Looking Deeper into Delivery of Care

In reviewing the dialysis surveys, we decided to take a deeper look into reasons for the cited deficiencies. As a result, we determined the following:

(1) Lack of adequate education and training for staff,
(2) Lack of staff understanding the consequences of not implementing correct practices that could result in a negative outcome for the patient,
(3) Lack of management understanding the necessity of ensuring their staff are implementing correct practices
(4) Lack of adequate unit-level supervision to ensure correct implementation of policies and procedures. and
(5) Lack of staff understanding that implementation of incorrect practices, e.g. infection control, could result in their own, or their families, acquiring an infection.

CMS does not provide suffiicient funding to CDPH (California Department of Public Health) in order to inspect facilities timely, e.g. every three years. However, California’s manual, to our understanding, states that facilities are to be inspected annually. This does not happen. What is of great concern is that many facilities have not been inspected in over 5-8 years, therefore, we have many questions:

(1) When a survey is conducted and deficiencies are cited:

(a) How long have these incorrect practices been happening?
(b) Considering, there is no event (error) reporting to the State, how
many preventable errors have resulted in actual harm, or death?
(c) What has actually happened in the facility between surveys, especially
if there are cited deficiencies that have placed patients in potential or
actual harm situation?

The bottom line is that the surveyors identify such deficient practices, either through observation, medical record review or interviews with staff and patients. Therefore, we ask, “Why did management not identify these problems?

Question: If staff are aware of correct practices, but do not implement same, is this considered an intentional act that places patient(s) in situations of potential or actual harm?

If a negative outcome occurs, as the result of a preventable error, and that staff person has been adequately trained and educated

Should the nurse, if there is a negative outcome, be reported to the Board of Nursing? Should the dialysis technician be reported to the oversight agency for technician certification?

These are questions that we hear often.



A DEEP look into
the real reasons
for preventable errors.
(this page will be updated – ongoing)

click on facility name

Davita – Montclair Dialysis Facility
(two complaint investigatigation
January 2020 and June 2020 –
repeat deficiency

Davita – Union City Dialysis Facility

DCI – Redding Dialysis Facility

FMC Rancho Cucamonga Dialysis

FMC San Bernardino Dialysis

FMC Santa Barbara Dialysis Unit /
FMC Santa Barbara Dialysis Unit REVIST

Independent (American Renal) Plumas Dialysis Unit

RAI Chula Vista

Home Dialysis Therapies of San Diego

Santa Clara Valley Medical / Santa Clara Valley Medical REVISIT
this facility according to CMS’ dialysis facility compare is an Independent company, however, other information we received stated Davita.