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)

V0551

POC-VA MONITOR/PREVENT FAILURE/STENOSIS
CFR(s): 494.90(a)(5)

The patient's vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis.

This STANDARD is not met as evidenced by:
Based on review of facility policy, medical records (MR) and staff interviews, it was determined the facility failed to ensure staff documented the presence/absence of a bruit and thrill (B/T) in 4 of 10 records reviewed with an AVF/AVG (arteriovenous fistula/graft). This affected PI (Patient Identifier) # 2, PI # 8, PI # 10, PI # 7, and had the potential to negatively affect all patients who dialyzed at the facility. Findings include: Facility Procedure: Access Assessment and Cannulation Published: 08/22/2018 Version: 1 Purpose ...of this procedure is to provide guidance for placement of needles in an AV (arteriovenous) Fistula or AV Graft... Policy New Access Care and Cannulation Evaluation and preparation of the access will be performed routinely prior to cannulation at each dialysis session. ...assign clinical staff for the initial cannulations based on experience and expertise. Check fistula for adequate bruit and thrill to confirm patency. Check for signs of infection. ...Perform skin disinfection as outlined in policy... Assessment of Vascular Access Follow the steps below to access the vascular access: 5. LOOK: Skin Discoloration/Redness/Bruising/lesion Hematomas Extremity or Other Swelling ...Greater than expected redness...Swelling 6...LISTEN: Bruit high pitch/whistle Bruit not present throughout access ...Document in eCC ("e-cube"-the facility electronic medical record documentation software) 7. FEEL: Pulse not soft/not easily compressible Thrill not strong at anastomosis Thrill not present throughout access Document in eCC. 1. PI # 2 was admitted to the facility 5/13/21 with diagnoses including End Stage Renal Disease (ESRD). MR review revealed Current Orders Report dated 8/26/21 Hemodialysis orders dated 9/7/21 for dialysis 3 times a week via an AVF. Review of the Treatment Sheets dated 9/2/21, 9/4/21, 9/7/21, and 9/14/21, 4 of 6 treatments reviewed, revealed no documentation staff assessed the condition of the AVF for the presence of a B/T or abnormal findings. An interview was conducted on 9/16/21 at 9:40 AM with Employee Identifier (EI) # 1, Clinic Manager, who confirmed the staff failed to follow the facility procedure for access site assessment. 2. PI # 8 was admitted to the facility 4/6/17 with diagnoses including ESRD. MR review revealed Hemodialysis orders dated 8/30/21 for dialysis 3 times a week via an AVF. Review of the Treatment Sheets dated 9/1/21, 9/3/21, 9/6/21, 9/8/21, 9/10/21, and 9/13/21, 6 of 6 treatments reviewed, revealed no documentation staff assessed the condition of the AVF for the presence of a B/T or abnormal findings. An interview was conducted on 9/16/21 at 9:10 AM with EI # 1 who confirmed the staff failed to follow the facility procedure for access site assessment. 3. PI # 10 was admitted to the facility 8/26/19 with diagnoses including ESRD. MR review revealed Hemodialysis orders dated 5/21/21 for dialysis 3 times a week via an AVF. Review of the Treatment Sheets dated 9/1/21, 9/3/21, 9/6/21, 9/8/21, 9/10/21, and 9/13/21, 6 of 6 treatments reviewed, revealed no documentation staff assessed the condition of the AVF for the presence of a B/T or abnormal findings. An interview was conducted on 9/16/21 at 9:14 AM with EI # 1 who confirmed the staff failed to follow the facility procedure for access site assessment. 30952 4. PI # 7 was admitted to the facility 9/7/17 with diagnoses including ESRD. Review of the Current Orders Report revealed Hemodialysis orders dated 8/5/21 for 3 x (times) a week dialysis treatments via an AVF. Review of the Treatment Sheets dated 9/4/21, 9/7/21, and 9/11/21, which was 3 of 6 treatments reviewed revealed no documentation of an AVF assessment which included the presence/absence of a B/T. During an interview conducted on 9/16/21 a 8:59 AM, EI # 1 confirmed staff failed to follow facility policy and perform and document AVF assessment findings.