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Based on interview and document review, it was determined that facility staff failed to follow policy related to the grievance process.

The findings are:

During the course of a complaint investigation, the surveyor had opportunity to discuss with Staff Member (SM) #2, the facility's process for resolution of patient grievances. SM #2 was asked if he/she recalled any interaction with Patient # 3 or the family of Patient #3 related to patient's treatment. SM #2 stated that he/she remembered the circumstances of Patient #3's discharge. SM #2 states he/she was out of work all week prior to the patient's discharge on 4/20/19. SM #3 states he/she checked e-mails on Sunday after the patient was discharged and was made aware of the patient's family member calling and speaking to the supervisor and requesting to speak to management about an interaction between the patient and the contracted dialysis nurse.

The family member of Patient #3 had stated to facility staff that the dialysis nurse informed the patient on 4/19/20 there are four (4) other people to dialyze and since you are going home tomorrow (4/20/19) and getting dialysis, you do not need treatment today.
SM #2 stated he/she contacted the family member on Monday and told the family member there was a meeting set up for Wednesday with the dialysis provider. SM #2 stated the patient's family member seemed satisfied and happy with the care provided for Patient #2 and stated the main concern was the missed dialysis treatment. A review of the facility complaint log failed to reveal evidence of a complaint by Patient #3 or his/her family members.

SM #2 was asked if the interaction and correspondence with the family member of Patient #3 would have been considered a grievance. SM #2 confirmed that by policy it would have been a grievance and should have been entered in the grievance log but he/she had failed to do so.

Facility policy #8, last reviewed 7/31/2018 read in part: "Complaints meeting any of the criteria below are considered grievances and require a written response. 2. Complaint regarding the patient's care or with an allegation of abuse , neglect, patient harm, or failure of the hospital to comply with one or more CoP's or other CMS requirements"

The above findings were shared with facility management at the time of discovery and again prior to exit on 6/27/2019. No further information was provided to the surveyor.

Based on observation, interviews and clinical record review, it was determined facility staff failed to ensure dialysis treatments were provided according to physician orders.

The findings include:

The clinical record for Patient #3 was reviewed with the assistance of Staff Member #5 on 6/26/19. Patient #3 was admitted to the facility on 4/05/19 for acute rehabilitation following a hospital stay for respiratory distress. Patient #3 had diagnoses which include end stage renal disease and is on hemodialysis. A review of most recent dialysis orders found the following "Hemodialysis Frequency 04/12/19 12:21:00 EDT, qM, W, F" and "Hemodialysis Details 04/12/19 12:21:00 EDW 3.5 hours, 350ml.=/min BFR, 600 ml/min DFR, 2.0 K+ mEq, 2.5 Ca+ HCO3 meq 144 Na+"

Patient #3 received dialysis as ordered until Friday 4/19/19, in a complaint related to this issue, a family member stated he/she was told by Patient #3 that the dialysis nurse informed the patient on 4/19/19 there are four other people to dialyze and since you are going home tomorrow (4/20/19) and getting dialysis, you do not need treatment today. A review of the clinical record confirmed the patient did not receive dialysis on 4/19/19. A review of patients scheduled for dialysis on 4/19/19 found four patients were to receive dialysis treatments that day, including the patient. A review of a Case Management progress note for 4/19/19 confirmed Patient #3 was scheduled for discharge at 0830 and dialysis at 11:15 on 4/20/19.

Further review of the clinical record failed to provide evidence of a physician's order to hold dialysis on 4/19/19. A review of progress notes by the physician and the nephrologist found both physicians were aware Patient #3 would not receive dialysis on Friday 4/19/19 but no order was given by either of the physicians to hold the dialysis treatment.

The failure by facility staff to obtain an order to hold an ordered dialysis treatment was discussed at the time of discovery on 4/26/19 at 2 p.m. and again with the management team prior to discharge. No further information was provided to the surveyor.