Rai - Centinela - Inglewood

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 51860 Based on observation, interview, and record review, the facility failed to have an adequate number of qualified personnel for two of three sampled patients (Patient 1 and Patient 2) when the facility failed to adjust the patient/staff ratio appropriate for the acuity of the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care needed to meet patients’ needs. This failure had the potential to result in nursing staff to have a delay of patients’ care and services and put patients’ safety at risk. Findings: 1. During a record review of an email dated 6/20/25 sent by the Facility Administrator (FA) 1, the email indicates the following: As outlined in CMS Condition V757, facilities are required to be ‘staffed adequately to meet the needs of patients,’ which allows for flexibility based on patient acuity, census, and clinical judgement. We do not govern our staffing by any fixed numerical ratios, as none are required. 2. During an interview on 6/17/25 at 10:15 a.m. with Area Team Lead (ATL), ATL stated staffing is managed in accordance with V757 guidance which ATL states is: a Registered Nurse will have assigned no more than 12 patients, and a Patient Care Technician (PCT) will have no more than 4 patients. 3. A review on 6/23/25 of the Federal Regulatory Group (the government agency that creates and enforces regulations) for ESRD (End Stage Renal Disease: A severe condition where the kidneys have permanently lost most of their function and can no longer effectively filter waste products from the blood) V757 states: V757 (Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20) (b) Standard: Adequate number of qualified and trained staff. The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; and Interpretive Guidance § 494.180 (b)(1): Guidance is pending and will be updated in future release. 4. During an interview and record review on 6/24/25 at 2:50 p.m. with Registered Nurse (RN) 4, RN 4 stated she has eleven to seventeen central venous catheters (a tube inserted into a large vein, typically near the heart, to provide access to the patient’s blood supply needed for dialysis) she is responsible for either initiating or terminating a dialysis treatment, or both. A licensed nurse must be the one to initiate and terminate a dialysis treatment for patients with catheters. Dialysis Patient Care Technicians (PCT: provides direct patient care during dialysis treatment under the supervision of a registered nurse) cannot initiate or terminate a dialysis treatment for patients with catheters. 5. During an interview on 6/24/25 at 2:50 p.m. with RN 4, RN 4 stated on Friday 6/13/25, in a matter of minutes sometime after 5:00 p.m., there were two catheter patients ready to be taken off dialysis treatment, another catheter patient asking to be taken off the dialysis treatment temporarily as he was about to have an episode of diarrhea (loose, watery stools), and a physician requesting immediate assistance with translating questions to a new Spanish speaking patient. RN 4 stated the time this was occurring she felt stressed and unsafe in providing quality care. RN 4 states on this day she was responsible for terminating the treatment (disconnecting the catheter from the dialysis treatment) of seven catheter patients after 5:00pm, which is the time the other staff members have ended their shifts and RN 4 is left with two PCTs. RN 4 stated the number of 3rd shift (set of times dialysis patients are scheduled to arrive for treatment, with the first group in the 1st shift category, followed by the second group of patients in the 2nd shift category, followed by another group called the 3rd shift) catheter patients has increased from eight in May to eleven in June, with more patients with catheters about to be admitted to Facility 1 for dialysis. RN 4 states has on more than one occasion notified management of the unsafe patient situation at the end of the day and has offered various suggestions to the daily schedule to balance out the catheter patients. RN 4 states has been notified by FA 1 there will be no change in schedule and reminded there is no overtime without prior approval. 6. During an interview on 6/23/25 at 2:40 p.m. with Patient 1, a Monday-Wednesday-Friday (a usual three times a week schedule for dialysis treatment days, the other schedule option is a Tuesday-Thursday-Saturday schedule) 3rd shift dialysis catheter patient, Patient 1 stated she now feels unsafe with the increased number of catheter patients RN 4 has to take off and put on dialysis treatment. Patient 1 stated has offered to miss a treatment so RN 4 will have a lesser number of catheter patients to treat and is aware this is not a safe nor long-term solution. Patient 1 explained several days ago, exact date not recalled, she was having a hypertensive (high blood pressure) episode. Due to the number of catheter patients who needed to be taken off their dialysis treatment, RN 4 had difficulty getting to Patient 1 promptly in order to administer the necessary medication to lower blood pressure. Patient 1 observed RN 4 telling ‘the administrators’ of the need to adjust the schedule of the 3rd shift catheter patients to better balance the number of 3rd shift catheter patients. 7. During an interview on 6/24/25 at 3:05 p.m. with Patient 2, a Monday-Wednesday-Friday 3rd shift fistula (a surgical connection between an artery and a vein, created to provide a reliable access point for dialysis) dialysis patient, Patient 2 stated she has observed RN 4 having a more difficult time providing care due to the increased number of catheter patients RN 4 is responsible for. Patient 2 stated has observed RN 4 asking other nurses for help, something she had not seen RN 4 do before the last few weeks but has not seen any help provided. 8. During an interview on 6/25/25 at 3:30 p.m. with Patient 3, a Monday-Wednesday-Friday 3rd shift catheter patient, Patient 3 stated he often has to wait to be taken off dialysis treatment because RN 4 is busy with other catheter patients. Patient 3 states the wait times to be taken off dialysis have increased in the last few weeks as the number of 3rd shift catheter patients has increased. Patient 3 states he is concerned for RN 4’s well-being. 9. A review of the facility’s dialysis schedule dated 06/13/25 for the Monday-Wednesday-Friday patients indicated there were seven catheter patients to be taken off treatment after 5:00 p.m. (the time at which RN 1, RN 5, and Licensed Practical Nurse (LPN) 1 are clocked out for the day), compared to 5 catheter patients in same time period in May (the facility’s dialysis schedule for May reviewed is dated 5/5/25). - The 06/13/25 catheter take off times after 5:00 p.m. were scheduled as follows: 5:05 p.m., 5:15 p.m., 5:25 p.m., 5:30 p.m., 5:40 p.m., 5:50 p.m., 6:20 p.m.. 10. A review of the RN Job Description dated 08/01/23 indicates the following, among other duties and responsibilities: - Provides safe and effective delivery of care to patients with ESRD. - Identifies and communicates patient related issues to Team Leader or physician. - Actively participates in the pre-evaluation, initiation, monitoring, termination, access (a method used to connect a patient’s bloodstream to a dialysis machine), homeostasis (a stable internal environment despite external influences), and post evaluation (an assessment done by a licensed nurse after a dialysis treatment, primarily to assess patient’s post-dialysis status and evaluate for any fluids not removed by the just completed dialysis treatment) of patients receiving hemodialysis (a medical procedure that filters a person’s blood to remove waste products and excess fluid when the kidneys are unable to do so effectively) treatment therapy according to established FMC (Fresenius Medical Care - a dialysis provider) procedures. - Maintains overall shift operations in a safe, efficient, and effective manner. - Routinely meets with the Clinical Manager to discuss personnel and patient care status, issues, and information. - Collaborate and communicate with physicians and other members of the healthcare team to interpret, adjust, and coordinate care provided to the patient.”