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 012501 (X3) Date Survey Completed 03/14/2019
Name of Provider or Supplier Gadsden Dialysis Street Address, City, State 409 South First Street, Gadsden, 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)
V0504 PA-ASSESS B/P, FLUID MANAGEMENT NEEDS
CFR(s): 494.80(a)(2)

The patient's comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs.


This STANDARD is not met as evidenced by:
Based on review of the facility's policies and procedures, medical records and interviews with staff, it was determined the agency failed to: 1) Document reasons for not meeting the physician's order on patient's estimated dry weight (EDW) post dialysis treatment. 2) Follow the physician's standing orders for Blood Pressure (BP) parameters. 3) Follow the physician's order for Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR). 4) Document vital signs every 30 minutes according to facility policy. This deficient practice affected 3 of 5 records reviewed including Patient Identifier (PI) # 1, # 3, # 4, and had the potential to negatively affect all patients served by the facility. Findings include: Title: Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment Policy No: 1-03-08 Revision Date: April 2017 Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient's dialysis treatment, monitoring during treatment and for reviewing the patient's response to the treatment and status prior to discharge. 12. The licensed nurse notifies the physician (or AHP (allied health professional ) as needed for changes in patient status. 1. PI # 1 was admitted in dialysis on 6/5/18 with the diagnoses including Anemia In Chronic Kidney Disease and End Stage Renal Disease. Review of the the Kardex/ Hemodialysis Treatment Orders dated 1/15/19 revealed the BFR (Blood Flow Rate) was at 400. Review of the Hemodialysis Treatment Sheet dated 2/25/19 revealed the BFR was reduced to 350 at 11:37 AM, then reduced to 200 at 2:30 PM . There was no documented reason for the decrease in the BFR. Review of the Hemodialysis Treatment Sheet dated 2/27/19 revealed the BFR was reduced to 350 at 11:31 AM, then to 300 from 12:01 PM to 3:54. There was no documented reason for the decrease in the BFR. Review of the Hemodialysis Treatment Sheet dated 3/1/19 revealed the BFR was reduced to 250 from 12:05 PM to 1:13. There was no documented reason for the decrease in the BFR. Review of the Hemodialysis Treatment Sheet dated 3/8/19 revealed the BFR was reduced to 350 from 10:59 AM to 2:02 PM. There was no documented reason for the decrease in the BFR. An interview was conducted on 3/14/19 at 9:30 AM with Employee Identifier (EI) # 1, Group Facility Administrator (GFA) who confirmed the staff failed to follow the physician's orders. 2. PI # 3 was admitted to dialysis on 7/4/18 with a primary diagnosis of End Stage Renal Disease. Review of the Hemodialysis Treatment Sheet dated 1/2/19 revealed BFR was ordered at 400 according to the physician's orders. Review of the Treatment Sheet dated 2/25/19 revealed the BFR was lowered to 300 at 10:30 AM until the end of treatment at 12:27 PM. There was no documentation of the reason BFR was not administered as ordered. Review of the Treatment Sheet dated 3/4/19 revealed the BFR was lowered to 350 from 10:13 AM until the end of treatment at 1:00 PM. The staff failed to ensure documentation was provided as to the reason the BFR was lowered. An interview was conducted on 3/14/19 at 9:45 AM with EI # 1, who confirmed the above mentioned findings. 3. PI # 4 was admitted to dialysis on 12/22/18 with a primary diagnosis of End Stage Renal disease. Review of the PRN (As Needed) Orders dated 12/23/18 revealed to administer Clonidine 0.20 mg. (milligram) by mouth 0.2 mg for systolic blood pressure (BP) greater (>) than 200. May repeat in 1 hour if systolic BP still > 200. Call physician (MD) if BP still >200 systolic after 2nd dose. Review of the Treatment Sheet dated 12/31/18 revealed BP was 206/132 at 1:01 PM and at 1:31 PM BP was 202/141. There was no documentation the anti hypertensive medications Clonidine was administered. An interview was conducted with EI # 1 at 9:40 AM on 3/14/19 who confirmed the aforementioned findings.