Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 852540 (X3) Date Survey Completed 04/20/2018
Name of Provider or Supplier Camilla Dialysis Street Address, City, State 251 Us 19 N, Camilla, GA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000 At the time of the survey, Mitchell County Dialysis was in compliance with 42 CFR Part 494.62, Emergency Preparedness Plan for End Stage Renal Dialysis Facilities, as a result of a Recertification survey. No deficiencies were cited.
V0000 {CORE}At the time of the survey, Mitchell County Dialysis was in substantial compliance with 42 CFR Part 494, End Stage Renal Disease Facilities, as a result of a Recertification survey. The following deficiencies were cited:
V0401 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:
Based on record reviews, observations and staff interviews, it was determined that the facility failed to provide a safe environment, free of hazards for staff and all 64 patients that dialyze at the facility. Findings were: During a tour of the facility on 4/18/18 between 3:00 p.m. and 4:00 p.m., accompanied by the facility administrator, the following was observed: - The door frames at the entry to the offices, the treatment area and the waiting room were damaged and discolored with black marks and, some of the paint was missing, exposing the metal underneath. - The walls in the treatment area next to station #1 and #7 had peeling paint and damaged areas measuring approximately 3-4 inches wide exposing white colored sheetrock. During a discussion with the facility administrator on 4/18/18 at approximately 4:30 p.m., he/she stated that management was aware that the walls in the treatment room between stations #1-#7 needed to be repaired.
V0715 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:
Based on medical record review and staff interviews, it was the determined that the medical director failed to ensure that staff adhered to Physicians' standing PRN (when necessary) orders for two (2) of five (5) patients (Patients #1 and Patient #5). Findings were: A review of medical records for patients #1- #5 and the facility's patient care policies and procedures revealed the following: Patient #1 - The dialysis Flowsheet dated 4/6/18 - 4/16/18, revealed documentation of high blood pressure (B/P) readings ranging from 186/107 - 200/119 (Hypertension), during 6 out of 10 dialysis treatments. The patient's medical records revealed Physician orders dated 1/9/18, showed orders for Clonidine 0.1 mg by mouth (PO), every 30 minutes, three (3) doses for hypertension. There was no documented evidence that the patient received Clonidine for Hypertension. Patient #5 - The dialysis Flowsheet dated 4/5/18 - 4/17/18, revealed documentation of high B/P readings ranging from 186/119 - 193/122 (Hypertension), during 12 of 12 dialysis treatments. Physician orders dated 1/9/18, showed PRN (when necessary) orders for Clonidine 0.1 mg PO every 30 minutes, three (3) doses for hypertension. There was no documented evidence that the patient received Clonidine for Hypertension. - The policy and procedure "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment dated 4/2017, showed that patients should be monitored and the Nurse will use his/her clinical judgement based on individual patient needs to determine if clinical interventions are necessary. There was no documented evidence that patients #1 and #5 received any clinical intervention by a Nurse. During a discussion with the facility administrator on 4/18/18 at 3:00 p.m., about the above findings, he/she stated that the Nurses should have followed the Physician's orders.