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 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)
V0726 MR-COMPLETE, ACCURATE, ACCESSIBLE
CFR(s): 494.170

The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.


This STANDARD is not met as evidenced by:
Based on review of facility PD (peritoneal dialysis) medical records (MR), policy and procedure (p/p), and staff interviews it was determined the staff failed to ensure PD treatment record pre and post monitoring and medication delivery documentation was complete. This affected PI (Patient Identifier) # 5, 1 of 2 PD records reviewed and had the potential to negatively affect all PD patients treated at the facility. Findings include: Peritoneal Dialysis Home Self-Monitoring Departmental Policy No.18359 (No date documented) I. Purpose: The purpose is to provide guidelines for routine PD home self monitoring III. Policy The patient and/or caregiver (cg)...on how PD will complete training and agree to daily monitoring, recording, and reporting of health status information. VI. Equipment A. Blood pressure (BP) monitor B. Scale C. Home flowsheet VII. Procedure A. Family must complete the training plan for PD which includes parameter...set between the cg and...nephrologist....notify the PD nurse or physician if...values outside of these parameters... B. Each night before starting treatment the cg should take a pre blood pressure, weight, and heart rate. This should be written down on the home flowsheet. E. Once treatment is complete, the cg should record the post BP, weight and heart rate (HR)... PD Training Manual ...Lesson 8; Dialysis Medications In This Lesson You Will Learn.... Anemia Treatment for Anemia If your child's hemoglobin level (a protein in the blood that contains iron and transports oxygen through the body) is less than 11, you will be trained on how and when to give this medication...Epogen... 1. 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. MR review revealed March 1, 2021 to April 6, 2021 PD Self-Care Record documentation, the Daily Routine recording pre and post BP (blood pressure) and recording pre and post weights were not documented on the following dates: 3/3/21-no post BP 3/7/21- no post weight 3/8/21-no pre BP, pre HR (heart rate) 3/10/21-no pre BP, pre HR 3/11/21-no pre BP, no pre HR 3/13/21-no pre BP, pre HR 3/16/21-no pre BP, pre HR, post weight 3/18/21-no pre weight, pre BP, pre HR 3/19/21-no pre BP, pre HR 3/21/21-no pre HR 3/22/21-no pre BP, pre HR 3/24/21-no pre BP, pre HR, post BP, post HR 3/25/21-no pre BP, pre HR 3/26/21-no pre BP, pre HR, post BP, post HR 3/28/21-no pre BP, pre HR 3/29/21-no pre BP, pre HR 3/30/21-no pre BP, pre HR 3/31/21-no pre BP, pre HR 4/2/21-no post weight 4/4/21-no pre BP, pre HR, post weight 4/6/21-no pre BP, pre HR Further review of the PD Self-Care Record revealed the home therapy RN (Registered Nurse) initials on the Daily Routine document. There was no reason why the pre-post daily routine recording documentation was not completed and no documentation the home therapy RN counseled the cg on daily routine recording. There was no documentation Epogen sq twice weekly was administered during March. In an interview on 6/24/21 at 8:30 AM, Employee Identifier # 9, RN, Home Therapy Training Nurse confirmed there was no reason the pre-post treatment monitoring was not documented as required. EI # 9 reported BP and HR monitoring can be difficult with infants using an electronic monitoring device and manual BP and HR monitoring was not taught to the cg. EI # 9 confirmed there was no documentation Epogen was administered in March and reported the facility has no policy for home Epogen administration documentation.