Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012306	(X3) Date Survey Completed 06/24/2021
Name of Provider or Supplier Childrens Hospital Of Alabama Esrd	Street Address, City, State 1600 7th Avenue South, Birmingham, AL
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)

V0586

H-PT/CAREGIVER DEMO COMPREHEND TRAINING
CFR(s): 494.100(b)(1)

The dialysis facility must - (1) Document in the medical record that the patient, the caregiver, or both received and demonstrated adequate comprehension of the training;

This STANDARD is not met as evidenced by:
Based on medical record (MR) review, the facility PD (Peritoneal) Training Plan, policy and procedure and staff interview, it was determined the facility staff failed to ensure all home PD therapy patient/caregiver (cg) education and training was documented and included the successful return demonstration for Epogen administration. This affected Patient Identifier (PI) # 4 and PI # 5, 2 of 2 PD records reviewed and has the potential to affect all home therapy patients served. Findings include: Peritoneal Dialysis Training Plan Section: PD Written: 6/18 Purpose To provide guidance for dialysis nurses who are training new PD patients and their families. Adding medications A. Sterile procedure B. Heparin C. Antibiotics Daily Routine A. Recording pre and post BP (blood pressure) B. Recording pre and post weights Miscellaneous B. Bringing pro card and records... PD Training Manual Lesson 1-Starting PD Lesson 2-Hand hygiene Lesson 3-Caring for the Catheter Lesson 4-Steps for a Safe Treatment Lesson 5-Making Decisions About Your Child's Care Lesson 6-Balancing Your Fluids Lesson 7-Nutrition for Chronic Kidney Disease on PD Lesson 8-Dialysis Medications Lesson 9-Caregivers (cg) Subject: Medication Reconciliation Nursing Policy & Procedure No. Last revised/reviewed: 10/12 IV. Procedure Patient/care provider will be asked to complete the provided medication reconciliation form... ...The medications/list will be compared to the actual prescribed medications by the RN (Registered Nurse) or pharmacist... 1. PI # 4 was admitted for PD Home Therapy services on 1/18/2020 and dialyzed with an AMIA, a continuous PD cycler. MR review revealed PD training documentation for the AMIA Automated PD System Training was completed (no date). There were PD training tests for sections 1,2 and 3 completed on 2/5/2020 and PD training tests for sections 4 and 5 were completed on 2/7/2020. There was no documentation PD training for lessons/sections 6-9, Fluids, Nutrition, Medications, and Caregivers were completed. Review of the record revealed Clinician nurse notes dated 8/10/2020 and 8/12/2020 which reported a future foster parent came to clinic for PD training. There was no documentation training/education was provided for lessons 6-9, Fluids, Nutrition, Medications and Caregivers. In an interview on 6/24/21 at 8:40 AM, EI (Employee Identifier) # 9, Registered Nurse, Home Therapy Training Nurse confirmed the training/education record documentation was not complete. 2. PI # 5 was admitted for PD Home Therapy services on 8/10/2020 and dialyzed with an APD (ambulatory) PD cycler. Review of physician orders dated 2/3/21 revealed "restart" Epogen 1000 units sq (subcutaneous) every Monday and Friday. Review of the PD Training Checklist for Patient and /or Caregiver, Teach Back Moment and Scope Competency Review revealed no documentation the cg received training on Lesson 8, Dialysis Medications which included Anemia and the sq administration of Epogen. There was no successful return demonstration for the Epogen administration documented. In an interview on 6/24/21 at 8:30 AM, EI # 9 confirmed there was no Epogen training and no return demonstration of Epogen administration documented in PI # 5's MR.