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 012508 (X3) Date Survey Completed 12/12/2019
Name of Provider or Supplier Birmingham East Dialysis Street Address, City, State 1105 East Park Drive, Birmingham, 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 observations, review of medical records, facility policy, and interviews, it was determined the facility failed to ensure: 1. Patient treatments were administered according to the physician orders for blood flow rate (BFR). 2. Heparin was administered as ordered. 3. Two teammates verified the dialysis prescription and machine settings before the initiation of treatment. This affected Patient Identifier (PI) # 1, PI # 3, PI # 4, 3 of 5 records reviewed and had the potential to negatively affect all patients that dialyze at this facility. Findings include: Title: Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment Policy Number: 1-03-08 Revision Date: April 2017 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... i. Correct dialysate composition ... and settings, including... 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... d. Hourly heparin infusion ordered by the physician... should be documented every 60 minutes... 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 9/23/19 with the diagnosis of ESRD. Review of the 11/26/19 Post Treatment sheet revealed documentation the total Heparin administered was 0.5 Units. The amount should have been 1600 Units, and no physician's order was obtained to change the hourly Heparin dosage. Review of the 11/29/19 Post Treatment sheet revealed the BFR was decreased from 400 to 350 at 12:30 PM to 1:42 PM, and there was no documentation why the BFR was decreased. Review of the 12/2/19 Post Treatment sheet revealed the BFR was decreased from 400 to 300 at 10:02 AM to 11:02 AM. There was no documentation why the BFR was decreased. Review of the 12/6/19 Post Treatment sheet revealed the BFR was decreased from 400 to 350 at 8:32 AM to 9:32 AM. There was no documentation why the BFR was decreased. In an interview conducted on 12/12/19, EI # 1, confirmed the staff failed to follow physician orders for Heparin and BFR. 22965 2. PI # 3 was admitted to dialysis on 4/12/15 with a primary diagnosis of End stage Renal Disease. Review of the Treatment Orders dated 11/18/19 revealed the following hemodialysis order: Dialysate Flow Rate (DFR) 800. Review of the Hemodialysis Post Treatment sheet dated 12/6/19 revealed the DFR was decreased from 800 to 180 at 6:00 AM to 7:05 AM. There was no documentation why the DFR was decreased. In an interview with EI # 1 conducted on 12/12/19 at 10:00 AM, EI confirmed the above mentioned findings. 3. PI # 4 was admitted to the facility on 4/11/18 with diagnoses of End Stage Renal Disease. Review of the 11/26/19 Post Treatment sheet revealed the dialysis treatment was initiated at 5:47 AM by the PCT and the RN verified the machine prescription at 7:36 AM, which was 109 minutes after treatment initiation. Review of the 12/6/19 Post Treatment sheet revealed the dialysis treatment was initiated at 5:42 AM by the PCT and the RN verified the machine prescription at 8:13 AM, which was 151 minutes after treatment initiation. Review of the 12/9/19 Post Treatment sheet revealed the dialysis treatment was initiated at 5:53 AM by the PCT and the RN verified the machine prescription at 7:35 AM, which was 102 minutes after treatment initiation. In an interview conducted on 12/12/19 at 10:16 AM, EI # 1 confirmed the above findings.