Davita Erie Dialysis

“PR-RECEIVE UNDERSTANDABLE INFORMATION CFR(s): 494.70(a)(2) The patient has the right to- (2) Receive all information in a way that he or she can understand; This Standard is not met as evidenced by: 31759 Based on review of facility policy, clinical records (CR), and staff (EMP) interviews, the facility failed to ensure the patient received information that he or she could understand for one (1) of (1) Spanish speaking patient (CR1). Findings included: Review of facility policy on March 3, 2025, at 11 a.m. “TITLE: COMMUNICATION WITH PERSONS WITH LIMITED ENGLISH PROFICIENCY ... POLICY: A. Davita will facilitate meaningful communication with LEP [limited English proficiency] patients ... This includes the communication of information contained in Vital Documents, including but not limited to, waivers of rights, consent to treat forms, and financial and insurance benefit forms. ... F. Providing Written Translations: 1. Vital documents will be made available to patients in their primary language.” Review of CR1 on March 3, 2025, at 10:40 a.m showed patient was admitted to the facility on November 7, 2024. The patient’s primary language was listed as Spanish with no secondary language indicated such as English. Review of consultation documentation from a hospitalization just prior to patient’s ESRD admission by two different physicians showed CR1 was a Spanish speaking patient, “Cardio-Consult ... October 29, 2024 ... History of Present Illness [...]-year-old Spanish speaking female.” “Endo [endocrinology]-Progress ... October 30, 2024 ... Subjective 10/30/2024: Unavailable at time of visit ... This is a pleasant [...]-year-old Spanish speaking female.” The ESRD facility’s admission forms signed by the patient on November 7, 2024, were in English and included, “HIPAA PERMISSION TO DISCUSS,” “PATIENT AUTHORIZATION & FINANCIAL DISCLOSURE,” “CONSENT - HEMODIALYSIS TREATMENT,” “GRIEVANCE PROCEDURE,” PATIENT RESPONSIBILITIES & STANDARDS OF CONDUCT,” “PATIENT RIGHTS,”HIPAA NOTICE ACKNOWLEDGEMENT,” AND “HIPAA AUTHORIZATION - PATIENT RECOGNITION.” The review revealed the patient was not provided admission/consent forms in Spanish. Interviews with facility administrator (EMP1) and clinic manager (EMP2) on March 3, 2025, at 1 p.m. confirmed above findings.”

“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: 31759 Based on review of facility policy, clinical records (CR), and staff (EMP) interview, the facility’s medical director failed to ensure facility staff followed policy and procedure for family notification concerning a patient’s change in condition for one (1) of three (3) records who experienced a medical emergency during dialysis (CR1). Findings included: Review of facility policy on March 3, 2025, at 11 a.m. “TITLE: CARDIOPULMONARY ARREST ... POLICY: ... 5. Patient’s nephrologist or licensed nurse teammate is responsible for notifying the patient’s next of kin ... of patients transfer to hospital.” “TITLE: MEDICAL EMERGENCY: ... POLICY: ... 7. Based on nurse’s assessment a reasonable attempt will be made to notify the patient’s designated contact/person representative ... of the patient’s change in condition or transfer to a hospital.” Review of CR1 on March 3, 2025, at 10:40 a.m. showed patient was admitted to the facility on November 7, 2024. On the day of admission, the patient’s hemodialysis treatment was initiated at 6:30 a.m. The patient experienced a medical emergency at 6:47 a.m. when he/she became unresponsive. At 7:20 a.m., EMS (emergency medical services) transported the patient to the hospital. Further review of CR1 showed the patient’s next-of-kin was his/her sibling who he/she lived with. However, CR1’s next-of-kin was not notified by the ESRD facility concerning CR1’s medical emergency and subsequent transport to the hospital. Interviews with facility administrator (EMP1) and clinic manager (EMP2) on March 3, 2025, at 1 p.m. confirmed above findings.”