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 012502 (X3) Date Survey Completed 01/08/2020
Name of Provider or Supplier Tuscaloosa University Dialysis Street Address, City, State 220 15th Street, Tuscaloosa, 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)
E0028 Dialysis Emergency Equipment

ยง494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available.


This STANDARD is not met as evidenced by:
Based on review of the AED (Automated External Defibrillator) Checklists, Emergency Equipment Checklists, policy and interview, it was determined the facility failed to ensure emergency equipment was checked per policy. This had the potential to affect all persons dialyzing at the facility. Findings include: Policy: Emergency Equipment Checks Policy Number: 1-02-08 Revision Date: April 2019 Purpose: To verify that emergency equipment is maintained in a ready-to-use condition. Policy: ...2. The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Daily: -Check Status Indicator light for Philips Heart Start... Break away lock is intact. Weekly: -Oxygen supply is adequate... ...Emergency cart (crash cart) is clean, operational and supplies have not expired. ...4. The emergency checklist will be developed by the facility based on Medical Director input as to the supplies needed on the emergency (crash) cart and will be used to verify that the cart has been checked. A review of the AED daily checklist for November 2019 revealed the following missing dates: 11/2/19 11/29/19 11/30/19 A review of the AED daily checklist for December 2019 revealed the following missing dates: 12/4/19 12/30/19 12/31/19 There was documentation the checklist was completed on 12/8/19, which was a Sunday, and the facility was closed. Review of the weekly Emergency Equipment Checklist for November and December of 2019 revealed the Emergency Cart information was left blank the week of 11/25/19. There was no documentation the week of 12/02/19 and the week of 12/30/19. An interview was conducted on 1/8/2020 at 12:18 PM with Employee Identifier # 1, Facility Administrator, who confirmed the missing dates.