Davita New Braunfels Dialysis

“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: 34839 Based on record review and interview, the facility’s internal grievance process failed to 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) Timeframe’s 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. Specifically, the facility failed to document a patient and staff grievance and were not provided a description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. Findings include: Review of the facility’s grievance log revealed 3 out of 3 patient/staff complaint forms were not initiated. Review of statements provided to the regional director from S#1 and S#2 stated in part, “ P#1 stated she was going to bring a gun to treatment on Monday ( 6/23/25) and shoot everybody, and P#2 (dialyzes in station and chair next to P#1 ) said that she was afraid to come to treatment on Monday because she overheard P#1 statement. “ Review of facility Policy and Procedure titled Dialysis Regulatory and Ancillary Policies & Procedures Policy: 3-01-06A Origination Date: March 2008 Revision Date: September 2008, March 2013, April 2021, October 2021, October 2024 Page 1 of 2 Confidential and Copyrighted 2008-2024 Policy: 3-01-06A Printed copies are for reference only. Please refer to the electronic copy for the latest revision. TITLE: ADDRESSING PATIENT GRIEVANCES: DAVITA TEAMMATES PURPOSE: To provide guidance to DaVita teammates for receiving and addressing Patient Grievances. POLICY: 1. Patient grievances may be verbal or written. They may be submitted directly to a facility teammate or submitted to the DaVita Guest Services department. 2. All complaints/grievances should be documented on the facility Patient Grievance Log. 3. All details of patient grievances and discussions will be documented. This documentation will be maintained in a separate file and kept in a secure and locked location. The Grievance Investigation Document may be used for this purpose. This form is not for patient use. Grievance documentation is not part of the patient medical record and should not be provided to the patient. 4. The DaVita teammate receiving the grievance should report the grievance to the charge nurse, Facility Administrator (FA), or Social Worker. 5. Based on the nature of the complaint, the appropriate member of the interdisciplinary team (IDT) will discuss the grievance with the patient and take appropriate action towards a solution, if possible. 6. If the patient grievance cannot be resolved, the FA will be notified. The FA will meet with the patient to discuss the grievance and take appropriate action towards a solution, if possible. If the grievance is not resolved, the patient should be invited to a grievance conference. The grievance conference should be coordinated to occur within 10 days of receipt of the complaint. 7. Grievances submitted to Guest Services will be communicated to the Facility Administrator (FA)/designee and Regional Operations Director (ROD) within one (1) business day for follow-up. FA or ROD should speak to the patient and if the grievance is not resolved, the patient should be invited to a grievance conference. The grievance conference should be coordinated to occur within 10 days of receipt of the Guest Services complaint. Dialysis Regulatory and Ancillary Policies & Procedures Policy: 3-01-06A Origination Date: March 2008 Revision Date: September 2008, March 2013, April 2021, October 2021, October 2024 Page 2 of 2 Confidential and Copyrighted .2008-2024 Policy: 3-01-06A 8. The patient will be invited to participate in a formal Grievance Meeting attended by the FA, SW, Medical Director and the ROD. The patient ’ s nephrologist may also be invited to participate. This grievance meeting should occur within 10 days of initial receipt of the grievance. 9. The Regional Operations Director and/or Medical Director will discuss the grievance with the patient and take appropriate action towards a solution, if possible. 10. Record of the meeting should be documented during the meeting. The Grievance Meeting Report may be used for this purpose. Grievance documentation is not part of the medical record and should not be provided to the patient. 11. If the patient grievance cannot be resolved by the Regional Operations Director and/or Medical Director during the grievance conference the Divisional Vice President will be notified. The Divisional Vice President will discuss the grievance with the patient and take appropriate action towards a solution, if possible. 12. The Divisional Vice President along with Group General Counsel will take the necessary steps to review and, if necessary, investigate and respond to the grievance. 13. The Divisional Vice President issues a written, final decision to the patient within 10 days of the grievance conference. Interview with the Facility Administrator and covering Regional Director on 12/15/2025 at 10:55 AM regarding the investigation of grievances on the Patient/Staff Complaint Form was not filled out, the covering Regional Director stated, “We did not do a grievance, we filed a police report and hired security.””