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)
V0634 QAPI-INDICATOR-MEDICAL INJURIES/ERRORS
CFR(s): 494.110(a)(2)(vi)

The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification.


This STANDARD is not met as evidenced by:
Based on review of medical record, observation and interview, it was determined staff failed to complete an adverse event report for a near miss, per policy. This affected 1 of 4 dialysate prescriptions confirmed during the flash tour of the facility. This near miss could have affected Patient Identifier (PI) # 2, and had the potential to affect all patients dialyzing at the facility. Findings include: Policy: Risk Event Reporting Policy Policy Number: 13-01-02 Revision Date: April 2019 Purpose: To establish the process for handling and investigating Risk Event Management (REM) Reports. Policy: A. Preparing a Risk Event Management Report (Event Report) 1. Any unexpected event that is inconsistent with the routine operation of a dialysis facility... may be a risk event. Such risk events include... personal injury or potential personal injury to a patient... or 'near miss' events... 2. All risk events will be promptly reported to the Facility Administrator... The teammate involved in the risk event or who witnessed the risk event firsthand will complete a REM Report. The teammate will complete the REM Report as soon after the occurrence as is reasonably possible, but no later than the completion of the teammates' shift during which the risk event happened. B. Handling of the Risk Event Management Report... ...3. RM Reports are to be trended and reviewed during the Facility Health Meeting. This includes "Near Miss" events. Any negative trend should result in a plan of action. ...Examples of Reportable Risk Events ...Dialysate Concentrate Issue ...Near Miss Events (use the appropriate adverse occurrence category) 1. PI # 2 was admitted to the facility on 8/2/19 with a primary diagnosis of Acute Kidney Injury. During the flash tour of the facility on 1/6/2020 at 9:43 AM the surveyor asked Employee Identifier (EI) # 7, RN (Registered Nurse) at station # 10 to confirm the dialysis orders and dialysate that the patient had connected. The dialysis machine was connected to the wall bath, which delivers a dialysate of K (Potassium): 2.00, Ca (Calcium): 2.50. Review of the physician's orders revealed the patient was ordered a dialysate of K: 2.00 and Ca: 2.00. The RN immediately retrieved a jug from the supply cart of the correct dialysate, and connected the tubing to the jug. During an interview on 1/8/2020 at 10:25 AM with Employee Identifier # 1, Facility Administrator, the surveyor requested any adverse event reports for PI # 2. EI # 1 stated there was none documented.