Fresenius Medical Care Columbia

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 30011 Based on interview and record review, the Governing Body failed to ensure the dialysis facility had sufficient measures in place to ensure patients requiring dialysis treatment were provided with treatment options for dialysis for 21 (twenty-one) patients whose dialysis was canceled for dialysis. There was no documentation that the physician)s) were notified or physician orders received for the cancellation of those affected patients. Those patients received dialysis only twice during the Thanksgiving holiday and one patient had to present emergently to the hospital in respiratory distress for dialysis. (Patient 1) The findings include: Record review of facility staffing logs on 12/04/23 at 2:25 PM revealed on 11/21/23 two nurses and 5 dialysis technicians scheduled for duty for 3 patient bays with 10 dialysis stations in each bay. Review of the patient schedule for dialysis treatment on 11/21/23 revealed 59 patients were scheduled for dialysis treatment with 21 patients noted as “did not run” on that day. Review of facility Governing Body minutes on 12/08/23 at 5:16 PM revealed no documentation for treatment options for 21 patients who were chosen to have their dialysis treatments canceled the week of Thanksgiving. Further review revealed no documentation of physician orders for the canceled treatments, orders for the change of days for treatment and/or a plan to accommodate for the number of patients who did not receive dialysis due to insufficient staffing for 11/21/23. Governing Body minutes were requested from October 1, 2023 to December 1,2023, with none provided by the facility. During an interview on 12/07/23 at 9:46 AM to 10:20 AM, the FA was asked who determined which patients to cancel for treatment on 11/21/23, the FA stated, “I remember calls being made on that day and I remember the previous Director of Operations (DO) had the nurse and the secretary to go over the list and decide which patients would be better (to cancel). I don’t remember which nurse calls were being made on the 20th”. When asked was a criteria used to determine which patients would be canceled, the FA stated, “I don’t know what the nurses normally do as an assessment. The nurses would have determined that”. When asked what was the plan for those patients who were not being treated, the FA stated, “The plan was to let them know we’re short staffed and they were told if they feel this or that to go to the ER. The following week calls were made to those who couldn’t come to treatment to get an extra treatment. We should have offered them another treatment”. When asked if the Medical Director was aware about the patients being canceled, the FA stated, “I don’t know if the former DO reached out to him/her”. When asked who approved the Thanksgiving holiday schedule change, the FA did not respond to the question asked. During an interview on 12/07/23 at 1:24 PM to 2:17 PM, the Medical Director (MD) stated, “I am aware of the holiday scheduling changes. The DO, the Vice President, and FA make me aware of any changes and if we had a Clinic Manager. Absolutely not was I aware or involved in the discussion for the patients being canceled. I was re-assured that every patient would have their dialysis treatment. Every person is to run their full treatment. I was upset on Monday when I found out about it. I asked the staff members and one of the patients told me he/she was in the hospital, and I asked if he/she could come in for another treatment. I spoke with the RVP (Regional Vice President) about what happened and still didn’t get a clear answer. I’m supposed to be notified if they (the facility) can’t run patients. I can’t tell you the last time I have been notified, it’s not consistent. Any schedule changes the nurses are to change the orders because its the same treatment”. During an interview on 12/08/23 at 12:55 PM to 1:23 PM, Registered Nurse (RN) 1 stated, “I worked Monday and realized we didn’t have enough staff for Tuesday. Some changes took place and I thought it was a bad idea and I thought we should have waited since we didn’t know how staffing was going to be. I called the FA because I hadn’t been made aware of any changes and was told that I am a PRN (as needed) interim float and they didn’t think it was necessary to tell me. I was going to take it upon myself to look at the patients and decide who might need it the most but I was told by Staff Member 1 that the decision was already made because he/she spoke with the FA already. So I didn’t have a decision on what patients ran. Staff Member 1 and the FA was to split the patients to be called but Staff Member 1 ended up making all the calls. The other nurse nor myself never called any patients. We had enough techs (technicians) but not enough nurses. I did tell Staff Member 1 to make sure that they let MD 1 know but don’t know if he/she knew”. During an interview on 12/08/23 at 4:08 PM to 4:12 PM, the Regional Vice President (RVP) stated, “We put out guidance and my preference was to be off for Thanksgiving. The leadership team decided to do the change. So we did the Monday, Wednesday, Friday group to dialyze on Sunday, Tuesday, and Friday and the TTS (Tuesday, Thursday, Saturday) group to Monday, Wednesday and Saturday. The RVP, DO, CM (Clinic Manager) or FA’s make up the leadership team”.”

“PQ-CHARGE NURSE-12 MO NURSING+3 MO DIALYSIS CFR(s): 494.140(b)(3)(i)-(ii) The charge nurse responsible for each shift must- (i) Be a registered nurse, a licensed practical nurse, or vocational nurse who meets the practice requirements in the State in which he or she is employed; (ii) Have at least 12 months experience in providing nursing care, including 3 months of experience in providing nursing care to patients on maintenance dialysis; This Standard is not met as evidenced by: 30011 Based on observations, interviews, and review of dialysis facility staffing logs, the dialysis facility failed to ensure a nurse was designated as a charge nurse for each patient shift. The findings include: Observations on 12/04/23 at 10:44 AM revealed 3 Bays in the dialysis treatment room with patients located in each bay. Bay 1 and 2 had 10 dialysis stations and Bay 3 had 8 dialysis chairs and an isolation room with two dialysis stations. Further observation revealed one nurse and two technicians in each bay. Review of facility staffing logs on 12/04/23 at 2:25 PM revealed there was no documentation of a nurse designated as a charge nurse. During an interview on 12/04/23 at 10:35 AM, the Facility Administrator (FA) stated, “We do not have a current charge nurse.””

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 30011 Based on record reviews and interview, the dialysis facility failed to ensure that an adequate amount of staff were present to provide dialysis care and meet the needs for 21 of 59 patients for dialysis treatments from November 19, 2023 through November 25, 2023. (Patients (PT) 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21). The findings include: The dialysis facility runs a Monday, Wednesday, and Friday schedule and a Tuesday, Thursday, and Saturday schedule. During the week of November 19, 2023 through November 25, 2023 (Thanksgiving week), in order for the dialysis clinic to close on Thursday, November 23, 2023, the dialysis devised a schedule for 21 of the Monday, Wednesday, and Friday scheduled patients whereby those patients would dialyze on Sunday, November 19, 2023 and on Tuesday, November 21, 2023, and again on Friday, November 24, 2023. On Monday, November 20, 2023, the dialysis facility unit secretary notified the Monday, Wednesday, and Friday (21 patients) that their dialysis for Tuesday, November 21, 2023 was canceled and their dialysis would resume on Friday, November 24, 2023 and also informed those patients if they needed dialysis that they were to go to a hospital’s emergency department. This decision resulted in these patients receiving dialysis on Sunday, November 19, 2023 and not again until Friday, November 24, 2023 which was 5 days later. Patient 1 was admitted to the hospital at 4:00 AM on Friday, November 24, 2023 with respiratory distress requiring an emergent dialysis treatment. Review of the dialysis facility’s staffing logs on 12/04/23 at 2:25 PM revealed on 11/21/23 the facility had two nurses and 5 dialysis technicians scheduled for duty for 3 patient bays with 10 dialysis stations in each bay. Review of the patient schedule for dialysis treatment on 11/21/23 revealed 59 patients were scheduled for dialysis treatment with 21 patients noted as “did not run” on that day because those patients were canceled. Review of Patient 1’s chart revealed the patient was admitted to the in-center dialysis facility on 03/23/23 with a diagnosis of End Stage Renal Disease (HERD). Physician orders dated 03/20/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving, the patient’s dialysis days was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physicians order. Review of the “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Patient 1 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the patient’s canceled treatment by the dialysis facility. Patient 1 was admitted to the hospital at 4:00 AM on Friday, November 24, 2023 with respiratory distress requiring an emergent dialysis treatment. Review of facility daily patient schedule on 12/05/23 at 8:35 AM revealed on Tuesday 11/21/23, Patient 1 was documented as “didn’t run”, and on Friday 11/24/23, as in the “hospital”. Further review revealed an “anchor” by Patient 1’s name which meant “do not change schedule”. Review of the physician progress note dated 11/29/23 revealed “patient was sent to ER (Emergency room) due to lack of staffing. Patients need to get extra treatments at the clinic and need enough notice. Discussed with DO. Will bring for extra HD (hemodialysis) tomorrow”. Patient 1’s hemodialysis treatment sheet dated 11/29/23 revealed 7.20 kilograms of fluid removed post treatment and on 11/30/23 for the extra treatment day, 3.10 kilograms of fluid was removed. The findings were verified on 12/08/23 at 2:00 PM by the Interim Director of Operations (DO). On 12/05/23 at 12:08 PM, review of Patient 2’s chart revealed Patient 2 was admitted to the in-center dialysis facility on 06/09/20 with a diagnosis of ESRD. Physician orders dated 10/30/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving, the patient’s dialysis days was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physicians order. Review of the dialysis facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed on Tuesday 11/21/23, Patient 2 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Patient 2 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:17 PM by the Interim Director of Operations (DO). On 12/05/23 at 12:54 PM, review of Patient 3’s chart revealed Patient 3 was admitted to the in-center dialysis facility on 11/28/22 with a diagnosis of ESRD. Physician orders dated 09/25/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving, the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23 and Friday 11/24/23, without documentation of a physicians order. Review of the dialysis facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Patient 3 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Patient 3 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:11 PM by the Interim DO. On 12/05/23 at 1:47 PM, review of Patient 4’s chart revealed Patient 4 was admitted to the in-center dialysis facility on 01/22/20 with a diagnosis of ESRD. Physician orders dated 10/30/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving, the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of the dialysis facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Patient 4 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Patient 4 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:23 PM by the Interim DO. On 12/05/23 at 2:39 PM, review of Pt 5’s chart revealed Pt 5 was admitted to the in-center dialysis facility on 11/17/20 with a diagnosis of ESRD. Physician orders dated 09/22/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving, the patients’ dialysis days was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 5 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 5 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:20 PM by the Interim Director of Operations (DO). On 12/05/23 at 3:33 PM, review of of Pt 6’s chart revealed Pt 6 was admitted to the in-center dialysis facility on 10/20/20 with a diagnosis of ESRD. Physician orders dated 11/15/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving the patients’ dialysis days was changed to Sunday, 11/19/23, Tuesday, 11/21/23 and Friday, 11/24/23, without documentation of a physicians order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM, revealed Tuesday, 11/21/23, Pt 6 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 6 did not receive a dialysis treatment on 11/21/23 with no documentation of a physicians order for the canceled treatment. The findings were verified on 12/08/23 at 2:12 PM by the Interim Director of Operations (DO). On 12/05/23 at 3:54 PM, review of Pt 7’s chart revealed Pt 7 was admitted to the in-center dialysis facility on 02/11/22 with a diagnosis of ESRD. Physician orders dated 10/16/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving, the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 7 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 7 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:17 PM by the Interim Director of Operations (DO). On 12/05/23 at 4:07 PM, review of Pt 8’s chart revealed Pt 8 was admitted to the in-center dialysis facility on 08/26/16 with a diagnosis of ESRD. Physician orders dated 09/22/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday, 11/19/23, Tuesday, 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 8 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 8 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:08 PM by the Interim Director of Operations (DO). On 12/05/23 at 4:22 PM, review of Pt 9’s chart revealed Pt 9 was admitted to the in-center dialysis facility on 01/02/20 with a diagnosis of ESRD. Physician orders dated 09/18/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 9 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 9 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:08 PM by the Interim Director of Operations (DO). On 12/06/23 at 10:00 AM, review of Pt 10’s chart revealed Pt 10 was admitted to the in-center dialysis facility on 11/01/21 with a diagnosis of ESRD. Physician orders dated 09/18/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM, revealed Tuesday 11/21/23, Pt 10 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 10 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:13 PM by the Interim Director of Operations (DO). On 12/06/23 at 10:18 AM, review of Pt 11’s chart revealed Pt 11 was admitted to the in-center dialysis facility on 02/15/22 with a diagnosis of ESRD. Physician orders dated 11/15/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 11 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 11 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:13 PM by the Interim Director of Operations (DO). Record review on 12/06/23 at 10:33 AM for Pt 12 revealed Pt 12 was admitted to the in-center dialysis facility on 01/27/22 with a diagnosis of ESRD. Physician orders dated 09/18/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 12 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 12 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:13 PM by the Interim Director of Operations (DO). On 12/06/23 at 11:10 AM, review of Pt 13’s chart revealed Pt 13 was admitted to the in-center dialysis facility on 10/01/19 with a diagnosis of ESRD. Physician orders dated 09/27/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 13 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 13 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:15 PM by the Interim Director of Operations (DO). On 12/06/23 at 11:34 AM, review of Pt 14’s chart revealed Pt 14 was admitted to the in-center dialysis facility on 02/26/21 with a diagnosis of ESRD. Physician orders dated 11/08/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physicians order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 14 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 14 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:15 PM by the Interim Director of Operations (DO). On 12/06/23 at 11:52 AM, review of Pt 15’s chart revealed Pt 15 was admitted to the in-center dialysis facility on 08/23/23 with a diagnosis of ESRD. Physician orders dated 11/10/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of the facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 15 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 15 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:16 PM by the Interim Director of Operations (DO). On 12/06/23 at 12:35 PM, review of Pt 16’s chart revealed Pt 16 was admitted to the in-center dialysis facility on 02/03/22 with a diagnosis of ESRD. Physician orders dated 05/16/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of the facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 16 was documented as “didn’t run”. Further review revealed no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:04 PM by the Interim Director of Operations (DO). On 12/06/23 at 12:57 PM, review of Pt 17’s chart revealed Pt 17 was admitted to the in-center dialysis facility on 01/04/01 with a diagnosis of ESRD. Physician orders dated 05/16/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 17 was documented as “didn’t run”. Further review revealed no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:05 PM by the Interim Director of Operations (DO). On 12/06/23 at 1:15 PM, review of Pt 18’s chart revealed Pt 18 was admitted to the in-center dialysis facility on 07/24/21 with a diagnosis of ESRD. Physician orders dated 10/17/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving, the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM, revealed Tuesday 11/21/23, Pt 18 was documented as “didn’t run”. Further review revealed no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:06 PM by the Interim Director of Operations (DO). On 12/06/23 at 1:37 PM, review of Patient 19’s chart revealed Pt 19 was admitted to the in-center dialysis facility on 03/28/23 with a diagnosis of ESRD. Physician orders dated 11/07/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of facility daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 19 was documented as “didn’t run”. Further review revealed no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:06 PM by the Interim Director of Operations (DO). On 12/06/23 at 12:58 PM, review of Patient (Pt) 20’s chart revealed Pt 20 was admitted to the in-center dialysis facility on 04/08/20 with a diagnosis of ESRD. Physician orders dated 09/14/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of the dialysis facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Pt 20 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Pt 20 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:07 PM by the Interim Director of Operations (DO). On 12/06/23 at 2:27 PM, review of Patient 21’s chart revealed Patient 21 was admitted to the in-center dialysis facility on 07/29/22 with a diagnosis of ESRD. Physician orders dated 09/18/23 revealed a dialysis prescription for treatment for 3 days a week on Monday, Wednesday, and Friday. Further review revealed the week of Thanksgiving that the patient’s dialysis day was changed to Sunday 11/19/23, Tuesday 11/21/23, and Friday 11/24/23 without documentation of a physician order. Review of the dialysis facility’s daily patient schedule on 12/05/23 at 8:35 AM revealed Tuesday 11/21/23, Patient 21 was documented as “didn’t run”. Review of “Missed (No Show) or Shortened Treatments” report on 12/08/23 at 10:40 AM revealed Patient 21 did not receive a dialysis treatment on 11/21/23 with no documentation of a physician order for the canceled treatment. The findings were verified on 12/08/23 at 2:07 PM by the Interim Director of Operations (DO). During an interview on 12/05/23 from 9:40 AM to 10:20 AM, Unit Secretary 1 stated, “I had to call the patients to tell them they couldn’t do treatment that day (Tuesday 11/21/23). I was told to figure out the patients which were not to run that day. Usually a senior nurse would figure this out. I told them I wasn’t comfortable with this. The FA was the one who called me and said we were only going to have two nurses tomorrow and to start calling some patients and canceling them. I asked for some type of direction, but he/she didn’t give me any. I mean, I know how to call patients, but to decide who to tell not to come I wasn’t comfortable with that. I asked the FA (Facility Administrator) to help me make the calls, and the FA said I had to do it. We only had two nurses that day so I suggested the ones who could drive be re-scheduled versus the ones who have transportation issues. I am not a nurse.” During an interview on 12/07/23 from 9:46 AM to 10:20 AM, the FA was asked who determined which patients to cancel for treatment on 11/21/23, and the FA stated, “I remember calls being made on that day. I remember the previous Director of Operations (DO) had the nurse and the secretary to go over the list and decide which patients would be better to cancel. I don’t remember which nurse calls were being made on the 20th”. When asked was a criteria used to determine which patients would be canceled, the FA stated, “I don’t know what the nurses normally do as an assessment. The nurses would have determined that.” When asked what was the plan for those patients who were not being treated, the FA stated, “The plan was to let them know we’re short staffed. They were told if they feel this or that to go to the ER. The following week calls were made to those who couldn’t come to treatment to get an extra treatment. We should have offered them another treatment.” When asked if the Medical Director was aware about the patients being canceled, the FA stated, “I don’t know if the former DO reached out to him/her”. When asked who approved the Thanksgiving holiday schedule change, the FA did not respond to the question asked. During an interview on 12/08/23 from 12:55 PM to 1:23 PM, Registered Nurse (RN) 1 stated, “I worked Monday and realized we didn’t have enough staff for Tuesday. Some changes took place, and I thought it was a bad idea, and I thought we should have waited since we didn’t know how staffing was going to be. I called the FA because I hadn’t been made aware of any changes and was told that I am a PRN (as needed) interim float and they didn’t think it was necessary to tell me. I was going to take it upon myself to look at the patients and decide who might need it the most, but I was told by Unit Secretary 1 that the decision was already made because he/she spoke with the FA already. So I didn’t have a decision on what patients ran. Unit Secretary 1 and the FA was to split the patients to be called, but Unit Secretary 1 ended up making all the calls. The other nurse nor myself never called any patients. We had enough techs (technicians) but not enough nurses. I did tell Unit Secretary 1 to make sure that they let Medical Doctor 1 know, but I don’t know if he/she knew.” During an interview on 12/07/23 from 1:24 PM to 2:17 PM, the Medical Director (MD) stated, “I am aware of the holiday scheduling changes. The DO, the Vice President, and FA make me aware of any changes, and if we had a Clinic Manager. Absolutely not was I aware of or involved in the discussion for the patients being canceled. I was re-assured that every patient would have their treatment. Every person is to run their full treatment. I was upset on Monday when I found out about it. I asked the staff members and one of the patients told me he/she was in the hospital, and I asked if he/she could come in for another treatment. I spoke with the RVP (Regional Vice President) about what happened and still didn’t get a clear answer. I’m supposed to be notified if they (the facility) can’t run patients. I can’t tell you the last time I have been notified, it’s not consistent. Any schedule changes, the nurses are to change the orders because its the same treatment. They (the staff) are not to pull over 5 kg (kilograms) over an hour. The hemodialysis treatment max you can pull is 13 cc/kg/hr (cubic centimeter/kilograms/hour) equals UF (ultrafiltration). What I expect is the nurse to call me for an extra treatment. They are not to pull 7200 mls (milliliters), but only if the Medical Director says its ok, and I didn’t order that”. During an interview on 12/08/23 from 4:08 PM to 4:12 PM, the Regional Vice President (RVP) stated, “We put out guidance and my preference was to be off for Thanksgiving. The leadership team decided to do the change. So we did the Monday, Wednesday, Friday group to dialyze on Sunday, Tuesday, and Friday and the TTS (Tuesday, Thursday, Saturday) group to Monday, Wednesday, and Saturday. The Regional Vice President, Director Operations, CM (Clinic Manager) or Facility Administrator’s make up the leadership team”.”

“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: 30011 Based on record reviews, interviews, and review of the dialysis facility policy and procedure, the dialysis facility did not demonstrate evidence that patient grievances were investigated, addressed in a timely manner, and the patient and/or designee was informed of the investigation and when resolution was attained for 4 of 4 acknowledged patient grievances. The findings include: Review of the dialysis facility’s grievance log on 12/04/23 at 3:00 PM revealed 3 patient grievances dated 02/28/23, 03/21/23, and 03/22/23 that had no additional documentation of each patient’s grievance. On 12/08/23 at 2:30 PM, the Social Worker provided emails of patient grievances dated 09/06/23, 10/18/23, and two patient grievances on 11/06/23 with no documentation of the investigation, follow-up of the grievance, and/or documentation of resolution with the patient. On 12/08/23 at 4:15 PM, the surveyor requested the dialysis facility’s Governing Body meeting minutes from October 2023 to December 2023. The dialysis facility only provided the governing body meeting minutes dated 12/05/23. The governing body meeting minutes revealed a plan of correction for recent patient grievances with no documentation that the patient grievances dated 02/28/2023, 03/21/2023, and 03/22/2023 were discussed. During an interview on 12/05/23 from 3:05 PM to 3:09 PM, the Interim Director of Operations (DO) stated, “We don’t have any information about our previous complaints because no one here knew how to put them in. The previous DO, I don’t know what he/she did with the information, but we do know we had some, and I am aware of one complaint which was filed on November 21,2023. We do not have a log of any complaints that we received here that were then sent to the previous DO”. During an interview on 12/06/23 at 4:08 PM to 4:27 PM, the Social Worker stated, “After the departure of two interim clinic managers, they were putting in the information (grievances) into the system. Any complaints given to me, I addressed as I could. If the patient wanted a call, then I would forward it to the Director of Operations or Clinic Manager (CM)) via email. Sometimes, if the DO or leadership was here at the clinic, then I could pull them into my office and let them talk with the patient. Prior to the current Facility Administrator (FA), there was no FA or Clinic Manager. Between August 2023 to November 2023, there were about 4-5 complaints and one complaint sent to the current FA a couple of weeks ago. The patient grievance can be reported to me, but the CM and higher leadership can only input the grievance information into the system. Any follow up would be addressed by leadership.” Facility policy, entitled, “Patient Grievance”, revealed, “All patient grievances received at the facility must be reported to QAI (Quality Assessment and Performance Improvement) Committee and to the Governing Body: The intent of QAI review is to use patient grievances and trends as a means to identify opportunities to improve care. Written documentation of the grievances and the actions taken to resolve it must be available in the QAI minutes. The intent of the Governing Body review is to ensure that: An effective internal grievance process is established and followed. Majors problems with care and safety of patients or patients’ rights are addressed and resolved. Description of patient grievance and the resolution offered to the patient is documented within the Governing Body meeting minutes...”.”