Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012500	(X3) Date Survey Completed 09/16/2021
Name of Provider or Supplier Fmc Capitol City	Street Address, City, State 255 South Jackson Street, Montgomery, 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)

V0544

POC-ACHIEVE ADEQUATE CLEARANCE
CFR(s): 494.90(a)(1)

Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.

This STANDARD is not met as evidenced by:
Based on review of medical records, facility policies, and interviews with staff, it was determined the facility failed to ensure the staff: 1. Followed the physician order for the Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR). 2. Administered mid-run and bolus Heparin as ordered. 3. Completed AMA (Against Medical Advice) forms for all dialysis treatments terminated early by the patient. This affected 8 of 10 records reviewed and did affect Patient Identifier (PI) # 2, PI # 4, PI # 6, PI # 8, PI # 10, PI # 3, PI # 7, PI # 9 and had the potential to affect all patients dialyzing at this facility. Findings include: Facility Policy: Patient Assessment and Monitoring Version: 3 Published Date: 09/29/2018 ...3. Machine Parameters and Extracorporeal Circuit Check machine settings and measurements. Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and prescribed flow is being delivered... Facility Policy: Early Termination or Arriving Late for Treatment Published: 07/04/2012 Version: 2 The purpose...is to provide guidelines for staff when patients arrive late for their scheduled treatment time or request early termination of treatment. Background... Serious health related consequences may result from missed treatments, or terminating earlier than prescribed. Policy: Early Termination If the patient insists on terminating treatment early...not...previously approved by the patient's physician, the patient must take full responsibility for the consequences... If a patient requests to leave treatment early: ...will be referred to the supervising registered nurse (RN). The RN will evaluate the patient... discuss... reasons for requesting to terminate their treatment... If the patient's reasons... are due to complications... such as cramping, discomfort... the RN... will implement any prescribed measures to alleviate the patient's symptoms... The RN is responsible to notify the physician, and document on the AMA (Against Medical Advice) form. Requirement Documentation - AMA forms AMA forms are: Signed by the patient and witnessed by the supervising nurse... Signed with each early termination event and files in the patient's medical records. Tracked, trended and reported to the QAI (quality improvement committee monthly)... Facility Policy: Heparinization Published: 08/03/2020 Version: 4 ...The policy provides guidelines for adequate dosing and use of heparin in hemodialysis patients. ...Dose and Method of Administration The physician must order the heparin dose and method of administration... Method of Administration...Bolus at initiation and a bolus mid dialysis... Description...A bolus loading dose is administered 3-5 minutes pretreatment with a second bolus dose administered mid treatment... 1. PI # 2 was admitted to the facility 5/13/21 with diagnoses including End Stage Renal Disease (ESRD). Review of the Current Orders Report dated 8/26/21 and Hemodialysis orders dated 9/7/21 revealed a treatment time of 4 hours, BFR of 400, and DFR Autoflow 2.0, which would be 800. Review of the Treatment Sheet dated 9/2/21 revealed the BFR was 400, and DFR was 500 from 10:59 AM to 12:30 PM. There was no documentation why the DFR was not at the ordered rate of 800. Further review of the Treatment Sheet dated 9/2/21 revealed, "hours on: 3:47 (minutes)", which was 13 minutes less treatment time than ordered. There was no documentation of an AMA as directed per the facility policy. An interview was conducted on 9/16/21 at 9:40 AM with Employee Identifier (EI) # 1, Clinic Manager, who confirmed the DFR was not run per physician orders, and early terminations were not documented per policy. 2. PI # 4 was admitted to the facility 9/18/15 with diagnoses including ESRD. Review of the Hemodialysis orders dated 6/14/21 revealed a BFR of 400, and DFR Autoflow 2.0, which would be 800. Review of the Treatment Sheet dated 9/1/21 revealed the BFR was 350, and DFR was 700 from 1:32 PM to 3:01 PM. There was no documentation why the BFR was not at the ordered rate. Review of the Treatment Sheet dated 9/3/21 revealed the BFR was 400, and DFR was 700 from 10:30 AM to 11:00 AM. There was no documentation why the DFR was not at the ordered rate of 800. Review of the Treatment Sheet dated 9/8/21 revealed the BFR was 400, and DFR was 500 from 11:39 AM to 2:31 PM, then from 2:31 PM until 3:00 the BFR was 0 and DFR was 500, then at 3:00 PM BFR was 350 and DFR was 500. There was no documentation why the BFR and DFR was not at the ordered rates. Review of the Treatment Sheet dated 9/10/21 revealed the BFR was 300, and DFR was 600 from 12:01 PM to 2:01 PM. There was no documentation why the BFR was not at the ordered rate. An interview was conducted on 9/16/21 at 9:40 AM with EI # 1 who confirmed the BFR's and DFR's were not run per physician orders. 3. PI # 6 was admitted to the facility to the facility 12/5/17 with diagnoses including ESRD. Review of the Hemodialysis orders dated 9/1/21 revealed a BFR of 350, and DFR Autoflow 2.0, which would be 700. Review of the Treatment Sheet dated 9/3/21 revealed from 6:00 AM to 7:04 AM the BFR was 350 and the DFR was 800. Then from 8:00 AM to 8:31 AM the BFR was 400 and the DFR was 800. There was no documentation why the BFR and DFR were not at the ordered rates. An interview was conducted on 9/16/21 at 9:28 AM with EI # 1 who confirmed the BFR's and DFR's were not run per physician orders. 4. PI # 8 was admitted to the facility to the facility 4/6/17 with diagnoses including ESRD. Review of the Hemodialysis orders dated 8/30/21 revealed a BFR of 350, and DFR Autoflow 2.0, which would be 700. Review of the Treatment Sheet dated 9/8/21 revealed the BFR was decreased to 0 and the DFR to 300 at 2:06 PM, then at 2:31 PM the BFR was 200 and the DFR was 400. There was no documentation why the BFR and DFR were not at the ordered rates. An interview was conducted on 9/16/21 at 9:10 AM with EI # 1 who confirmed the BFR's and DFR's were not run per physician orders. 5. PI # 10 was admitted to the facility 8/26/19 with diagnoses including ESRD. Review of the Orders Summary Report revealed orders for Heparin 2000 U (Units) IVP (Intravenous Push) mid-run every treatment dated 11/11/2020 and HD (Hemodialysis) orders dated 5/21/21, dialysis treatments 3 times a week for 4 hr 0 minutes (240-minutes). Review of the Treatment Sheet dated 9/6/21 revealed the treatment started at 10:45 AM and at 11:24 AM, staff documented the mid-run heparin was administered. This was 39 minutes into the 240-minute treatment, which is not mid-run or middle of the dialysis treatment. An interview was conducted on 9/16/21 at 9:14 AM with EI # 1 who reported the policy for mid-run Heparin was Heparin administration at the middle of the treatment, and not 39 minutes into a 240-minute treatment. EI # 1 verified the staff failed to follow the physician HD orders. 30952 6. PI # 3 was admitted to the facility 6/3/21 with diagnoses including ESRD. Review of the Current Orders Report revealed orders for Heparin 2000 Units (U) IVP (intravenous push) mid-run every treatment dated 8/12/21 and Hemodialysis (HD) orders dated 8/31/21, dialysis treatments 3 times a week for 4 hours (hr) 15 minutes (255-minutes), a BFR of 400, and DFR Autoflow 2.0, which would be 800. Review of the Treatment Sheet dated 9/4/21 revealed the treatment started at 10:34 AM and at 11:36 AM, staff documented the mid-run heparin was administered. This was 61 minutes into the 255 minute treatment, which is not mid-run or middle of the dialysis treatment. Review of the Treatment Sheet dated 9/14/21 revealed no BFR and DFR documented from 11:05 AM to 12:06 PM which was 61 minutes. There was no documentation the BFR was 400 and DFR 800 per physician orders. An interview was conducted on 9/16/21 at 9:42 AM with EI # 1 who reported the policy for mid-run Heparin was Heparin administration at the middle of the treatment, and not 61 minutes into a 255-minute treatment. Staff failed to follow the physician HD orders. 7. PI # 7 was admitted to the facility 9/7/17 with diagnoses including ESRD. Review of the Current Orders Report revealed orders for Heparin 3000 U IVP mid-run every treatment dated 6/5/21 and HD orders dated 8/31/21 for dialysis treatment for 4 hours (240 minutes) 3 times week. MR review revealed a Treatment Sheet dated 9/2/21 with documentation the treatment started at 6:32 AM and the mid-run heparin was administered at 7:12 AM, which was 40 minutes into a 240-minute treatment which was not mid-run administration. Record review revealed a Treatment Sheet dated 9/9/21 with documentation the treatment started at 6:32 AM and the mid run heparin was administered at 7:30 AM, which was 58 minutes of a 240-minute treatment which would not be mid run administration. In an interview on 9/16/21 at 8:59 AM, EI # 2, Director of Operations reported mid run of a 4- hour treatment would be 2 hours (120 minutes) and Heparin was not administered according to physician orders. 8. PI # 9 was admitted to the facility 4/16/2020 with diagnoses including ESRD. Review of the Rounding Report revealed physician orders dated 4/17/21 for Heparin, 2000 U bolus every treatment, and orders dated 4/20/21 for Heparin catheter lock arterial and venous port 1000 U/ml (milliliter) 1.8 post dialysis every treatment. Review of the Treatment Sheet dated 8/25/21 revealed an Ultrafiltration treatment was performed via a central venous catheter. There was no documentation staff administered the Heparin bolus and the catheter arterial/venous lock per physician orders. In an interview on 9/16/21 at 8:54 AM, EI # 1 confirmed there was no documentation Heparin was administered as ordered.