to verify ongoing compliance with the standards. Members of the Governing Body including Medical Director, FA, Regional Operations Director have agreed to meet daily until otherwise determined by the Governing Body to monitor the facilities ongoing progress towards compliance of this plan. The Governing Body will review FHM minutes and activities to verify action plans evaluated for effectiveness, new plans developed as applicable. This plan of correction also reviewed during Facility Health Meetings and the FA will report progress, as well as any barriers to maintaining compliance with supporting documentation included in the meeting minutes. FA & Medical Director are responsible for compliance with this plan of correction. The facility’s plan of removal was validated prior to survey exit on 04/17/24 at 11:00 AM, and the Immediate Jeopardy was lifted. Findings Include: The facility failed to ensure regulatory requirements and facility policy and procedure were followed for the notification of Patient Rights and Responsibilities and Patient’s Standard of Conduct, Responsibilities and Facility Rules for Patient 1, 10 and 11. (Refer to V751)”

“GOV-ID GOV BODY W/FULL AUTHORITY/RESPONS CFR(s): 494.180 The ESRD facility is under the control of an identifiable governing body, or designated person(s) with full legal authority and responsibility for the governance and operation of the facility. The governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patients ’ personal and property rights, and to the general operation of the facility. This Standard is not met as evidenced by: 46640 The ESRD facility is under the control of an identifiable governing body, or designated person(s) with full legal authority and responsibility for the governance and operation of the facility. The governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patients’ personal and property rights, and to the general operation of the facility. This STANDARD is NOT MET as evidenced by: Based on document review, record review, and staff interview, the above-named End Stage Renal Disease (ESRD) facility’s Governing Body failed to ensure the facility staff adhered to the regulatory requirements and facility policy and procedure for 3 of 11 patients (Patient 1, 10, and 11) who did not receive their Patient Rights and Responsibilities and Patient’s Standard of Conduct, Responsibilities and Facility Rules. This deficient practice violates the patients’ rights and responsibilities and could result in serious injury, serious harm, serious impairment, or death. Findings Include: Review of a Policy, “PATIENT’S STANDARDS OF CONDUCT, RESPONSIBILITIES AND FACILITY RULES,” revised 10/2021, showed, “ ...I have the responsibility to follow the directions of the charge nurse while in the facility ...I am responsible for treating other patients, visitors and facility teammates with consideration and respect. I will not engage in any behavior that endangers, threatens or harms others, or use profanity ...My failure to comply may result in ... temporary or permanent dismissal from the facility. If I behave in a way that violates these Patient’s Standards of Conduct, Responsibilities and Facility Rules, the administrator, physician or regional director, as applicable, will discuss the behavior with me ...” Patient 1 Review of Patient 1’s medical record showed a 31-year-old male, admitted to the above named ESRD facility on 03/30/24 and patient discharge on 04/05/24. Patient 1 had previously been dialyzed at another dialysis center. Past medical history showed ESRD. Patient 1 was involuntarily discharged on 04/05/24 after verbal abuse and threats physical violence towards facility staff members. Review of Patient 1’s medical record failed contain a signed copy of the Patient Rights and Responsibilities and Patient’s Standards of Conduct, Responsibilities and Facilities Rules. Review of a letter, dated 04/08/24, signed by Staff C, Facility Administrator, showed that Patient 1 was discharged on 04/06/24 for making verbal/physical threats to staff. Further review of the letter showed, “...You will no longer be able to seek treatment at Wichita Dialysis Center DaVita effective immediately. A list of alternate dialysis providers and hospitals in the area is attached and you will need to seek treatment at one of the following dialysis facilities or the nearest emergency room ...Placement is ultimately your responsibility.” During an interview on 04/15/24 at 1:00 PM with Staff A, Registered Nurse Clinical Coordinator stated and confirmed ...that Patient 1 did not receive his patient rights and responsibilities prior to his first treatment. She went on to state that Patient 1 had behavioral issues on his very first treatment, prior to the 2nd treatment with behaviors that led to the IVD. During an interview on 04/16/24 at 9:10 AM, Staff C, Facility Administrator, stated and confirmed that no attempt was made between Patient 1’s first treatment on 04/30/24 and the next scheduled treatment 04/02/24 to hold an IDT meeting with the patient regarding his behavior on his first treatment nor an attempt to explain his Patient Rights and Responsibilities and Patient’s Standards of Conduct prior to his next treatment. The facility’s failure to provide and/or inform Patient 1 of his Patient Rights and Responsibilities and Patients Standards of Conduct resulted in an Involuntary Discharge (an unplanned discharge) (IVD) without Patient 1 knowing the consequences of his behaviors. Patient 10 Review of Patient 10’s medical record showed an 80-year-old female, admitted to the above named ESRD facility on 01/06/20. Past medical history showed ESRD. Patient 10 started In-Center Hemodialysis (ICHD) on 03/17/20 after failed Percutaneous Dialysis (PD) treatment and dialyzes three times a week. Review of Patient 10’s medical record failed to contain a signed copy of the Patient Rights and Responsibilities and Patient’s Standards of Conduct, Responsibilities and Facilities Rules. Patient 11 Review of Patient 11’s medical record showed a 74-year-old female, admitted to the above named ESRD facility on 01/19/24. Past medical history showed ESRD, diabetes mellitus (too much sugar in the blood) type 2 and hypotension (low blood pressure). Patient 11 has dialysis three times a week. Review of Patient 11’s medical record failed to contain a signed copy of the Patient Rights and Responsibilities and Patient’s Standards of Conduct, Responsibilities and Facilities Rules. During an interview on 04/16/24 at 12:30 PM with Staff I, Administrative Assistant (AA), stated that the facility failed to provide the Patient Rights and Responsibilities and Patient’s Standards of Conduct, Responsibilities and Facilities Rules to Patients 10 and 11.”