Davita Rockwall Dialysis Center

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 28297 Based on record review, interview, and review of the “Emergency Management Plan,” the facility failed to ensure that four of six (Patients (P)1, P2, P3, and P6) received training annually on Emergency Preparedness on whom to contact and failed to provide an alternate emergency phone number if an emergency occurred while the patient was absent at the dialysis facility. Failure to ensure patients were adequately trained to respond to emergencies could result in a delayed or inappropriate response, thereby exposing all 47 in-center hemodialysis patients at the facility to possible adverse outcomes. Findings include: Review of the facility’s “Emergency Management Plan (EMP),” revised in April 2023, read in pertinent part, “The Facility Administrator or designee is responsible for implementation, adherence to, and training patients on the “Emergency Management Plan (EMP).” Teammates are responsible to: Demonstrate knowledge of: Facility EMP ii. Emergency procedures b. Provide clear instructions to the patients: i. What to do in an emergency: 2. At home 3. Away from the facility ii. Where to go in an emergency 1. ln the dialysis facility: a. Facility evacuation plans and routes b. Shelter in place location(s), as applicable c. Rally points outside of facility 2. Away from facility, to include but not limited to a. Local shelters b. Evacuation / emergency routes iii. Who to call in an emergency: Emergency contact numbers for the facility a. Facility phone numbers.” 1. Review of the medical record for P1 revealed the facility admitted the patient on 07/20/22 with Diagnosis of End Stage Renal Disease (ESRD). There was no documentation that P1 had received annual training on Emergency Preparedness Training since admission, or was provided emergency phone numbers. 2. Review of the medical record for P2 revealed the facility admitted the patient on 05/09/22 with Diagnosis of End Stage Renal Disease (ESRD). There was no documentation that P2 had received annual training on Emergency Preparedness Training since admission, or was provided emergency phone numbers. 3. Review of the medical record for P3 revealed the facility admitted the patient on 07/01/16 with Diagnosis of End Stage Renal Disease (ESRD). There was no documentation that P3 had received annual training on Emergency Preparedness Training since admission, or was provided emergency phone numbers. The last “Dialysis Emergency Training” was completed on 10/05/22. 4. Review of the medical record for P6 revealed the facility admitted the patient on 11/27/20 with Diagnosis of End Stage Renal Disease (ESRD). There was no documentation that P6 had received annual training on Emergency Preparedness Training since admission, or was provided emergency phone numbers. During an interview on 12/20/23 at 11:40 AM the Interim Facility Administrator stated “Patients were required to be trained on Emergency Preparedness upon admission and annually to ensure patients know what to do in the event a disaster occurred in their current location. He/she stated the “Emergency Preparedness Training,” form should be printed out every year in March for all patients to receive the training on Disaster Preparedness.”

“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: 28297 Based on observation, interview, and policy review the facility failed to ensure patients were encouraged to wash or sanitized their hands after holding their access sites (a vascular access is created so that blood can be drawn from the body and run through a dialysis machine) for one of three survey days. The failure for patients to wash or sanitize hands after holding access site had the potential for cross contamination and could affect 47 in-center patients. In addition, staff failed to change gloves and complete hand hygiene when going from an area of contamination to touching clean supplies for one of three days. The failure to change gloves and sanitize hands had the potential for contamination of clean supplies and could affect 47 in-center patients. Findings include: 1. Observation on 12/18/23 at 2:20 PM revealed the patient at Station 5 applied pressure to the left upper arm access site until bleeding had stopped. When finished the patient removed his/her glove and Patient Care Technician (PCT) 11 taped up the patient’s arm and gathered the patient’s supplies. Registered Nurse (RN) 8 assisted the patient to the scale to obtain weight and escorted the patient to the lobby area. The PCT and RN did not assist or encourage the patient to wash or sanitize their hands before leaving the facility. During an interview on 12/20/23 at 12:15 PM RN 8 acknowledged the patient at Station 5 did not wash or sanitize hands that he/she knew of, and RN 8 confirmed he/she did not instruct or assist the patient the wash or sanitize hands after holding access sites but should have to prevent cross contamination. During an interview on 12/20/23 at 1:35 PM the Nurse Manager confirmed that patients were required to wash or sanitize hands after holding access sites to prevent cross contamination. Review of the facility policy “Infection Control for Dialysis Facilities,” revised April 2023 revealed the following: “Patients and caregivers will be encouraged to: a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area.” 2. Observation on 12/18/23 at 2:20 PM PCT 11 was at Station 5 discontinuing the treatment via a left upper arm access site to a Patient. PCT 11 removed the tape from the needle and the patient asked for a glove to hold access site. PCT 11 used the same contaminated gloves and reached into the clean box of gloves and retrieved a glove for the patient. During an interview on 12/18/23 at 2:35 PM PCT 11 confirmed he/she did use a contaminated glove to retrieve a glove for the patient and should not have due to cross contamination. During an interview on 12/20/23 at 1:35 PM the Nurse Manager confirmed the above observation was cross contamination of clean gloves. Review of the facility policy “Infection Control for Dialysis Facilities,” revised April 2023 revealed the following: “ Hand Hygiene: All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, 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 ...””

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 28297 Based on interview, record review, and policy review, the facility failed to ensure that one of six (Patients (P) 3) had a completed initial Plan of Care within 30 days of admission as required. The failure to complete an initial Plan of Care as required had the potential for missed opportunities for improved outcomes and could affect any new patients admitted to the facility. Findings include: Review of the medical record for P3 revealed the facility admitted the patient on 04/09/21 with diagnosis including End Stage Renal Disease (ESRD). An initial Plan of Care was completed on 04/30/21. P3 was scheduled for an annual Plan of Care in April 2022, however the patient was hospitalized with a kidney transplant. Hospital document review revealed the kidney transplant failed and the patient had an extended hospitalization. P3 was readmitted to the facility on 07/22/22 with diagnosis including ESRD, and failed kidney transplantation. There was no documentation of any care plan completion for P3 after readmission on 07/22/22. During an interview on 12/19/23 at 1:35 PM the Interim Facility Administrator stated an Initial Plan of Care should have been generated for P3 after a readmission from a failed transplant within 30 days of admission. However, that was with the old computer program that would have required it to be done manually and it was not completed. Review of the facility policy “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised July 2023 revealed the following: “A comprehensive assessment will be conducted on all new patients within 30 calendar days or l3 outpatient dialysis sessions beginning with the first outpatient dialysis treatment or per state guidelines ... New Patient ... A patient returning from failed transplant is treated as a new patient to dialysis (assessment and POC would be needed in 30 days (28 in New Jersey) of admission) ...””

“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: 28297 Based on interview, review of the “Grievance Report Summary,” review of the “Facility Health Report, (FHR),” and policy review, the facility failed to document an investigation and complaint resolution date for two of four reported grievances reviewed from January 2023 until November 2023. The failure to document a follow up on grievance in a timely manner had the potential for missed opportunities for improved care and could affect the 47 in-center patients. Finding include: 1. Review of the “Grievance Report Summary,” from June January 2023 through November 2023 revealed a grievance was reported in January 2023 and the patient transferred in July 2023. The Social Worker resolved the grievance, and a “Grievance/Investigation Document” was started but not completed. 2. In August 2023 a grievance was reported, and the Social Worker resolved the grievance in September 2023, and the patient was educated on fluid gains. Review of the “FHR” report for October 2023 revealed all grievances had been reported in the documentation however there was no documentation of any follow up with the patient or resolution as of 12/20/23. During an interview on 12/20/23 at 11:05 AM the Social Worker stated he/she was the covering Social Worker for this facility since June 2023. The Social Worker stated there had been three grievances reported since he/she had been at this facility but was unsure who was responsible to document the investigation and follow up resolution with the patient. The Social Worker stated there was not a specific person delegated to do the investigation and resolution. During an interview on 12/20/23 at 11:40 AM the Interim Facility Administrator confirmed there was no documented investigation or follow-up regarding the grievances reported in the “Grievance Report Summary.” The Interim Facility Administrator stated a “Grievance/Investigation Document” should be completed for each grievance per facility policy. Review of the facility policy “Addressing Patient Grievance, Davita Teammates,” revised October 2021 revealed the following: “ ...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. Grievance/Investigation Document may be used for this purpose. This form is not for patient use. Grievance documentation is not part of the patient’s medical record and should not be provided to the patient. The DaVita teammate receiving the grievance should report the grievance to the charge nurse, Facility Administrator (FA), or Social Worker. 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. 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 l0 days of receipt of the complaint ...””