Dci Dawson

“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: 03383 Based on interviews, observation, and a review of records and facility policy, it was determined that the governing body failed to ensure that the facility met the State regulations pertaining to patient-to-staff ratio requirements. This facility did not have adequate number of qualified staff to meet the needs of all patients as evidenced by a lack of at least one licensed and qualified nurse to provide nursing services (such as patient assessments before and after dialysis treatment, preparation and administration of medications, carry out changes in dialysis orders, treatment prescription assessment and dry weight evaluation, emergency medical interventions, and other nursing care/duties) for every 12 patients who were receiving dialysis care; and who was not counted as a dialysis care giver in the staff-to-patient ratio of one dialysis care giver to four patients (in addition to performing charge nurse and team leader duties). This deficient practice had the potential to negatively affect the health and safety of 38 patients who dialyzed at this facility. Findings were: During an interview on 7/25/24 at 9:46 a.m., the Administrative Assistant (AA) stated the facility is only open on Mondays, Wednesdays, and Fridays and run 2 shifts; have 20 stations including one Isolation Room and had a census of 38 patients. During an interview on 7/25/24 at 12:18 p.m., the Nurse Manager (NM) confirmed the above information provided by the AA. The NM stated the facility was closed on 12/31/22, was closed all of 2023 due to major renovations, and reopened on 2/5/24. Two PCTs (Patient Care Technicians) were hired on 2/29/24 but were no longer at this facility; one left in May 2024 due to attendance and the second PCT walked out after break in June 2024. The facility had one position open to increase patient numbers in the future. During an interview on 7/26/24 at 8:02 a.m., LPN CC stated “When there are staff callouts or no shows, a patient is added to my workload; usually if I only have 3 patients, and typically care for 8 patients between first and second shift. They try to staff with six: Two RNs (Registered Nurses), two LPNs (Licensed Practical Nurses), and two PCTs. A staff member is currently on medical leave and has been for about five weeks. When callouts happen, one of the RNs must pick up a load, must run that row (Pod of four patients). It’s been like this since staff member went on medical leave. Today, there are five staff here, two RNs, one LPN and two PCTs. There is also a PCT here in training and has been here for about a month. We are short today, the other LPN requested to be off today. My workload increased; had another PCT here but she walked out.” During an interview on 7/26/24 at 9:06 a.m., PCT DD indicated the following: Have worked here for 20 years; is an opener (first to arrive in early morning), closer (last to leave at the end of day), and a preceptor. PCT DD is currently training a new PCT; stated “It’s hard to train new staff when I am still carrying a full workload (four patients per shift). Has worked with current PCT for five weeks. Nurses initiate dialysis for catheter patients and PCTs monitor them. Patients are spaced out every 15 minutes which helps. I feel overwhelmed working with five patients. Staffing will not improve until person on medical leave returns. All clinics are short, it’s really hard working like this. The charge nurse has a full load of patients and the team leader has a full load of patients. It is hard, I usually go home and collapse.” During an interview on 7/26/24 at 8:14 a.m., RN BB stated the facility had 20 Stations and five sections (Pods with four Stations each). When staff calls out, the charge nurse is assigned a section. Both RNs have a section, and also must complete duties assigned to the charge nurse. One RN is assigned to be the charge nurse and the other RN is the team leader. Stated it is not safe when RNs are assigned to a section, especially when there are patients who were experiencing problems during dialysis like hypotension (low blood pressure). There are three patients who currently experience hypotension during treatment. Nurses and PCTs are assigned to care for four patients each. However, RNs must also complete direct patient care tasks that included machine set up, nursing assessments, preparation and administration of medications, initiation of dialysis, termination of dialysis, removal of blood lines, wipe down machines and chairs, monitor any issues that arise with patients during dialysis, provide chairside education, review lab reports and report labs to the doctor, schedule vascular appointments, order medication refills, and all of the other duties the charge nurse had been assigned to do. RN BB stated that this has been going on for about seven months. RN BB indicated that she is struggling with close monitoring of patients during dialysis and patient education when she must work a section. Two PCTs were hired recently, and both had quit because of the workload. Stated they (Administration) have tried to hire people but are having a hard time finding people to work. Today, RN BB is the team leader; there were 19 patients on first shift; one LPN and one PCT were off today; both RNs were assigned to four patients each. RN BB had four patients on second shift and the charge nurse had three patients in addition to her charge nurse duties. Second shift had several patients with catheter [A central venous catheter (CVC) is a soft plastic tube that’s inserted into a large vein in the neck or groin and used to provide hemodialysis (HD) for patients. The catheter is advanced until the end is in the inferior vena cava, superior vena cava, or right atrium of the heart]. CVC site dressing changes, initiation and termination of dialysis via CVC were performed by licensed nurses. During observations in the treatment area on 7/26/24 from 9:35 a.m. to 10:50 a.m., the following was revealed: There were five direct patient care staff plus one trainee who were present in the treatment area including RN BB, RN GG, LPN CC, CCHT DD, CCHT JJ, and PCT LL in training. - RN BB was assigned to be the team leader and was also assigned to care for four patients on the first shift and three patients on second shift. RN BB performed pre and post assessments on three patients on first shift and four patients on second shift. RN BB was observed terminating dialysis treatment on four patients. This included removing lines from the machines, wiping down machines and chairs, and setting up machines for patients on the second shift. - RN GG was the charge nurse and was also assigned to care for two patients on the first shift and three patients on second shift. In addition, RN GG performed pre (before dialysis) and post (after dialysis) assessments on five patients on the first shift and four patients on the second shift. - All of the staff present in the treatment area were moving at a fast pace to terminate dialysis treatment on current patients and set up dialysis machines for the second shift patients (change over). PCTs were observed requesting nurses to perform post assessment for their assigned patients. - The NM conducted one post assessment, wiped down a machine at Station (S) 17, emptied saline bags in dirty sink, and documented machine values on flowsheet. - CCHT DD and PCT LL worked together to terminate dialysis in one Pod while RN BB terminated dialysis on patients in S9, S10, S11 (isolation room), and S12; removed lines and dialyzer (artificial kidney) from the machines, cleaned and disinfected the dialysis chairs and the machines, and set-up machines at S9, S10, S11, and S12; performed post assessment for patients in S6 and S7; and administered medication to a patient in S5. A review of the Daily Assignment Sheets with the NM on 7/25/24 at 1:00 p.m., revealed that the facility had five direct patient care staff who worked on 6/7/24, 6/10/24, 6/19/24, 6/21/24, 6/24/24, 6/28/24, 7/12/24, 7/22/24, 7/26/24); and had six staff on 6/3/24, 6/5/24, 6/12/24, 6/14/24, 6/17/24, 6/26/24, 7/1/24, 7/3/24, 7/5/24, 7/10/24, 7/15/24, 7/19/24, and 7/24/24. A review of the Daily Assignment Sheets and flowsheets dated 7/19/24, 7/22/24, and 7/26/24 revealed the following: On 7/19/24: - RN BB was the charge nurse and performed nine patient assessments on the first shift. RN BB was also assigned and cared for three patients (in S3, S4, S7); and performed five additional assessments on the second shift, in addition to her duties as the charge nurse. Two of the second shift patients had catheter as an access. - RN GG was assigned and cared for three patients (in S17, S18, S20) on the first shift and two patients (in S16 and S17) and one shared patient (performed assessment) on the second shift. One of the second shift patients had catheter as an access. - LPN FF was assigned and cared for three patients and one shared patient on the first shift; one patient and one shared patient on the second shift. One of the first shift patient had a catheter access. - LPN CC was assigned and cared for four patients and one shared patient on first shift; three patients and one shared patient on second shift. One of the first shift patient had a catheter access. - Certified Clinical Hemodialysis Technician (CCHT) DD was assigned to one patient and one shared patient with PCT LL (Trainee) on the first shift; two patients and one shared patient on second shift with PCT LL. - CCHT JJ was assigned and cared for four patients and one shared patient on first shift; one patient and one shared patient on second shift. On 7/22/24: - RN GG was the charge nurse. RN GG was also assigned and cared for four patients (in S18, S17, S19, and S20) and performed six patient assessments on first shift; had two patients (in S17, and S20) and performed eight assessments on second shift in addition to her duties as a charge nurse. - RN BB was assigned and cared for four patients (in S9, S10, S11, and S12) and three shared patients (performed pre assessments) on first shift; had four patients (in S9, S10, S11, and S12) and one shared patient (performed pre-assessments) on second shift. - LPN CC was assigned to four patients on first shift; two patients and one shared patient on second shift. - CCHT DD was assigned to one patient and three shared patients on first shift; and five shared patients on second shift. - CCHT JJ was assigned to two patients on first shift and two patients on second shift. On 7/26/24: - RN GG was the charge nurse and was also assigned and cared for two patients (in S18 and S20) and had five shared patients (assessments) on first shift; had three patients (in S17, S19, and S20) and performed four additional assessments on second shift along with her charge nurse duties. - RN BB was assigned and cared for four patients (in S9, S10, S11, and S12) and four shared patients (performed assessments) on first shift; three patients (in S10, S11, and S12) and four shared patients (assessments) on the second shift. - LPN CC was assigned to four patients on the first shift and four patients on second shift. - CCHT DD was assigned to one patient and three shared patients with PCT LL (Trainee) on the first shift; four patients and four shared patients on second shift with PCT LL. - CCHT JJ was assigned to four patients on first shift; three patients and one shared patient on second shift. - NM completed one patient assessment on second shift. A review of RM Occurrences - Multiple Patient Detail Report from 6/1/24 to 7/26/24 revealed the following: On 6/7/24 at 7:33 a.m.: Machine alarmed, and black blood and bubbles were discovered in venous line. Staff were unable to reset the machine. Lines were discarded along with 250 cc (cubic centimeter) of patient’s blood that could not be returned. New system was set-up and the treatment was resumed. The facility was staffed with two RNs, two LPNs, and one PCT. All five staff were assigned to care for four patients each on the first shift including the charge nurse and the team leader. A review of Policy No. (A 1 of 2) V-17 titled, “Charge Nurse Responsibilities” with the latest revision date of May 2010 showed the following: CHARGE NURSE RESPONSIBILITIES 1. Check assignments - make necessary changes due to calling out tardies, etc. 2. Pre-Dialysis conference 10 minutes before patients are called in. 3. Call patients in at assigned times. Timeliness is crucial to patient satisfaction. 4. Ascertain blood tubes are out - should be done by depending on opening time, but check to see that it is done. 5. Advise members of staff to read patient’s chart: A. New orders B. Treatment changes C. Previous treatment complications D. Access changes *INCLUDE SPECIAL INSTRUCTIONS FOR STAFF - HbSag, NEW ROUTINE, ETC.* 6. Weigh in patients - record weights, weight changes, check patients status, B/Ps (Blood Pressure), temperature, pulse, C/Os (Complaints), lungs, edema, access status, Hcts (Hematocrit - volume percentage of red blood cells in blood), and all TICKLER ITEMS on flow sheets and D/C (discontinue) all fulfilled orders. 7. Prepare for physician rounds weekly: Ensure lab results in patient’s chart, have results of previous dictation orders (i.e., X-ray, physician appointment), blank order sheets, prescription sheets, etc. are available. 8. Review Hcts weekly and make necessary protocol changes prior to the a.m. shift on Wednesday (for Monday-Wednesday- Friday patients) and prior to a.m. shift. Thursday (for Tuesday-Thursday-Saturday patients if lab results have been made available). 9. Assign changeover, lunch relief, transfer patient assignments, make out assignments for next day. Review Calcium and Phosphorus levels on days of physician’s rounds. Transcribe orders after rounds. Medication Changes: Make changes in computer as ordered by physician. If a home medication change, print new med sheet and place in chart. Makes changes in computer on patient prescription as ordered by physician. Dialysis order changes: Enter into computer. Notification if required to staff assigned to patient. Have physician initial lab, X-ray reports, or other test results that have been viewed and place in chart. Take break as time permits. 13. Supervise changeover - assist as necessary. 14. Check chlorine and hardness test results, verify and sign RO (Reverse Osmosis) and water system log and monitors are WNL (Within Normal Limits). Check that conductivity (ability to conduct electrical current), temperature and pH (acidity) have been recorded by the AM personnel on each flowsheet prior to calling patients in at beginning of a day. 15. Check to make sure machine test on flowsheet has been initialed on the a.m. shift by the AM personnel and the AM personnel has signed appropriately. 16. Once the patients are called in, round as necessary for double checking treatment prescription, assessments and changing dry weights as needed when the patient is in the treatment chair. Monitor hallway entrance door to make sure it is kept locked. Perform Mock Codes monthly. 19. Reports to Nurse Manager on the functioning problems of the unit and/or employees not following the rules and regulations. 20. Exhibits ability to delegate the workload among staff to get the work done efficiently. 21. Acts as supervisor in the unit under supervision of Nurse Manager. 22. Completes and implements monthly care plans and annual assessments as assigned. 23. Calls physician with findings outside normal limits. First Shift - Get patients on the machine on time by patient schedule - Do patient rounds within 30 minutes of patient getting on machine - Verify patient prescription is correct and matches machine - Verify air detector is armed, UF (Ultra Filtration - removal of excess fluid from the blood) correct, all safety checks - Verify pre-assessments done - Address patient problems - Address patient problems: Inform MD (Physician) - Process MD orders, sign off and implement - Assign patients to staff; licensed and unlicensed per acuity - Document on progress notes/MIS as necessary - Ensure vital signs and machine checks done q (every) 30 minutes - Ensure machine numbers and station numbers are recorded on flowsheets and in the MIS and that they are correct - Code flowsheets for missed treatments Medications - EPO (medication that is used to treat anemia) count prior to giving meds as assigned - Validate all medications given/initialed/signatures on Medication Administration Log and on flowsheet. This includes comparing amount taken out of cabinet to amount entered on the flowsheets. - Compare to ending inventory (total meds given) as assigned - Enter EPO overfill in MIS as assigned Second Shift - Get patients on the machine on time by patient schedule - Do patient rounds within 30 minutes of patient getting on machine - Verify patient prescription is correct and matches machine - Verify air detector is armed, UF correct, all safety checks - Verify pre-assessments done - Address patient problems - Address patient problems: Inform MD - Process MD orders, sign off and implement - Assign patients to staff; licensed and unlicensed per acuity - Document on progress notes/MIS as necessary - Ensure vital signs and machine checks done q 30 minutes - Ensure machine numbers and station numbers are recorded on flowsheets and in the MIS and that they are correct - Code flowsheets for missed treatments - Validate chlorine before each shift - Order meds when low or expired - Enter Epogen (EPO) overfill and monitor daily - Round with doctor and enter orders Completion of the Day - Validate water hardness test and RIO checks and ensure entered into TechNet correctly - Complete checklist at bottom of Daily Assignment Sheet - EOC/Infection Control/Access Logs recorded - EOC/hospitalizations date entered into MIS - data entry - Edit HD (Hemodialysis) orders for changes in pt. (patient) tx (treatment) day or shift - End modality (pts no longer on HD) data entry - Enter order/complete form for extra tx. scheduled - Verify all medications are given, signed, correct dosage and wastage entered before staff leave for the day - Ensure flowsheet documentation is complete - pt. assessments done and procedures circled before staff leave for the day - Assign staff to check lab orders/lab tubes on chart - Ensure machine numbers and station numbers are written on each flowsheet. Ensure occurrence reports are done for the day. Unit Shutdown - Validate oxygen tanks are off - Discard any documents with PHI into destruction box - Lock charts, cabinets, office - Log off computers/screens off/computers covered - Complete end of day checklist (needs to be developed) Infection Control - Ensure PPE (Personal Protective Equipmenet) worn throughout the day - Ensure machines are disinfected between treatments and patient supplies not mixed on machine at shift change - Ensure handwashing and gel are used appropriately during and between treatments - Ensure drugs are dated and initialed as soon as they are opened - Ensure hepatitis testing is done on first treatment and hepatitis vaccine started within 30 days of admission - Ensure hepatitis vaccine is given throughout the series on time Miscellaneous - Ensure data entry is done timely and correctly CHARGE NURSE CHECKLIST - Morning meeting reminders 10 minutes prior to patients being called - Review orders - Print flowsheets - Print Heparin labels - Print med labels - Print medication administration log - Print assignment sheets (2): Patient and clinic assignments - Check flowsheets against med log and assignment sheet - Check flowsheets for completion before staff is dismissed - Make assignments for next day - Check refrigerator temperatures - Check glucose meter - Check 02 (oxygen) tanks - Weekly drain checks - Check technical log completion daily - Check crash cart and all expired meds - Check Dialyzer sheet at end of day - Check assignment completion before staff is dismissed - Assure unit is covered at all times with correct number of staff during break assignments - Monitor for infection control issues and counsel staff of report to NM (Nurse Manager) A review of undated document titled, “Duties and Responsibilities of the Team Leader (LPN or RN)” showed the following: - The Team Leader will function as the medication nurse. - The medication nurse will draw up and give all of the medications. - Assess the PCT’s patient’s pre and post dialysis. - Dismiss the PCT’s patients. - Make sure that all the occurrences are completed. - Make sure that the staff goes on break and are back on time. - Help on the rows or stations when an emergency arises. - Balance the patients (make changes after it has been established that the patients are too close or they are coming off at the same time as the other patients they are assigned to. - Make sure that the protocols are followed by checking the H & H (Hemoglobin and Hematocrit) and the CA (Calcium) & PHOS (Phosphorus), the I.V. (Intravenous) Iron, and the FERRITINS (Protein that stores iron in cells, in the blood). During an interview on 7/26/24 at approximately 12:40 p.m., this surveyor and the Department’s program manager (via telephone) notified the Assistant Director of Operations/NM of the above findings. The NM stated she thought they were in compliance with staffing ratio requirements when there were five direct patient care staff who worked and cared for 20 patients. This included the charge nurse and the team leader who were assigned/performed the above mentioned nursing duties.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 25727 Based on observation, a review of the CDC guidelines, and staff interviews, it was determined that the Infection Control Committee failed to ensure that two of two Registered Nurses (RN AA and RB BB) and one of one Licensed Practical Nurse (LPN AA) observed, utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of two of two in-center hemodialysis patients (P#1 and P#2) who dialyzed at this facility. Findings include: During observation in the Patient Treatment Room on 1/31/24 between 11:00 a.m. and 1:00 p.m., the following was revealed: - RN AA, RN BB, and LPN AA touched the dialysis machine panels at Stations 19 and 20 (dirty task) and charted on paper flowsheets while they wore contaminated gloves. - When finished, the flowsheets were placed on the counter of the nurses station (clean area). According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area), could cause cross contamination that spread bacteria/infections. During an interview on 1/31/24 between 11:30 a.m. and 12:30 p.m., RN AA, RN BB, and LPN AA confirmed the above findings. RN AA stated that they should have removed the contaminated gloves and performed hand hygiene prior to charting.”