Usrc Cumming Dialysis

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 50523 Based on facility record review, and staff interviews, it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This deficient practice had the potential to negatively affect the health and safety of 31 in-center hemodialysis patients who received hemodialysis services at this facility. Findings include: Cross-Reference: V 757 - Failure of the Governing Body to ensure that the facility had adequate number of qualified staff to meet the needs of all patients and provide safe patient care; and to be in compliance with the minimum State required staffing ratios of one licensed and qualified nurse for every 12 patients who were receiving dialysis care and one qualified dialysis care giver for every four patients.”

“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, staff interviews, and a review of minimum state required staffing ratios, it was determined that the Governing Body failed to ensure that the Facility Administrator employed 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, other medical issues and emergencies, 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, access sites, or problems with the dialysis equipment. Additionally, insufficient staffing could mean slower responses to alarms, missed complications including but not limited to intradialytic hypotension (sudden drops in blood pressure [BP] which can occur when fluid is removed rapidly), hypertension (elevated BP), arrhythmias (irregular heartbeat), and other medical issues and emergencies related to hemodialysis. The facility had 31 in-center hemodialysis patients. Findings include: - A review of “Patient and Teammate Schedule” (schedule of the number of patients dialyzing each shift, with their assigned Dialysis Care Givers, namely: Patient Care Technicians (PCTs) (PCT AA, PCT BB, and PCT CC) as well as Registered Nurses (RNs) (RN AA and RN BB), for the month of June, 2025, revealed the following: - The Patient Treatment Room had four Pods (sections) with four patient Stations (S) in each Pod. - On Mondays, Wednesdays and Fridays (MWF) schedule, there were three shifts, with a total of 14 patients on first shift, 16 patients on second shift, and six patients on third shift. RN AA and RN BB alternated between being assigned to Pod 3 as Dialysis Care Givers (providing total care of three to four patients on first shift), as well as being Charge Nurses (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 two PCTs (PCT AA, and PCT BB) on first shift and three PCTs (PCT AA, PCT BB, and PCT CC) on the second and third shifts, especially 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. - On 6/2/25, 6/4/25, 6/6/25, 6/9/25, 6/11/25, 6/13/25, and 6/16/25 - two PCTs and two RNs were each assigned a Pod (as Direct Care Givers) during the first shift. The RNs during the first shift also performed their nursing duties for all patients, in addition to being Direct Care Givers to their assigned Pods. Then on the second and third shifts, three PCTs and one RN were each assigned a Pod (as Direct Care Givers). - Pod 1: RN BB (or alternating with RN AA), was assigned as a Dialysis Care Giver to patients at S3, S4, and S6. During the first shift, one of three patients (P), (P#1), had a CVC which required CVC care by licensed nurses only (i.e. RN or LPN- Licensed Practical Nurse), for the initiation and termination of dialysis treatments and any CVC problems or complications that may arise. In addition to being assigned as Direct Care Givers, RN BB or RN AA also functioned as Charge Nurses. On the second shift, all four patients, (P#2, P#3, P#4, and P#5), had CVCs. On the third shift, one of two patients, (P#6), had a CVC. - Pod 2: PCT AA was assigned as a Dialysis Care Giver to patients at S1, S2, S9, and S10. On the first shift, one of four patients (P#7), had a CVC (which required licensed nurses only for CVC care). - Pod 3: RN AA (or alternating with RN BB), was assigned as a Dialysis Care Giver to patients at S11, S12, S13 and S14 during the first shift, and one of four patients (P#8), during the first shift, had a CVC. PCT CC was assigned to Pod 3 during the second and third shifts (to relieve the assigned Charge Nurse - RN AA or RN BB). However, during the second shift, one of four patients, (P#9), had a CVC, and on the third shift, one of one patient, (P#10), had a CVC. The Charge Nurse will perform CVC care for these patients with CVCs. - Pod 4: PCT BB was assigned as a Dialysis Care Giver to patients at S7, S8, S15, and S16. One of two patients, (P#11), had a CVC during the third shift. - During an interview with RN AA on 6/16/25 at 11:05 a.m., she stated that there were two RNs and two PCTs during the first shift and an additional PCT (PCT CC), on the second and third shifts, during the MWF schedule. RN AA explained that she and RN BB alternated between being a Charge Nurse. RN AA added that if she or RN BB was assigned as the Charge Nurse, the Charge Nurse will be assigned to Pod 3 (as a Direct Care Giver to four patients), during the first shift. RN AA further stated that PCT CC was scheduled and assigned to Pod 3 (to relieve the Charge Nurse) during the second and third shifts, which meant that the Charge Nurse will not have an assigned Pod (during the second and third shifts), and can focus on overseeing patient care. - On 6/16/25 at 11:18 a.m., RN BB stated that she and RN AA would divide the patient load (as Charge Nurses) during the first shift while also being assigned to a Pod (as Direct Care Givers). RN BB stated that once PCT CC relieved the RN/Charge Nurse assigned to Pod 3, she (RN AA) was then able to focus more effectively on her own assigned Pod (as a Direct Care Giver), while the Charge Nurse can concentrate on overseeing the patients at the remaining three Pods (who were assigned to the three PCTs), and also be able to provide CVC care to patients with CVCs at these Pods. - On 6/16/25 at 12:21 p.m., the Facility Administrator confirmed what RN AA stated above regarding the RNs’ schedule and responsibilities.”