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 09/12/2023
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)
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, facility policy, and interviews with staff, it was determined the facility failed to ensure staff documented and reported early termination of treatments to the physician, per policy. This affected two of three in-center records reviewed including Patient Identifier (PI) # 1, PI # 3, and had the potential to negatively affect all patients dialyzing at this facility. Findings include: Facility Policy: CWOW (Clinic Without Walls) Prescribed Treatment Time Not Met Policy number: 1-01-09 Date revised: October 2022 Purpose: To provide requirements for teammates to follow when a patient's treatment is terminated early. Policy: A. Completion of the Early Termination of Treatment Against Medical Advice Form 1. The RN (Registered Nurse) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form 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... form prior to the patient being rinsed back from their treatment... 4. A RN must countersign all... forms. A witness signature is required only if the patient refuses to sign the form... B. Prescribed Treatment Time Not Met 1. If shortened/ early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient's attending nephrologist to discuss the appropriate interventions (if any)... 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 by which the treatment was shortened; -A description of why the treatment was shortened; -Whether the patient's nephrologist was notified... - A copy of the Early Termination of Treatment Against Medical Advice form... ...5. The facility's FA (Facility Administrator) will verify that all shortened treatments are recorded and trended, and the FA shall verify that such records are reviewed and discussed at the Facility Health Meetings (FHM), as appropriate... 1. PI # 1 was admitted to the facility on 1/13/23 with a primary diagnosis of End Stage Renal Disease (ESRD). Review of the Treatment Detail Report (TDR) revealed the dialysis prescription for a treatment time of 3 hour 15 minutes. Review of the TDR dated 8/18/23 revealed the treatment start time was 2:30 PM and the end time was 4:32 PM (2 hours and 2 minutes). There was no documentation of an AMA form being obtained for early termination of treatment. There was no documentation the RN notified the physician, per policy. An interview was conducted on 9/12/23 at 11:36 AM with Employee Identifier (EI) # 1, FA, who confirmed the staff failed to document and report the early termination of treatment to the physician, per policy. 2. PI # 2 was admitted to the facility on 3/29/22 with a primary diagnosis of ESRD. Review of the IDT (Interdisciplinary Team) Rounding Worksheet: Active Treatment Orders dated 8/22/23 revealed, "Tx (Treatment) Time: ... 270 mins (minutes)." Review of the TDR dated 9/7/23 revealed the treatment start time was 6:25 AM and the end time was 10:20 AM (235 minutes). There was no documentation of an AMA form being obtained for early termination of treatment. There was no documentation the RN notified the physician, per policy. An interview was conducted on 9/12/23 at 11:47 AM with EI # 1, who confirmed the staff failed to document and report the early termination of treatment to the physician, per policy.