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 02/27/2025
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 medical record (MR) reviews, facility policy, and interviews with staff, it was determined the facility failed to ensure staff adjusted heparin infusions as ordered and documented heparin dosages adjustments in the patient MR. This affected Patient Identifier (PI) # 4, PI # 2, in two of two incenter hemodialysis (HD) record reviews, and had the potential to affect all patients treated at the facility. Findings include: Facility Policy: Documentation Multidisciplinary Procedure No. (Number) 2.04 Date Published: None Listed I. Purpose To provide a record of patient care... III. Policy A....to ensure accurate patient medical records thorough, accurate documentation... Findings include: 1. PI # 4 was admitted to the facility on 8/1/22 with a diagnosis of End Stage Renal Disease (ESRD). Record review revealed a Normal Heparin Infusion Sliding Scale Standing Order dated 11/21/24 which revealed the following: ACT (activated clotting time test, a rapid blood test used to monitor heparin therapy, assessing how long it takes blood to clot, and is often used during procedures requiring blood clot prevention) Greater that 200 Decrease Infusion Adjustment by 4 units/kg/hr (units/kilogram/hour) 180-200 Decrease Infusion Adjustment by 2 units/kg/hr 160-180 (optimum range) No Change 140-160 Increase by 2 units/kg/hr Less than 140 Increase by 4 units/kg/hr MR review included incenter HD Treatment documentation dated 2/12/25, 2/14/25, 2/17/25, 2/19/25, 2/24/25, which revealed the ACTs results met the Normal Heparin Infusion Sliding Scale criteria for dosage adjustments. There was no documentation heparin dosages were adjusted per the heparin sliding scale standing order. An interview was conducted on 2/27/25 at 11:47 AM, with Employee Identifier (EI) # 1, Director of Nurses, who confirmed the MR documentation did not include heparin sliding scale dosage adjustments. 2. PI # 2 was admitted to the facility on 1/24/25 with a diagnosis of ESRD. Record review revealed a Normal Heparin Infusion Sliding Scale Standing Order dated 1/23/25 (before admission) and an order reprint requisition dated 2/12/25 which revealed the following: ACT Greater that 200 Decrease Infusion Adjustment by 4 units/kg/hr 180-200 Decrease Infusion Adjustment by 2 units/kg/hr 160-180 (optimum range) No Change 140-160 Increase by 2 units/kg/hr Less than 140 Increase by 4 units/kg/hr MR review included incenter HD Treatment documentation dated 2/12/25, 2/14/25, 2/17/25, 2/19/25, 2/21/25, 2/24/25 which revealed the ACTs results met the Normal Heparin Infusion Sliding Scale criteria for dosage adjustments. There was no documentation heparin dosages were adjusted per the heparin infusion sliding scale standing order. An interview was conducted on 2/27/25 at 12:50 PM, with EI # 1, who confirmed the MR documentation did not include heparin sliding scale dosage adjustments.