Davita North Fulton Dialysis

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 50523 Based on a review of facility records, patient and staff interviews, and a review of minimum state required staffing ratios, it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This failure had the potential to negatively affect the health and safety of 37 in-center hemodialysis patients who were under the care of this facility. Findings include: Cross Reference: V 757 - Failure of the Facility Administrator to ensure the facility employed an 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 (who was not counted as a dialysis care giver in the staff-to-patient ratio of one dialysis care giver to four patients), who was readily available to provide nursing care, take charge and deal with unexpected complications of dialysis, for every 12 patients receiving dialysis care and that each care giver was not assigned more than four patients at any given time.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 50523 Based on medical record review, including facility Policy and Procedures (P&P), and staff interview, it was determined that the facility failed to ensure that five of five in-center hemodialysis (ICHD) patients (P#1, P#2, P#3, P#4 and P#5) sampled, had a Patient Care Plan that reflected participation of all members of the Interdisciplinary Team (IDT), including the patient or patient representative. This lack of IDT collaboration and participation had the potential failure to identify new patient concerns and outcomes that were not achieved. This deficient practice had the potential to negatively affect the health and safety of P#1, P#2, P#3, P#4 and P#5 and the other 44 ICHD patients who were under the care of this facility. Findings Include: During a review of patients’ medical records, the following was revealed: - P#1 was admitted on 8/3/23. The Annual Care Plan was dated 4/22/24. The nephrologist’s signature was missing. - P#2 was admitted on 6/19/17. The last Annual Care Plan was dated 5/6/24. - P#3 was admitted on 1/27/23. The Annual Care Plan was dated 9/13/24. The nephrologist’s signature was missing. - P#4 was admitted on 5/7/24. The Annual Care Plan was dated 2/10/25. The nephrologist’s signature was missing. - P#5 was admitted on 11/15/24. The Annual Care Plan was dated 2/10/25. The nephrologist’s signature was missing. - P#1, P#2, P#3, P#4 and P#5 were diagnosed with End Stage Renal Disease (ESRD) and were receiving hemodialysis treatment three times per week. There was no documentary evidence that all of these five patients or their patient representatives, were included in the development nor discussion of their Annual Care Plan, as required. -A review of Policy 1-14-01 titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care”, with latest revision date of October 2020, stated: Plan of Care 13. The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or non-physician practitioner (NPP), if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social work, and a dietician. 14. The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided. -The above findings were acknowledged by the Facility Administrator on 2/15/25 at 12:30 p.m., during the exit interview.”

“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: 50523 Based on a review of facility records, patient and staff interviews, and a review of minimum state required staffing ratios, it was determined that the Facility Administrator failed to ensure the facility employed an 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 (who was not counted as a dialysis care giver in the staff-to-patient ratio of one dialysis care giver to four patients), who was readily available to provide nursing care, take charge and deal with unexpected complications of dialysis, for every 12 patients receiving dialysis care and that each care giver was not assigned more than four patients at any given time. This deficient practice had the potential to cause a delay in monitoring patients for issues such as fluid overload (an excessive amount of fluid in the body), changes in vital signs, or problems with the dialysis equipment. Additionally, insufficient staffing could mean slower responses to alarms, delayed adjustments, or missed complications including but not limited to: intradialytic hypotension (sudden drops in blood pressure which can occur when fluid is removed too rapidly), arrhythmias (irregular heartbeat), and other medical issues and emergencies related to hemodialysis. Findings include: - A review of “Patient and Teammate Schedule” (schedule of the number of patients dialyzing each shift, with their assigned Dialysis Care Givers: Patient Care Technicians (PCTs AA, BB, CC, and DD) and Registered Nurses (RN AA and RN BB), from December 2024 to February 12, 2025, revealed the following: - The Patient Treatment Room had five Pods (sections) with four patient Stations (S) in each Pod. - The facility was open on Mondays, Wednesdays and Fridays (MWF) only (for patients’ hemodialysis treatments), with three shifts, and a total of 18-19 patients per first and second shifts, and nine patients on third shift. - The MWF “Patient and Teammate Schedule” reviewed between December 2024 and February 12, 2025, revealed that RN AA and RN BB alternated between being assigned to Pod 1 as Dialysis Care Givers, providing total care of four patients per first and second shifts and two patients on third shift, in addition to providing nursing care/tasks that included, but not limited to: pre and post dialysis assessments, preparation and administration of medications, communicating with doctors as needed, as well as assisting with the care of other patients who were assigned to the other four PCTs (AA, BB, CC, and DD), especially those patients with Central Venous Catheters (CVC - A flexible tube inserted into a vein and threaded into a large vein above the right side of the heart), as their primary dialysis access. - Pod 1: RN BB (or RN AA), was assigned as Dialysis Care Giver to patients at S1, S2, S3, and S4. On first shift, three of four patients (P), (P#6, P#7, P#8), had CVCs which required catheter care (during initiation and termination of dialysis treatments and any CVC problems or complications), by licensed nurses only: (i.e.RN or LPN- Licensed Practical Nurse). On second shift, all four patients, (P#9, P#10, P#11, and P#12), had CVCs, and on third shift, two of two patients, (P#13, and P#14), had CVCs. - Pod 2: PCT AA was assigned as Dialysis Care Giver to patients at S5, S6, S7, and S8. On second shift, one of four patients (P#15), had a CVC (which required licensed nurses only for CVC care). - Pod 3: PCT BB was assigned as Dialysis Care Giver to patients at S9, S10, S11 and S12. On first shift, two of four patients (P#16 and P#17), had CVCs. On second shift, one of four patients (P#18), had a CVC. On third shift, one of one patient (P#19), had a CVC. - Pod 4: PCT CC was assigned as Dialysis Care Giver to patients at S13, S14, S15, and S16. On first shift, one of four patients (P#20), had a CVC. On second shift, one of four patients (P#21), had a CVC. On third shift, one of one patient (P#22), had a CVC. - Pod 5: PCT DD was assigned as Dialysis Care Giver to patients at S17, S18, S19 and S20, however, the facility was using only two to three stations (S17, S18, and S19) for hemodialysis treatment per shift. On second shift, one of two patients (P#23), had a CVC. - During an interview with RN AA on 2/10/25 at 10:45 a.m., he stated that there were always two scheduled RNs and four PCTs per shift on MWF. RN AA also stated that he and RN BB alternated between being a Charge Nurse or being assigned to a Pod. RN AA added that managing a full Pod of patients while also supervising the treatment of patients outside their designated Pod can be challenging, overwhelming, and it’s dangerous to leave the designated Pod alone while preparing and administering medications, conducting nursing assessments, and assisting with the care of five other patients. Additionally, RN AA stated that the facility had a high number of catheter patients who were assigned to the RN’s Pod, as well as catheter patients outside of the RN’s Pod which required for an RN to initiate and terminate dialysis treatments. - On 2/12/25 at 10:40 a.m., the Facility Administrator confirmed what RN AA stated above regarding the RNs’ schedule and responsibilities. - On 2/12/25 at 11:31 a.m., RN BB stated that it was unsafe for an RN to be assigned a Pod and still provide nursing care for five additional patients outside of their assigned Pod. She also stated that when an RN was assigned a Pod, the RN must also perform direct patient care duties, such as setting up the machine, initiating and discontinuing hemodialysis treatments, removing blood lines, disinfecting dialysis chairs and machines, and keeping an eye out for any patient problems that may come up during dialysis, on top of performing nursing assessments, preparing and administering medications, etc. RN BB also stated that she and RN AA would split the number of patients each shift to render care to.”