Davita West Georgia Dialysis

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 03383 Based on observation, staff interview, and a review of facility policy, it was determined that the facility failed to ensure that all Direct Patient Care Staff cleaned up blood that spilled on the floor and splattered on the wall in the treatment area per facility policy. This deficient practice had the potential for cross contamination and increased risk of infection and could negatively affect the health and safety of 77 patients who were dialyzing at this facility. Findings include: An observation in the treatment area on 11/13/24 at 11:37 a.m., revealed the following: This surveyor observed red drops that looked like blood on the floor in front and side of Station (S) 1; the drops led to the front of Biomed room. The blood was also splattered on the wall next to S1. During an interview with the Facility Administrator on 11/13/24 at 11:37 a.m., the Facility Administrator agreed with the findings and stated that the red drops and splatter appeared to be blood. A review of Policy 1-05-01 titled, “Infection Control For Dialysis Facilities” dated April 2023 showed: Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials... At the end of each treatment, the dialysis station will be cleaned and disinfected.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 03383 Based on a review of medical records, staff interviews, and review of Policy and Procedures (P&P), it was determined that the interdisciplinary team (IDT) failed to ensure that two of two patients sampled (P#5 and P#6) who experienced extremely elevated blood pressure (BP), received medical care/interventions appropriate to the patient’s dialysis needs. The professionally accepted clinical practice standards for volume status for an adult hemodialysis patient was euvolemic (normal volume of blood or fluids in the body) and BP below 140/90 mmHg before dialysis and below 130/80 mmHg after dialysis. This was based on the Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations and the Measures Assessment Tool (MAT) per Centers for Medicare and Medicaid Services - Version 2.5. Uncontrolled BP in dialysis patients can lead to severe consequences such as increased risk of heart attack, stroke, and heart failure, as the damaged kidneys are unable to regulate fluid and BP effectively, making cardiovascular complications a major concern for dialysis patients. The facility census was 77. Findings include: A review of “Treatment Details Report” dated 9/26/24 - 11/11/24 showed the following: P#5: P#5 had an order for Clonidine (medication used to treat high BP) 0.1mg by mouth every four hours as needed. The order did not include parameters. On 10/30/24: - P#5’s BP was 222/129 mmHg (millimeters of mercury) with a heart rate of 97 during initiation of dialysis treatment at 12:15 p.m. - At 12:32 p.m., P#5’s BP was 240/126 mmHg with a heart rate of 101. - At 1:02 p.m., P#5’s BP was 216/122 mmHg with a heart rate of 105. - At 1:32 p.m., P#5’s BP was 203/116 mmHg with a heart rate of 107. - At 2:02 p.m., P#5’s BP was 188/109 mmHg with a heart rate of 106. - At 2:32 p.m., P#5’s BP was 200/122 mmHg with a heart rate of 107. - At 3:01 p.m., P#5’s BP was 203/114 mmHg with a heart rate of 103. - There was a lack of documented evidence that a licensed nurse was notified of the extremely elevated BP readings per facility P&P until 3:01 p.m. - At 3:02 p.m., P#5’s BP was 203/113 mmHg with a heart rate of 102. - At 3:32 p.m., P#5’s BP was 211/123 mmHg with a heart rate of 107. Clonidine 0.1 mg was administered by an RN. - At 3:36 p.m., P#5’s BP was 212/117 mmHg with a heart rate of 110. - At 4:02 p.m., P#5’s BP was 201/115 mmHg with a heart rate of 113. - P#5 was discharged home with a BP of 215/123 mmHg and was 4.0 kg (kilogram) over her target weight (estimated dry weight of 65.5 kg that was updated on 9/11/24). - There was a lack of documented implementation of the patient’s plan of care pertaining to BP and fluid management coaching. - There was a lack of documentary evidence that the physician was notified of the persistently elevated BP readings before, during, and after dialysis treatment. - There was also a lack of documented evidence that the physician was notified of P#5’s post weight to obtain an order for extra treatment to remove excess fluids. On 11/8/24: P#5’s BP was 205/121 mmHg during initiation of dialysis treatment at 12:35 p.m. Treatment was initiated by RN CC. Documentation did not show that Clonidine was given, or the physician was notified. - At 1:01 p.m., P#5’s BP was 200/117 mmHg. - At 1:31 p.m., P#5’s BP was 171/103 mmHg. - At 2:01 p.m., P#5’s BP was 183/109 mmHg. - At 2:31 p.m., P#5’s BP was 200/122 mmHg. - At 2:50 p.m., P#5’s BP was 196/126 mmHg. - At 3:01 p.m., P#5’s BP was 210/127 mmHg. - At 3:37 p.m., P#5’s BP was 190/113 mmHg. - P#5 was discharged home with a BP of 190/113 mmHg and was 4.5 kg over her estimated dry weight. - There were a lack of documented interventions for the extremely elevated BP readings before, during, and after dialysis treatment. - There was a lack of documented implementation of the patient’s plan of care pertaining to BP and fluid management coaching. - There was also a lack of documented evidence that the physician was notified of P#5’s post weight to obtain an order for extra treatment to remove excess fluids. A review of P#5’s “Patient Plan of Care” dated 10/8/24 showed the following: - Current goals for Fluid/BP: Meet and maintain a post-weight in relation to ordered target weight to avoid complications related to hyper- or hypo-volemic states. - Plan: Provide ongoing fluid management coaching. P#6: P#6 had an order for Clonidine (medication used to treat high BP) 0.1mg transdermal (skin patch) every four hours as needed. The order did not include parameters. On 9/30/24: - P#6’s BP was 175/115 mmHg during initiation of dialysis treatment at 11:18 a.m. Treatment was initiated by PCT HH. Documentation did not show that the nurse was notified about elevated BP. - At 11:31 p.m., P#6’s BP was 195/122 mmHg. - At 12:01 p.m., P#6’s BP was 177/107 mmHg. - At 12:31 p.m., P#6’s BP was 175/102 mmHg. - At 1:01 p.m., P#6’s BP was 183/105 mmHg. - At 1:31 p.m., P#6’s BP was 185/92 mmHg. - At 2:01 p.m., P#6’s BP was 151/109 mmHg. - At 2:30 p.m., P#6’s BP was 169/112 mmHg. - At 2:34 p.m., P#6’s BP was 177/115 mm Hg. - P#6’s post dialysis weight was 66.5 kg which was 0.5 kg over his estimated dry weight. - There was a lack of documented evidence that a licensed nurse and the physician were notified of the elevated BP readings. - There was no documented interventions for the elevated BP readings. A review of P#6’s “Patient Plan of Care” dated 6/21/24 showed the following: - Goal for Fluid/BP: Maintain post weight compared to target weight. Blood pressure within range. - The BP range was not identified in the patient’s plan of care. The Facility Administrator was notified of the above findings on 11/15/24 at 10:45 a.m. and stated the staff should have done more about the patients’ high BP. During an interview on 11/15/24 at approximately 11:00 a.m., the Manager of Clinical Services (MCS) agreed with the above findings and stated they would be making changes to the provider’s PRN (as needed) orders for Clonidine and develop parameters. A review of Policy: 1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised April 2024, stated: Pre-Treatment Data Collection/Assessment Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment collection will be documented and immediately reported to the licensed nurse. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. Abnormal Findings: Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. Blood pressure: Pre-dialysis: Systolic greater than 180 mmHg or less than 90 mmHg Diastolic greater than or equal to 100 mmHg Blood pressure - Intradialytic: Systolic greater than 180 mmHg or less than 90 mmHg Diastolic greater than or equal to 100 mmHg or less than 50 mmHg Blood Pressure Post Treatment: - If the patient can stand: o Standing systolic BP greater than 140 mmHg or less than 90 mmHg o Standing diastolic BP greater than 90 mmHg or less than 50 mmHg If the patient is not able to stand, document reason and sitting BP: Sitting BP for patient’s that cannot stand: o Sitting systolic BP greater than 140 mmHg or less than 90 mmHg o Sitting diastolic BP greater than 90 mmHg or less than 50 mmHg Heart or Pulse Rate Pre/Intra/Post: - Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heartbeat”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 03383 Based on a review of the facility’s Fiscal Year (FY) 2025 Dialysis Facility Report (DFR - A report prepared by the Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients), Quality Assessment and Performance Improvement (QAPI) meeting minutes, and staff interviews, it was determined that the QAPI Committee failed to track, trend, analyze, and develop plans of action to improve and sustain the facility’s Mineral Metabolism and Bone Disorder and Vascular Access Management, for six of six months (April 2024 - September 2024) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of 77 in-center hemodialysis patients who were receiving dialysis services at this facility. Findings include: A review of the FY2025 Quarterly DFR, (first quarter 2024) revealed that the facility was above the United States (US) threshold in: 1. Mineral Metabolism and Bone Disorder - [Phosphorus greater than (>) 7.0] - the facility was 20.9%; US was 12.6%. 2. Vascular Access - (Long-Term Catheter Rate) - the facility was 27%; US was 10.7%. A review of the facility’s last six months of QAPI meeting minutes from April 2024 - September 2024, revealed the following outcomes that were greater than the US threshold. Specifically, 1. Mineral Metabolism and Bone Disorder - The % of patients with Phosphorus >7.0 was 18.6 % in April 2024, 24.3% in May 2024, 19.4% in June 2024, 18.6% in July 2024, 19% in August 2024, and 27% in September 2024. 2. Vascular Access - The % of patients with CVC only > 90 days was 37.1% in April 2024, 36.5% in May 2024, 37.5% in June 2024, 35.7% in July 2024, 34.9% in August 2024, and 34.9% in September 2024. The facility’s QAPI meeting minutes from April 2024 - September 2024 showed that the interdisciplinary team (IDT) conducted a comprehensive review of mineral/bone and vascular access with no changes made to the action plans to ensure and sustain improvement in mineral/bone and vascular access. During an interview on 11/15/24 at 8:33 a.m., the Facility Administrator stated that more needed to be done to improve numbers for phosphorus and catheter use. The Manager of Clinical Services (MCS) stated that the IDT will work toward improvement of these outcomes. The MCS confirmed no changes were made to the plan for mineral/bone (phosphorus) in May, June, July, August, or September 2024.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 03383 Based on a review of medical records, staff interview, and review of Policy and Procedures (P&P), it was determined that the medical director failed to ensure that all Direct Patient Care Staff adhered to facility P&P pertaining to hypertension [elevated blood pressure (BP)] to ensure that two of two patients sampled (P#5 and P#6) who experienced elevated blood pressure, received medical care/interventions appropriate to the patient’s dialysis needs. According to current guidelines, an acceptable BP for a dialysis patient is typically considered to be below 140/90 mmHg before dialysis and below 130/80 mmHg after dialysis; this was based on the Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations. Uncontrolled high BP in dialysis patients can lead to severe consequences like increased risk of heart attack, stroke, and heart failure, as the damaged kidneys are unable to regulate fluid and BP effectively, making cardiovascular complications a major concern for dialysis patients. The facility census was 77. Findings include: A review of “Treatment Details Report” dated 9/26/24 - 11/11/24 showed the following: P#5: A review of records dated 10/30/24 showed an order for Clonidine (medication used to treat high BP) 0.1mg every four hours as needed. The order did not include parameters. On 10/30/24: - P#5’s BP was 222/129 mmHg (millimeters of mercury) with a heart rate of 97 during initiation of dialysis treatment at 12:15 p.m. - At 12:32 p.m., P#5’s BP was 240/126 mmHg with a heart rate of 101. - At 1:02 p.m., P#5’s BP was 216/122 mmHg with a heart rate of 105. - At 1:32 p.m., P#5’s BP was 203/116 mmHg with a heart rate of 107. - At 2:02 p.m., P#5’s BP was 188/109 mmHg with a heart rate of 106. - At 2:32 p.m., P#5’s BP was 200/122 mmHg with a heart rate of 107. - At 3:01 p.m., P#5’s BP was 203/114 mmHg with a heart rate of 103. - There was a lack of documented evidence that a licensed nurse was notified of the extremely elevated BP readings until 3:01 p.m. - At 3:02 p.m., P#5’s BP was 203/113 mmHg with a heart rate of 102. - At 3:32 p.m., P#5’s BP was 211/123 mmHg with a heart rate of 107. Clonidine 0.1 mg was administered by an RN. - At 3:36 p.m., P#5’s BP was 212/117 mmHg with a heart rate of 110. - At 4:02 p.m., P#5’s BP was 201/115 mmHg with a heart rate of 113. - P#5 was discharged home with a BP of 215/123 mmHg and was 4.0 kg (kilograms) over her target weight (estimated dry weight). - There was a lack of documentary evidence that the physician was notified of the persistently elevated BP readings before, during, and after dialysis treatment. - There was also a lack of documented evidence that the physician was notified of P#5’s post weight to obtain an order for extra treatment to remove excess fluids. On 11/8/24: P#5’s BP was 205/121 mmHg during initiation of dialysis treatment at 12:35 p.m. Treatment was initiated by RN CC. Documentation did not show that Clonidine was given or the physician was notified. - At 1:01 p.m., P#5’s BP was 200/117 mmHg. - At 1:31 p.m., P#5’s BP was 171/103 mmHg. - At 2:01 p.m., P#5’s BP was 183/109 mmHg. - At 2:31 p.m., P#5’s BP was 200/122 mmHg. - At 2:50 p.m., P#5’s BP was 196/126 mmHg. - At 3:01 p.m., P#5’s BP was 210/127 mmHg. - At 3:37 p.m., P#5’s BP was 190/113 mmHg. - P#5 was discharged home with a BP of 190/113 mmHg and was 4.5 kg over her estimated dry weight. - There was a lack of documented interventions for the extremely elevated BP readings before, during, and after dialysis treatment. - There was also a lack of documented evidence that the physician was notified of P#5’s post weight to obtain an order for extra treatment to remove excess fluids. P#6: On 9/30/24: - P#6’s BP was 175/115 mmHg during initiation of dialysis treatment at 11:18 a.m. Treatment was initiated by PCT HH. Documentation did not show that the nurse was notified about elevated BP. - At 11:31 p.m., P#6’s BP was 195/122 mmHg. - At 12:01 p.m., P#6’s BP was 177/107 mmHg. - At 12:31 p.m., P#6’s BP was 175/102 mmHg. - At 1:01 p.m., P#6’s BP was 183/105 mmHg. - At 1:31 p.m., P#6’s BP was 185/92 mmHg. - At 2:01 p.m., P#6’s BP was 151/109 mmHg. - At 2:30 p.m., P#6’s BP was 169/112 mmHg. - At 2:34 p.m., P#6’s BP was 177/115 mm Hg. There was a lack of documented evidence that a licensed nurse was notified and there was no documented interventions for the elevated BP readings. The Facility Administrator was notified of the above findings on 11/15/24 at 10:45 a.m. and stated the staff should have done more about the patients’ high BP. During an interview on 11/15/24 at approximately 11:00 a.m., the Manager of Clinical Services (MCS) agreed with the above findings and stated they would be making changes to the provider’s PRN (as needed) orders for Clonidine and develop parameters. A review of Policy: 1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised April 2024, stated: Pre-Treatment Data Collection/Assessment Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment collection will be documented and immediately reported to the licensed nurse. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis. Abnormal Findings: Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. Blood pressure: Pre-dialysis: Systolic greater than 180 mmHg or less than 90 mmHg Diastolic greater than or equal to 100 mmHg Blood pressure - Intradialytic: Systolic greater than 180 mmHg or less than 90 mmHg Diastolic greater than or equal to 100 mmHg or less than 50 mmHg Blood Pressure Post Treatment: - If the patient can stand: o Standing systolic BP greater than 140 mmHg or less than 90 mmHg o Standing diastolic BP greater than 90 mmHg or less than 50 mmHg If the patient is not able to stand, document reason and sitting BP: Sitting BP for patient’s that cannot stand: o Sitting systolic BP greater than 140 mmHg or less than 90 mmHg o Sitting diastolic BP greater than 90 mmHg or less than 50 mmHg Heart or Pulse Rate Pre/Intra/Post: - Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heartbeat”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 03383 Based on observation and staff interviews, it was determined that the facility failed to maintain a clean, orderly, and comfortable environment. These environmental concerns were observed in one of one Patient Treatment Room. The facility census was 72. Findings were: During observation in the Patient Treatment Room on 5/8/24 between 9:25 a.m. and 11:00 a.m., the following was revealed: - The room had a subtle odor that smelled like rotten eggs and germicide mixed. - The floor tiles had light and dark stains; and scraped marks/defects that ranged from small areas of discoloration to large scraped areas that marked larger sections of the tiles. - There were thick layers of caked dirt between the baseboard and floor tiles; and between the floor tiles. - There were balled up tape, papers, roll of tape, measuring cup, and debris that were scattered throughout the treatment floor. During an interview with the Facility Administrator (FA) and Biomed Technician (BMT) on 5/8/24 at 12:02 p.m., it was revealed that the FA had been trying to get the flooring in the treatment area replaced. An onsite visit was conducted by internal contractor on 4/3/24. However, the FA has not heard anything more about the flooring. When asked how often drains were cleaned and maintained, it was revealed that the BMT did not know when the drains were last cleaned. The BMT stated drains were not on a routine maintenance schedule.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 03383 Based on observation and staff interview, it was determined that the facility failed to maintain a safe environment for all staff and patients as evidenced by non-functional mechanism and torn leather upholstery on 12 of 20 patient treatment chairs. This failure could hinder effective cleaning/disinfection and could have a negative effect on the health and safety of all staff and 72 patients who were receiving dialysis treatment at this facility. Findings were: During observation in the Patient Treatment Room on 5/8/24 between 9:25 a.m. and 11:00 a.m. the following was revealed: - There were five patients who arrived via transport staff on a gurney. - Transport personnel were observed to have some difficulties with opening and closing the arm of dialysis chairs while preparing to transfer patients from the gurney to the treatment chair. - Patient Care Technician (PCT) AA was observed using a tool to close the right side of a treatment chair when the arm of chair would not close properly and was leaning to the right side. - At least twelve treatment chairs had broken reclining mechanism and/or broken frames, severely cracked/torn upholstery in numerous areas, worn out seat, and/or broken latches (hard to open/close/releases on its own). For example: - Chair #1 had severely cracked/torn upholstery on both arms, worn out seat, and non-functional latch. - Chairs #2 and #3 had broken (leaning) recliners. - Chair #4 had a broken frame that only reclined. - Chair #5 had a severely cracked arms that did not close. - Chair #6 had a broken frame. - Chair #6 had severely cracked/torn upholstery on both arms, worn out seat, and non-functional latch. - Chair #7 had a bent frame and torn upholstery on several areas. - Chair #8 had a bent frame/recliner. - Chair #9 had a broken latch that opened arm freely. - Chair #10 had torn upholstery on multiple areas on the arms of the chair and in the middle of the back rest. - Chair #11’s seat was damaged/worn out. - The plus size chair had broken latches (hard to open/close and releases on its own). During an interview on 5/8/24 at 12:05 p.m., the Facility Administrator stated she had ordered treatment chairs on October 2023, but they have yet to receive the chairs.”

“MD RESP-DEVELOP, REVIEW & APPROVE P&P CFR(s): 494.150(c)(1) The medical director must- (1) Participate in the development, periodic review and approval of a “patient care policies and procedures manual” for the facility; This Standard is not met as evidenced by: 03383 Based on observation and staff interviews, it was determined that the Medical Director failed to ensure that this facility had an established policy that addressed routine patient care relative to promptly responding to machine alarms, to ensure safe patient care. This deficient practice had the potential to negatively affect the health and safety of 72 patients who were dialyzing at this facility. Findings were: During observation in the Patient Treatment Room on 5/8/24 between 10:02 a.m. and 10:17 a.m., the following was revealed: - At 10:02 a.m., the machine at Station (S) 6 sounded an alarm with a message displayed as “BPM cuff pressure low” and showed blood pressure (BP) 147/112 mmHg. The diastolic (bottom number - refers to the pressure in the blood vessels between heartbeats) BP was extremely elevated. The last documented BP reading taken at 9:01 a.m., was 106/68 mmHg. - While the machine was alarming, RN AA was observed terminating dialysis treatment on a patient at S5 (next to S6). - PCT BB, PCT CC, and PCT DD passed/walked by S6 while the machine continued to sound an alarm for 15 minutes, but PCT BB, PCT CC, and PCT DD ignored the alarm. - At 10:15 a.m., the machine at S6 began sounding a different alarm and displayed, “UF goal reached”. - At 10:17 a.m., RN AA addressed the alarm at S6 after completing termination of dialysis treatment on a patient at S5. During an interview on 5/8/24 at 12:13 p.m., it was revealed that the Biomed Technician (BMT) was not sure what “BPM cuff pressure low” meant and stated will have to check it out, but believed it had something to do with the blood pressure cuff. The Facility Administrator (FA) stated it meant that the blood pressure cuff needed to be readjusted; the patient’s arm may have moved and loosened the cuff so blood pressure could not be accurately tested. The FA was notified of the above findings when the machine alarm was not addressed for 15 minutes. This surveyor asked the FA for a policy that addressed responding to machine alarm. The FA stated they do not have one. FA confirmed that staff’s response to machine alarm was unacceptable. The FA also stated if BP pump was still running, staff may not respond to alarm, but this did not excuse them for not responding to the alarm.”

“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 a review of facility records and patient and staff interviews, it was determined that the governing body failed to ensure that the facility had adequate number of qualified staff to meet the needs of all patients and provide safe patient care. This deficient practice had the potential to negatively affect the health and safety of 112 patients who dialyzed at this facility. Findings were: A review of staff assignments and Patient and Teammate Schedule/MAESTRO from 02/15/24 to 02/29/24 showed the facility had four Pods with five Stations (S) in each Pod. Each PCT was assigned to care for five patients in a Pod. For example: On 02/15/24 (Thursday, first shift): - PCT FF was assigned to care for five patients at S11 - S15 in Pod 1; one patient (P#15) had a catheter. - PCT EE was assigned to care for five patients at S16 - S20 in Pod 2; one patient (P#12) had a catheter. - PCT GG was assigned to care for five patients at S6 - S10 in Pod 3; one patient (P#8) had a catheter. - PCT DD was assigned to care for five patients at S1 - S5 in Pod 4; one patient (P#19) had a catheter. - Licensed Practical Nurse (LPN) CC and Registered Nurse (RN) BB were scheduled to work. However, the Treatment Details Report (TDR) did not show that LPN CC worked on 2/15/24. On 2/20/24 (Tuesday, first shift): - PCT FF was assigned to care for five patients at S11 - S15 in Pod 1; one patient (P#15) had a catheter. - PCT DD was assigned to care for five patients at S16 - S20 in Pod 2; one patient (P#12) had a catheter. - PCT GG was assigned to care for five patients at S6 - S10 in Pod 3; one patient (P#8) had a catheter. - PCT HH was assigned to care for five patients at S1 - S5 in Pod 4; one patient (P#19) had a catheter. - LPN CC and RN BB were scheduled to work. RN BB was the charge nurse. On 2/22/24 (Thursday, first shift): - PCT DD was assigned to care for five patients at S11 - 15 in Pod 1; one patient (P#15) had a catheter. - PCT GG was assigned to care for five patients at S16 - 20 in Pod 2; one patient (P#12) had a catheter. - PCT EE was assigned to care for five patients at S6 - S10 in Pod 3; one patient (P#8) had a catheter. - PCT FF was assigned to care for five patients at S1 - S5 in Pod 4; one patient (P#19) had a catheter. - RN AA and RN BB were scheduled to work. RN AA was the charge nurse. On 2/24/24 (Saturday, first shift): - PCT HH was assigned to care for five patients at S11 - S15 in Pod 1; one patient (P#15) had a catheter. - PCT GG was assigned to care for five patients at S16 - S20) in Pod 2; one patient (P#12) had a catheter. - PCT FF was assigned to care for five patients at S6 - S10 in Pod 3; one patient (P#8) had a catheter. - PCT DD was assigned to care for five patients at S1 - S5 in Pod 4; one patient (P#19) had a catheter. - LPN CC and RN AA were scheduled to work. RN AA was the charge nurse. On 2/27/24 (Tuesday, first shift): - PCT FF was assigned to care for five patients at S11 - S15 in Pod 1; one patient (P#15) had a catheter. - PCT EE was assigned to care for five patients at S16 - S20 in Pod 2; one patient (P#12) had a catheter. - PCT HH was assigned to care for five patients at S6 - S10 in Pod 3; one patient (P#8) had a catheter. - PCT GG was assigned to care for five patients at S1 - S5 in Pod 4; one patient (P#19) had a catheter. - RN BB was scheduled to work as the charge nurse. There was no other nurse who was scheduled to work on 2/27/24. On 2/29/24 (Thursday, first shift): - PCT FF was assigned to care for five patients at S11 - S15 in Pod 1; one patient (P#15) had a catheter. - No one was assigned to care for five patients at S16 - S20 in Pod 2; one patient (P#12) had a catheter. - PCT GG was assigned to care for five patients at S6 - 10 in Pod 3; one patient (P#8) had a catheter. - PCT DD was assigned to care for five patients at S1 - S5 in Pod 4; one patient (P#19) had a catheter. - RN AA and RN BB were scheduled to work. RN BB was the charge nurse. However, the TDR did not show that RN AA worked. Instead, Staff MM, whose title was not documented in TDR, worked on 2/29/24. A review of medical records dated 2/15/24, 2/16/24, and 2/29/24 showed delayed initiation of dialysis treatment for 45 minutes up to one hour and 47 minutes; and delayed termination of dialysis treatment for up to 36 minutes. For example: On 2/15/24 (Thursday, first shift): - P#4’s scheduled start time was at 6:00 a.m. PCT GG initiated dialysis treatment at 6:46 a.m. - P#8’s scheduled appointment was at 5:00 a.m. PCT GG initiated dialysis treatment at 6:12 a.m. - P#13’s dialysis treatment was initiated by RN BB at 5:49 a.m. for three hours as prescribed. Dialysis was terminated by RN BB at 9:25 a.m., which was a 36-minute wait for P#13 to be taken off dialysis after treatment was completed. - P#19’s scheduled start time was at 5:45 a.m. RN BB initiated dialysis treatment at 6:49 a.m. On 2/16/24 (Friday, first shift): - P#23 had a RIJ (Right Internal Jugular) CVC as her dialysis access. P#23’s scheduled appointment was at 5:30 a.m. Dialysis treatment was initiated by PCT HH at 6:27 a.m. - P#31 had a LIJ (Left Internal Jugular) CVC access. Her scheduled appoitment was at 5:00 a.m. PCT EE initiated dialysis at 5:55 a.m. - P#40’s scheduled appointment was at 5:00 a.m. RN BB initiated dialysis at 6:47 a.m. On 2/29/24 (Thursday, first shift): - P#4’s scheduled appointment was at 6:00 a.m. PCT GG initiated dialysis treatment at 6:49 a.m. - P#5’s scheduled appointment was at 5:30 a.m. PCT GG initiated dialysis treatment at 6:17 a.m. - P#10’s scheduled appointment was at 5:30 a.m. PCT GG initiated dialysis treatment at 6:35 a.m. - P#13’s scheduled appointment was at 5:30 a.m. RN BB initiated dialysis treatment at 6:53 a.m. During patient and staff interviews on 2/29/24 between 10:15 a.m. and 2:00 p.m., the following was revealed: - P#41 stated the facility had staff shortage at times. - P#4 stated he had been late getting on the dialysis machine at times. Sometimes it was because of water problems and sometimes, staff was slow to react or get to him when he was cramping, so he had to walk it off. P#4 also added that sometimes, staff was slow to take him off dialysis. - Pt#10 stated she has been dialyzing at this facility for four years and she’s happy with the staff. However, there were times when they had been late putting her on and taking her off dialysis because they were too busy. - PCT FF stated we had been assigned to care for five patients every day. The “five patients to one PCT” ratio has been the same on Mondays, Wednesdays, and Fridays since August or September of last year. Stated “I have worked here for a very long time and this was the first time I’ve ever wanted to quit. It’s been too much”. - RN BB stated “There are five staff: 2 RNs and 3 PCTs. We split the floor; the PCT to patient ratio is one PCT to five patients and the ratio for licensed nurse is one nurse to 10 patients. The number of patients with a catheter (CVC) has increased, and the nurse must initiate and terminate treatment on patients with a catheter. - PCT GG stated “I have worked here for so many years. The ratio of patients to PCT is five patients to one PCT. It is not safe for the patients and very hard on us because we still must complete the same tasks and responsibilities as when the ratio was four patients to one PCT. But now with another patient added, it is compromising patient safety and it takes longer to get to patients. So, we work faster and the patients have to wait. This increases the chances of making a mistake and the potential risk is higher with a ratio of five to one”. - During an interview with the Senior Manager of Clinical Services (SMCS) and Program Manager on 2/29/24 at 1:45 p.m., it was confirmed that the staffing schedule showed a five to one ratio for PCTs. Although the nurses were responsible for initiating and terminating dialysis treatment for patients with a CVC, it was revealed that PCTs were responsible for monitoring five patients each throughout dialysis treatment after the initiation of dialysis via CVC by a nurse.”