Davita Barker Cypress Dialysis

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 37492 Based on record review and interview, the Facility’s governing body failed to ensure the State Agency (Health and Human Services Commission) was notified of an ambulance transfer from the dialysis facility to a hospital due to a fall while the patient was in their facility in 1 of 4 sampled patient (#6). Review of Texas State form 6103 (ESRD facility Incident Report), updated 10/2023, gives the following information: Reporting Information: incident reports are required for the following: 2. any ambulance transport from the dialysis facility to a hospital due to the patient’s emergent medical condition; this includes ambulance transport after a call to 911, whether the lights are flashing and or the siren is on as the ambulance leaves. Reportable Incident - Within 10 working days Form 6103, End Stage Renal Disease Facility Incident Report “ Hospital Transfer - Any ambulance transport from the dialysis facility to a hospital because of the patient’s medical condition. This includes emergent and non-emergent hospital transfers via ambulance whether the lights are flashing, the siren is on or both as the ambulance leaves the dialysis facility or parking lot.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 30124 Based on observation, interview and record review, facility’s direct care staff failed to administer patient’s hemodialysis treatment based on the physician’s order and outlined in the patient plan of care in 1 of 9 sampled patients (Patient #7). The facility has a current census of 71 incenter hemodialysis patients. Review of the facility’s current policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment”; Policy: 1-03-08, last revision April 2024. Purpose: To obtain and document baseline and ongoing information about the patient before during and after dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Policy: 2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). a. The assessment includes the following components: i. Review of patient reports, data collection, complaints, and response to treatment. ii. Verification that machine safety checks have been completed and documented. iii. Verification that the patient access is visible, and face is not covered. V. Review of documentation for accuracy, completion, and patient data. Vi. A physical assessment of the patient which includes 1. Apical heart rate and rhythm. 2. Auscultation of the lungs. 3. Evaluation of volume status including edema. 4. Bruising or bleeding. 5. Patient statement of well-being, level of pain or discomfort. 6. And other components which if observed/informed will be documented, including but no necessary limited to the following: Change in normal level of consciousness, mobility, or mental status. Complaints of nausea, vomiting, diarrhea, constipation, skin changes, headache, respiratory distress, angina, weakness, fever, cramping dizziness. Reports of illness or/or injuries, falls, conditions/complications or other problems patient has experienced since the last dialysis. 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to a. Dialyzer make and model. b. Treatment time. c. Target weight. d. UFR and Max UFR .e. UF Profiling. f. Blood flow rate. g. Dialysate flow rate. h. All accesses evaluated. i Correct dialysate composition (potassium, calcium, base sodium, and bicarb) and settings. j Heparinization (intradialytic infusion setting). Observation of the patient treatment area on 10/29/2024 at 13:30 PM along with staff ID #F patient ID #7 was observed receiving dialysis via an arterial venous fistula with a blood flow of 400 mls/minute and dialysate flow of 800 mls/minute. Review of the patient’s hemodialysis prescription set on the machine during his revealed 2.0 potassium, 2.5 calcium, 137 sodium, bicarb 35. Review of patient ID #7’s physician prescription document a bicarb of 37 was ordered. Interview with staff ID #F confirmed the above findings and stated the hemodialysis machine was not set at the bicarb as order by the physician and immediately made the correction on the machine.”

“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: 30124 Based on record review and interview the facility’s medical diector failed to ensure nursing staff followed the facility’s policy and procedures to prevent or reduce complications pre, during or post treatment in that the nursing staff did not: 1. Complete the initial nursing assessment within the first hour of treatment in 1 of 9 records reviewed. (Patient ID #2). 2. Staff failed to notify the charge nurse of specific patient parameters that were identified to be out of range and nursing staff failed address abnormal finding by reassessment of patients in 3 of 9 records reviewed. (Patient ID #s 1, 2, 4) The facility currently has a census of 71 hemodialysis patients that could be affected by the nursing staff failing to complete the initial nursing assessment within the first hour of hemodialysis treatment. Policy Reviewed: Review on 10/29/2024 of the facility’s current policy titled: “Pre-Inter-Post Treatment Data Collection, Monitoring and Nursing Assessment”; Policy: 1-03-08; Latest Revision: April 2024. Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment and status prior to discharge. Pre-Treatment Data Collection/Assessment 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. 7. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated. Intradialytic Data Collection/Assessment 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner as required by state law. Review on 10/29/2024 of facility specific parameters utilized by dialysis staff. Reads as follows: “Abnormal Findings, Report to RN !!!” Pre-Treatment: Weight - Weight gain more than 4 kg or any weight loss from target weight. Blood Pressure - Systolic > 180 or < 100 Diastolic >110 or < 50 Unless noted ono patient’s chart. Heart Rate - > 100 BPM or < 55 BPM Temperature - > 100 F Respirations > 24 or < 12 During Treatment: 20 mm/Hg increase or decrease from previous BP (blood pressure). Notify CN (Charge Nurse) if any parameters from pre-treatment were exceeded during treatment. Notify CN (Charge Nurse) of any change in the BFR (blood flow rate). Notify CN (Charge Nurse) of any complaints. Post Treatment Blood Pressure - Systolic > 180 or < 100 Diastolic >110 or < 50 Unless noted ono patient’s chart. Heart Rate - > 100 BPM or < 55 BPM Temperature - > 100 F Respirations - > 24 or < 12 Weight - Leaving above or below 1 KG from target weight. Records Reviewed: Review on 10/30/2024 along with the charge nurse, staff ID #A of selected patient records identified the following: Patient ID #1 hemodialysis treatment sheet reviewed: 10/26/2024 pre-treatment blood pressure documented as a standing BP of 160/76, pulse 82. At 8:01 AM blood pressure documented by Patient Care Technician, staff ID #H, BP 177/84, 8:06 AM BP 196/87 No documentation was found that Patient Care Technician (PCT), staff ID #H notified the charge nurse of BP that was out of parameters prior to initiating treatment. No documentation was found of assessment or reassessment of the patient with abnormal blood pressure out of parameters by the nurse. 10/19/2024 pre-treatment blood pressure documented as a standing B 153/73, pulse 71. At 9:02 AM blood pressure documented by Patient Care Technician, staff ID #I BP 195/82. No documentation was found that Patient Care Technician (PCT), staff ID #I notified the charge nurse of BP that was out of parameters prior to initiating treatment. No documentation was found of assessment or reassessment of the patient with abnormal blood pressure out of parameters by the nurse. Patient ID #2 hemodialysis treatment sheet: 10/19/2024 hemodialysis treatment initiated 9:45 AM, pre-nursing assessment documented by nurse at 11:10 AM. 10/15/2024 hemodialysis treatment initiated 9:31 AM, pre-nursing assessment documented by nurse at 10:40 AM. 10/15/2024 pre-treatment blood pressure documented as a standing BP of 210/90, pulse 68. No documentation was found that Patient Care Technician (PCT), staff ID #G notified the nurse of BP that was out of parameters prior to initiating treatment. 10:01 AM note by PCT, staff ID #G BP 212/86,”Patient awake; alert; and states no complaints at this time”. 10:31 AM note BP 222/86 note Patient blood pressure is elevated; Patient awake; alert and states no complaints at this time. 10:35 note Updated by PCT #G, Patient blood pressure is elevated. Patient states no complaints as this time; charge nurse elevated. 11:01 AM note BP 224/84 Patient blood pressure elevated; patient awake; alert and states no complaints at this time; charge nurse aware. 11:31 AM, BP 201/82, note Patient monitored eyes closed; patient resting. 12:01 PM, BP 193/76, note Patient monitored eyes closed; patient resting appears to be tolerating treatment well at this time. 12:31 PM BP214/81 note patient monitored eyes closed; patient resting. 13:02 PM BP 210/71 note treatment terminated. Medication record reviewed documented registered nurse, staff ID #A gave patient Clonidine 0.1 milligrams at 10:41 AM (anti-hypertensive blood pressure medication). At 11:41 AM Staff ID #A documented response “minimal” on medication record. No documentation was found of assessment or reassessment of the patient with abnormal blood pressure out of parameters by the nurse. Patient ID #4 hemodialysis treatment sheet: 10/26/2024 pre-treatment blood pressure documented as a standing BP of 180/74, heart rate 95. At initiation of hemodialysis treatment at 10:32 AM by Patient Care Technician, staff ID #H documented BP 182/93, pulse 95; 11:02 AM documented BP 182/90, heart rate 106, 11:31 AM BP 170/88, pulse 108. No documentation was found that Patient Care Technician (PCT), staff ID #H notified the nurse of BP or heart rate that was out of parameters. No documentation was found of assessment or reassessment of the patient with abnormal blood pressure out of parameters by the nurse. Interview 10/30/2024 with staff ID #A confirmed the above finding and stated the assessment by the nurse should be done within the first hour of hemodialysis.”

“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: 30124 Based on a review of documentation and interview, the facility failed to ensure that the facility implemented and enforced procedures for the resolution of complaints relevant to quality of care or services rendered by licensed health care professionals and other members of the facility staff, including contract services or staff. The facility shall document the receipt and the disposition of the complaint. Findings included: Review on of the facility’s current policy and procedure title, “Addressing Patient Grievances: Teammates”; Policy:3-01-06A ; last revision October 2021 reads in part: Purpose: To provide guidance to teammates for receiving and addressing Patient Grievances. Policy: 2. All complaints/grievances should be documented on the facility Patient Grievance Log. 3. All details of patient grievances and discussion 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. 4. The 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. Review of the facility’s current policy and procedure titled, “Patient Grievance”; Policy: 3-01-06A; last revision October 2024 reads in part: “INTERNAL GRIEVANCE PROCESS: ... A. Grievances may be reported to a DaVita teammate either verbally or in writing. Grievances should be submitted to a DaVita teammate within 30 days of the date the person filing the grievance became aware of the issue. B. The DaVita teammate should report the grievance to the charge nurse. If a solution to the grievance is not reached through this discussion, the charge nurse is to notify the Facility Administrator (“FA”) and the Regional Operations Director (“ROD”) within one (1) business day for follow-up. C. The FA (or her/his designee) is to discuss the grievance with the patient, investigate and take appropriate action towards a solution, if possible. This discussion should occur within 10 days of receipt of the grievance. If the patient’s grievance cannot be resolved by the FA, the ROD and Medical Director will be notified. D. The ROD and/or Medical Director will discuss the grievance with the patient and take appropriate actions towards resolution, if possible. This discussion should occur within 10 days of receipt of the grievance from the FA. lf the patient grievance cannot be resolved by the ROD and/or Medical Director, the Divisional Vice President will be notified.” Review of the facility grievance log on 10/29/204 along with staff ID #C for September 2024 Patient Grievance Long revealed the following: Patient ID #10 Submitted a formal grievance to the facility dated 09/2024. Subject of complaint listed as “chair time”. Date TM (teammate) reported of grievance to CN (charge nurse or FA (Facility administrator) 09/2024. Date FA discussion with Patient - Blank Date Grievance meeting Held - Blank Date pf Resolution- Blank Grievonce Report completed 09/12/2024. Patient ID # 1 Submitted a formal grievance to the facility dated 09/05/2024. Subject of complaint listed as, “new staff and changing chair section she sits in”. Date TM (teammate) reported of grievance to CN (charge nurse or FA (Facility administrator) 09/05/2024. Date FA discussion with Patient - Blank Date Grievance meeting Held - Blank Date of Resolution- Blank Grievance Report completed - Blank. Patient ID #12 Submitted a formal grievance to the facility dated 09/05/2024. Subject of complaint listed as, “getting placed on the chair late”. Date TM (teammate) reported of grievance to CN (charge nurse or FA (Facility administrator) 09/05/2024. Date FA discussion with Patient - Blank Date Grievance meeting Held - Blank Date of Resolution- Blank Grievance Report completed - Blank. Patient ID #13 Submitted a formal grievance to the facility dated 09/09/2024. Subject of complaint listed as, “patient dry weight calculated, weighing wheelchair”. Date TM (teammate) reported of grievance to CN (charge nurse or FA (Facility administrator) 09/09/2024. Date FA discussion with Patient - Blank Date Grievance meeting Held - Blank Date pf Resolution- Blank Grievance Report completed - Blank. Patient ID #14 Submitted a formal grievance to the facility dated 09/10/2024. Subject of complaint listed as, “not seeing the dietitian”. Date TM (teammate) reported of grievance to CN (charge nurse or FA (Facility administrator) 09/09/2024. Date FA discussion with Patient - Blank Date Grievance meeting Held - Blank Date of Resolution- Blank Grievance Report completed - 09/12/2024. Patient ID #15 Submitted a formal grievance to the facility dated 09/12/2024. Subject of complaint listed as, “patient feeling threatened by PCT”. Date TM (teammate) reported of grievance to CN (charge nurse or FA (Facility administrator) 09/12/2024. Date FA discussion with Patient - Blank Date Grievance meeting Held - Blank Date of Resolution- Blank Grievance Report completed - Blank. Patient ID #2 Submitted a formal grievance to the facility dated 09/25/2024. Subject of complaint listed as, “interaction, patient feeling about FA”. Date TM (teammate) reported of grievance to CN (charge nurse or FA (Facility administrator) 09/25/2024. Date FA discussion with Patient - Blank Date Grievance meeting Held - Blank Date of Resolution- Blank Grievance Report completed - Blank. Interview with the Social Worker, staff ID #K on 10/30/2024 confirmed she was aware of the complaint and had spoken with the patient and the FA about the patient’s concerns. Staff ID #K stated the FA had told her she had spoken with the patient about her concerns. Interview on 10/30/2024 with staff ID #C confirmed the above finding and stated the facility administrator who was at the facility should have completed the documentation to ensure a grievance reported to the facility was investigated and a resolution documented in the Patient Grievance Log. Staff ID #C stated the facility administrator is no longer at the facility, and off on leave. No additional documentation was presented.”