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 852582 (X3) Date Survey Completed 06/24/2025
Name of Provider or Supplier West Clayton Dialysis Street Address, City, State 100 Promenade Pkwy Suite C, Fayetteville, 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)
V0000 An unannounced onsite visit to investigate complaint #GA00255259 was conducted at West Clayton Dialysis from June 24, 2025 through June 24, 2025. One of one allegation (Nursing Services) was substantiated. A deficiency was cited.
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 a review of facility records, staff interviews, and a review of the facility's Policies and Procedures (P&P), it was determined that the Medical Director failed to ensure that all Direct Patient Care (DPC) Staff (Registered Nurses - RNs and Patient Care Technicians - PCTs), adhered to prescribed hemodialysis orders relative to ultrafiltration rate (UFR - the speed at which excess fluid is removed from the body during hemodialysis treatment which is at or below 13 mL/kg/hr [milliLiter per kilogram per hour] - the maximum safe rate for fluid removal during treatment), of seven of eight sampled patients, (Ps) (P#1, P#2, P#3, P#4, P#5, P#6, and P#7). Excessive ultrafiltration (UF) during hemodialysis can lead to serious complications due to rapid fluid removal which can result in intradialytic hypotension (low blood pressure during dialysis), muscle cramping, dizziness, nausea, vomiting, syncope (fainting) and potentially contribute to long-term cardiovascular complications and even mortality. The facility census was 88 in-center hemodialysis patients. Findings include: A review of the "Treatment Detail Report" of each seven patients (P#1, P#2, P#3, P#4, P#5, P#6, and P#7) sampled, between June 10, 2025 through June 24, 2025, revealed the following: The ordered UFR for all seven patients was: Maximum UFR 13.0 mL/kg/hr. P#1: - On 6/16/25, post treatment actual UFR was 13.6 mL/kg/hr. P#2: - On 6/11/25, post treatment actual UFR was 15.8 mL/kg/hr. - On 6/13/25, post treatment actual UFR was 16.0 mL/kg/hr. - On 6/18/25, post treatment actual UFR was 14.0 mL/kg/hr. P#3: - On 6/17/25, post treatment actual UFR was 16.2 mL/kg/hr. P#4: - On 6/21/25, post treatment actual UFR was 17.8 mL/kg/hr. P#5: - On 6/23/25, post treatment actual UFR was 15.3 mL/kg/hr. P#6: - On 6/23/25, post treatment actual UFR was 15.4 mL/kg/hr. P#7: - On 6/24/25, post treatment actual UFR was 15.7 mL/kg/hr. There was no documentary evidence to support why all seven patients' UFRs exceeded 13.0 mL/kg/hr. - On 6/24/25 at 1:50 p.m., the Facility Administrator acknowledged the findings and stated that it had been the responsibility of the assigned nurses on the treatment floor to verify the accuracy of each patient's prescription, including pre-assessment calculations, ensuring they were properly programmed and reflected on the hemodialysis machines prior to initiating treatment. A review of facility Policy: 1-03-08, titled, "Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment", with latest revision date of April 2024, stated: 3. Patient identity, prescription, and machine settings are verified by the teammate prior to initiation of treatment with the exception of the blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of the treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: d. UFR and Max UFR 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed.