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 012507 (X3) Date Survey Completed 03/14/2019
Name of Provider or Supplier Fresenius Kidney Care Mobile Street Address, City, State 2620 Old Shell Road, Mobile, 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), the facility's policy and procedures and interview with facility staff, it was determined the facility failed to ensure the staff followed the physician's order for the Dialysate Flow Rate (DFR). This affected 1 of 10 records reviewed including Patient Identifier (PI) # 10 and had the potential to negatively affect all patients served by the facility. Findings include: Facility Policy: Auto Flow Dialysate Policy Document Number: FMS-CS-IC-105-017A Revision Date: 04-APR-2012 Purpose: The purpose of this policy is to provide guidance on the use of the auto flow dialysate option. Overview: ...The Auto Flow feature allows for automatic optional dialysate flows proportionate to the blood flow rate. The Auto Flow Option automatically adjusts the dialysate flow at either 1.5 times the blood flow... or 2.0 times the blood flow ... with a maximum dialysate flow rate of 800 ml (milliters) / min (minute). There are two Auto Flow selections: Option 1- selects the minimum dialysate flow rate during dialysis when Auto Flow is selected to either 300 or 500. (500 is the default selection) Auto Flow Rate: Blood Flow Rate (BFR) using Auto Flow 1.5: 316 - 415 Blood Flow Rate equals 500 Minimum Dialysate Rate. 1. PI # 10 transferred to the facility from a sister clinic on 2/7/19 with diagnoses including End Stage Renal Disease. Review of the physician orders dated 1/11/19 and 3/7/19 revealed orders for BFR 350, DFR autoflow 1.5. Record review for 6 treatment sheets between 2/7/19 to 3/9/19 revealed the treatment sheets dated 2/7/19, 2/9/19, 2/12/19 and 3/7/19 had the incorrect DFR of 600. An interview was conducted on 3/14/19 at 9:15 AM with Employee Identifiers (EI) # 1, Clinic Manager, and EI # 2, Director of Operations, who confirmed the documented DFR should have been 500.