Davita Newark Mt Pleasant

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 39223 Based on staff interviews and review of facility documents, it was determined that the Governing Body failed to demonstrate responsibility and oversight for the operation of the facility by failing to ensure that: 1) all patients are treated with respect and recognition of their personal needs (Tag V-452); 2) all staff are educated on handing off patient care to another care provider prior to exiting the building (Tag V-710); and 3) a Registered Nurse (RN) is available at all times including closing of the day when patients are waiting for transportation (Tag V-759). Cross reference: 494.70(a)(1) - Patients Rights - Respect & Dignity 494.150 - Responsibilities of the Medical Director 494.180(b)(2) - RN present at all times”

“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: 48966 Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that all patients are treated with respect and recognition of their personal needs. Findings include: A review of the Governing Body Meeting minutes, dated 1/16/25, stated that a patient was left behind in the building at the end of the day on 1/15/25. Staff (S) 3, Facility Administrator, confirmed that the patient was Patient (P)1. A review of P1’s medical record indicated that the patient was wheelchair bound due to amputation of both legs and that he/she resided in a nursing home. P1’s hemodialysis flowsheet from 1/15/25 revealed that hemodialysis treatment was terminated at 2:09 PM. During an interview at 11:49 AM, S1, Administrative Assistant, stated that he/she called P1’s transportation company multiple times on 1/15/25, to confirm the pickup time, initially being told it would take 30 minutes. After a second follow-up call, transportation provided another 30 minute estimate. S1 informed S2, the Charge Nurse of the status of transportation pick up time for P1 before leaving for the day. During an interview on 1/22/25 at 9:35 AM, S2 stated he/she left for the day about 15 minutes after helping move P1 into his/her wheelchair. After leaving for the day, S2 called the hemodialysis unit to inform the closing RN (Registered Nurse), S6, to check all areas of the building including the lobby and bathrooms before closing the unit for the day. During an interview on 1/22/25 at 10:28 AM, S6, a Registered Nurse, recalled receiving a phone call from S2 to check all areas of the building including the lobby and bathrooms before closing the unit for the day. S6 stated that he/she checked for patients, but missed P1 because the patient was in an area off to the side of the hemodialysis treatment floor by the scale, described as a “blind spot.” S6 was not aware that P1 was still in the building. S6 along with S7, a Patient Care Technician, utilized the back door by the offices to leave the hemodialysis treatment floor at the end of the day and exited the building through the lobby. Later in the day, S6 received a call that P1 was left alone in the facility. *Please clarify. Facility policy titled, “Patient Rights,” revised October 2021, stated, “... YOUR RIGHTS AS A PATIENT: ... 3. To be treated with (i) respect, dignity, and recognition of my individuality, choices, strengths, abilities, cultural values, religious beliefs, and personal needs, to the extent possible during treatment ...””

“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: 39223 Based on staff interviews and review of facility documents, it was determined that the Medical Director failed to ensure that all staff are educated on handing off patient care to another care provider prior to exiting the building. Findings include: The patient schedule for 1/15/25 indicated that Staff (S) 2, the Charge RN (Registered Nurse), S6, a RN, and S7, a Patient Care Technician (PCT), were scheduled to work until the end of the business day at the facility. A review of Patient (P) 1’s hemodialysis treatment flowsheet revealed that the patient completed his/her treatment at 2:10 PM. A review of the facility’s Governing Body Meeting minutes, dated 1/16/25 stated, “... Patient was left in the clinic post treatment by the Registered Nurse and Patient Care Technician. GFA [Group Facility Administrator] received a call from Patient Concierge at 4:54 pm concerning a patient trapped in the Newark Mt Pleasant Clinic. ... AFA [Assistant Facility Administrator] arrived at 5:25 PM and met with the police officer and EMS. EMS assessed the patient and patient was alert and oriented with no signs of distress. ... Patient was safely transported back to the Nursing Home. ...” A review of video monitoring recording of the lobby revealed that at 3:54 PM, S2 left the building through the front lobby door. At 4:10 PM, S6 and S7 also exited the facility through the front lobby door. During an interview at 11:49 AM, S1, Administrative Assistant, explained he/she called P1’s transportation company multiple times on 1/15/25, to confirm P1’s pickup time. P1 was still waiting for transportation when S1 left work for the day. S1 informed S2 of the status of transportation pick up time for P1 before leaving for the day. During an interview on 1/22/25 at 9:35 AM, S2 stated that he/she provided care for P1 and after treatment was completed. S2 stated that when he/she left at the end of the day, he/she exited through the front lobby and had expected to see P1 waiting for his/her transportation. When he/she did not see P1, he/she called S6 from his/her car and instructed S6 to check all areas of the building and all bathrooms before leaving to make sure there were no patients in the building. During an interview on 1/22/25 at 12:12 PM, S7 stated after S2 helped move P1 into his/her wheelchair, P1 did not want to wait in the lobby. P1 was adamant to be placed off to the side in the corner near the scale so P1 could see the lobby through the window of the door. After moving the patient, S7 went off the hemodialysis treatment floor to perform other work duties. When S7 returned, he/she asked S6 if the building was inspected and if any patients were still in the building. S6 informed S7 that no patients were present in the building. S6 and S7 utilized the office hallway door to exit the hemodialysis treatment floor, clocked out, and exited the building through the lobby. During an interview on 1/22/25 at 10:28 AM, S6 recalled receiving a phone call from S2 to check all areas of the building including the lobby and bathrooms before closing the unit for the day. S6 utilized the back door by the offices and checked the lobby and bathrooms. S6 was unaware that P1 was placed off to the side of the hemodialysis treatment floor by the scale, described as a blind spot. S6 stated after checking for patients, he/she along with S7, a PCT, utilized the back door by the offices to exit the hemodialysis treatment floor, clocked out, and left the building through the lobby. After leaving, S6 received a call that P1 was left in the hemodialysis unit. When S6 returned to the building, Emergency Medical Services (EMS) was attending to the patient. S6 assessed P1 and he/she was found to be alert and oriented but visibly upset. During a telephone interview on 1/22/25 at 1:44 PM, S8, the covering Facility Administrator, stated that a Governing Body meeting was held and a process to check for patients at the end of the day was implemented. S8 also stated that on 1/17/25, staff education was provided on the new process and that a nurse-to-nurse handoff report was discussed. Review of documentation for staff education provided on 1/17/25 lacked documented evidence that a nurse-to-nurse hand off report was reviewed. Upon request for a policy or process regarding handing of patient care from one nurse to another, S3, the Facility Administrator, and S4, the Manager of Clinical Services, failed to provide.”

“GOV-RN PRESENT AT ALL TIMES CFR(s): 494.180(b)(2) The governing body or designated person responsible must ensure that- (2) A registered nurse, who is responsible for the nursing care provided, is present in the facility at all times that in-center dialysis patients are being treated; This Standard is not met as evidenced by: 39223 Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that a Registered Nurse (RN) is available at all times, including closing of the day when patients are waiting for transportation. Findings include: The patient schedule for 1/15/25 indicated that Staff (S) 2, the Charge RN, S6, a RN, and S7, a Patient Care Technician (PCT), were scheduled to work until the end of the business day at the facility. A review of Patient (P) 1’s medical record indicated that P1 was wheelchair bound due to amputation of both legs. On 1/15/25, P1 completed his/her treatment at 2:10 PM. A review of the facility’s Governing Body Meeting minutes, dated 1/16/25 stated, “... Patient was left in the clinic post treatment by the Registered Nurse and Patient Care Technician. GFA [Group Facility Administrator] received a call from Patient Concierge at 4:54 pm concerning a patient trapped in the Newark Mt Pleasant Clinic. ... AFA [Assistant Facility Administrator] arrived at 5:25 PM and met with the police officer and EMS. EMS assessed the patient and patient was alert and oriented with no signs of distress. ... Patient was safely transported back to the Nursing Home. ...” A review of video monitoring recording of the lobby revealed that at 3:54 PM, S2 left the building through the front lobby door. At 4:10 PM, S6 and S7 also exited the facility through the front lobby door. During an interview on 1/22/25 at 10:28 AM, S6, a RN, recalled receiving a phone call from S2 to check all areas of the building including the lobby and bathrooms before closing the unit for the day. S6 utilized the back door by the offices to exit the hemodialysis treatment floor and walked down the hallway to access the lobby. S6 stated he/she checked the lobby and bathrooms and found no patients. S6 was unaware that P1 was placed off to the side on the hemodialysis treatment floor by the patient scale, described as a blind spot. S6 stated after confirming no patients were in the building, he/she along with S7, a PCT, utilized the back door by the offices to leave the treatment floor. They walked the back hallway to clock out and then left the building via the lobby. After leaving, S6 received a call that P1 was left in the hemodialysis unit. When S6 returned to the building, EMS (Emergency Medical Services) was attending to the patient. S6 assessed P1 and he/she was found to be alert and oriented but visibly upset. During a telephone interview on 1/22/25 at 1:44 PM, S8, the covering Facility Administrator, stated he/she determined that S6 failed to check the lobby area and all restrooms before leaving. S8 stated that S6 glanced at the areas, but did not walk over to the bathrooms or scale area before exiting. The patient was alone in the building after staff left. A Governing Body meeting was held and a new process to check the building at the end of the day was developed and implemented the next day, 1/16/25. Upon request for a policy on closing the facility at the end of the day, S3, the Facility Administrator, and S4, the Manager of Clinical Services, failed to provide.”

“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: 22676 Based on observation, interview, and review of facility policy, it was determined that the facility failed to ensure patients were visualized by the staff and the hemodialysis access sites were uncovered and visible for one of three days of the survey. The patient and the access site (faces, needle insertion sites and line connections) for all patients on treatment must always be visible to staff, to ensure the lines and needles do not become dislodged or disconnected. Excessive blood loss can result from needle dislodgement, resulting in dire consequences such as severe hypotension, hospitalization, blood transfusions, and death, and could affect all 53 in-center hemodialysis patients receiving care at the facility. Findings include: Observation on 04/15/24 from 9:15 AM to 10:00 AM, revealed the patients at Station 1 and 12 were sitting in two different treatment areas (PODs). Station 1 was at the entrance to the treatment floor. Station 12 was the last chair on the right-side wall, approximately 50 feet away from Station 1. From 9:00 AM until 9:10 AM, there was no staff that could visualize the access and face of Patient (P)8, that was sitting at Station 1. From 9:15 AM until 9:30 AM no staff could visualize the face and access of P4 who was sitting at Station 12. In an interview with Certified Hemodialysis Technician (CHT)12 on 04/15/24 at 9:30 AM, CHT 12 confirmed that he/she was assigned to P4 and P8 who were sitting approximately 50 feet from each other. CHT12 confirmed he/she could not visualize both patients access and face when caring for the other patient. During an interview with Registered Nurse (RN)8 on 04/15/24 at 10:45 AM, he/she stated that the facility does not make assignments based on area but as the patients come in, so sometimes he/she cares for patients across the room from each other. He/she confirmed that the patients could not be visualized if the staff were not in the area. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revision date April 2024, indicated, “The vascular access site, blood line connections and patient’s face should be visible throughout the dialysis treatment.” N.J.A.C. 8:43A-24.4(a)”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 22676 Based on record review, interviews, and review of the facility’s policy, it was determined that the facility failed to ensure that one of seven patients (Patient (P) 1) reviewed participated in the plan of care (POC), or received the information within a timely manner. Failure to ensure the patients reviewed the POC and understand the goals set has the potential to negatively impact the effectiveness of the dialysis treatments for the 53 patients receiving dialysis treatments at this facility. Findings include: Review of P1’s “30-day POC,” found in the electronic medical record (EMR) under the “Plan of Care” section, dated 07/27/23, revealed the facility failed to ensure the patient was provided the POC information in a timely manner. The patient received the information on 09/14/23 and there was no documentation that the information had been provided to the patient before he/she signed the POC signature form. During an interview on 04/16/24 at 12:15 PM, Administrator 2 confirmed the facility failed to ensure the POC information was provided to P1 in a timely manner. Review of the facility’s policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care July 2023 indicated, “. . .14. The patient’s plan of care will be completed by facilities interdisciplinary team, including patient or the personal representative and be signed by the team members including the patient or the patient’s personal representative...” N.J.A.C. 8:43A-24.4(a)”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 22676 Based on record review, interviews, and review of facility policy, it was determined that the facility failed to ensure one of seven patients (Patient (P) 7) 30-day plan of care (POC) was completed within 13 treatments or 30 days as required by federal regulations. Failure to ensure the POC was completed within the first 13 treatments or within 30 days of admission has the potential to negatively impact the effectiveness of the dialysis treatments for all 53 patients receiving dialysis at this facility. Findings include: Review of P7’s electronic medical record (EMR) revealed the patient was admitted on 11/20/23. Review of the EMR under the “Plan of Care” section indicated that the facility failed to conduct a POC meeting within 13 treatments or 30 days as required. According to the EMR, the POC the 30-day meeting was not held until 02/02/24. During an interview on 04/16/24 at 12:15 PM, Administrator 2 confirmed the patient was admitted on 11/20/23 and the POC meeting was not held until 02/02/24. Administrator 2 confirmed the staff did not follow the Federal Regulations and facility policy. Review of facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” date 07/2023 indicated, “. . .An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days or 13 outpatient dialysis sessions for hemodialysis beginning with the first outpatient dialysis treatment or per state guidelines.” N.J.A.C. 8:43A-24.13(b)”