Statement of Deficiencies

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)

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 observation, review of medical records (MR), facility policies and interviews, it was determined the facility failed to ensure patient signs an AMA (Against Medical Advice) form when unable to complete treatment and treatment time as ordered by the physician. This deficient practice affected 3 of 5 MR reviewed including Patient Identifier (PI) # 4, # 5, # 2, and had the potential to negatively affect all patients served by the facility. Findings include: Title: Shortened/ Early Termination Of Treatment Or Extended Treatment Policy No: 1-01-09 Revision Date: October 2017 Purpose: To provide requirements for teammates to follow when a patient's treatment is terminated early or extended. Policy: 1. The RN (registered Nurse) verify that a patient signs and Early Termination of Treatment Against Medical Advice for any time the patient requests to terminate their treatment earlier than the prescribed run time. 3. The RN will obtain the patient's signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. ... 4. A RN must countersign the Early Termination of Treatment Against Medical Advice form. ... B. Shortened/ early Termination Of Treatment 3. If a patient's treatment is shortened/ early terminated, the RN will document the event in the patient's medical record. Documentation will include, as appropriate: The amount of time of which the treatment was shortened. A description of why the treatment ws shortened A copy of the early Termination of Treatment Against Medical Advice form signed by the patient, ... 1. PI # 4 was admitted to dialysis on 12/22/18 with a primary diagnosis of End Stage Renal Disease. Review of the Hemodialysis Treatment Orders 12/23/18 revealed patient's treatment time was 240 minutes. Review of the Treatment sheet dated 1/30/19 ended at 221 minutes, a difference of 19 minute from the ordered treatment time.The staff failed to obtain a signed Against Medical Advice (AMA) form from the patient. An interview was conduct 03/14/19 at 9:40AM with EI # 1, Group Facility Administrator, who confirmed the above mentioned findings. 37268 2. PI # 5 was admitted to dialysis on 5/9/18 with a primary diagnosis of ESRD. Review of the Hemodialysis Prescription Information dated 2/22/19 revealed documentation the ordered treatment time was 240 minutes. Review of the Post Treatment Sheet 2/22/19 revealed documentation of the treatment time was 187 minutes, 53 minutes less than the ordered treatment time. There was no documentation of an AMA. An interview was conducted on 3/14/19 at 10:00 AM with EI # 1, who confirmed the above mentioned findings. 3. PI # 2 was admitted to dialysis on 12/7/18 with a primary diagnosis of ESRD. Review of the Hemodialysis Prescription Information dated 2/27/19 revealed documentation the ordered treatment time was 240 minutes. Review of the Post Treatment Sheet 2/27/19 revealed documentation of the treatment time was 213 minutes, 27 minutes less than the ordered treatment time. There was no documentation of an AMA. An interview was conducted on 3/14/19 at 10:00 AM with EI # 1, who confirmed the above mentioned findings.