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 06/30/2021
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 review of medical records (MR), facility policy, and interviews with staff, it was determined the facility failed to ensure the staff followed the physician orders for the Blood Flow Rate (BFR). This affected 3 of 5 MR's reviewed including Patient Identifier (PI) # 1, PI # 2, PI # 3 and had the potential to negatively affect all patients who dialyze at this facility. Findings Include: Policy Number: 1-03-08 Title: Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment Revision Date: April 2021 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... Policy: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: 3. Patient...prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment... Prescription components include but are not necessarily limited to: ... f. Blood flow rate Intradialytic Data Collection/Assessment 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: ...b. At a minimum, obtain and document the following: iii. Blood and dialysate flows, arterial and venous pressures 10. If the dialysis prescription is not being met (including dialysis flow rate or change to / inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed... 1. PI # 1 was admitted to the facility on 5/7/21 with a primary diagnosis of End Stage Renal Disease (ESRD). Review of the hemodialysis orders dated 6/9/21 revealed a BFR of 400. Review of the Post Treatment Sheet dated 6/11/21 revealed the BFR was decreased to 350 from 10:01 AM until the end of treatment at 1:23 PM. There was no documentation why the BFR was not at the ordered rate of 400. Review of the Post Treatment Sheet dated 6/14/21 revealed the BFR was decreased to 350 at 3:02 PM. Then at 3:31 PM the BFR was decreased to 300 until the end treatment at 4:12 PM. There was no documentation why the BFR was not at the ordered rate of 400. Review of the Post Treatment Sheet dated 6/18/21 revealed the BFR was decreased to 350 from 9:59AM until the end of treatment at 1:43 PM. There was no documentation why the BFR was not at the ordered rate of 400. Review of the Post Treatment Sheet dated 6/25/21 revealed the BFR was run at 300 from 10:31 AM to 1:42 PM. Then the BFR was increased to 350 until the end of treatment at 1:42 PM. There was no documentation why the BFR was not at the ordered rate of 400. An interview was conducted on 6/30/21 at 11:40 PM with Employee Identifier (EI) # 1, Facility Administrator, who confirmed the BFR was not run at the ordered rate. 2. PI # 2 was admitted to the facility on 6/5/18 with a primary diagnosis of ESRD. Review of the hemodialysis orders dated 2/19/21 revealed a BFR of 350. Review of the Post Treatment Sheet dated 6/23/21 revealed the BFR was run at 300 from initiation of treatment at 9:39 AM until 12:35 PM. There was no documentation why the BFR was not at the ordered rate of 350. An interview was conducted on 6/30/21 at 11:42 PM with EI # 1 who confirmed the BFR was not run at the ordered rate. 42144 3. PI # 3 was admitted to the facility on 4/3/19 with a primary diagnosis of ESRD. Review of the hemodialysis orders dated 5/17/21 revealed a BFR of 450. Review of the Post Treatment Sheet dated 6/18/21 revealed the BFR was run at 400 from 8:01 AM until 11:02 AM. There was no documentation why the BFR was not at the ordered rate of 450. Review of the Post Treatment Sheet dated 6/25/21 revealed the BFR was run at 375 from 8:01 to 10:48. There was no documentation why the BFR was not at the ordered rate of 450. An interview was conducted on 6/30/21 at 11:40 AM with EI # 1 who confirmed the BFR was not run at the ordered rate.