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)
V0550 POC-VASCULAR ACCESS-MONITOR/REFERRALS
CFR(s): 494.90(a)(5)

The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.


This STANDARD is not met as evidenced by:
Based on review of medical record (MR), policy and procedure, staff and patient interviews, it was determined the facility failed to ensure the staff followed their own policy and procedure for care of an AVF/AVG (Arteriovenous Fistula/Graft). This affected 1 of 1 records reviewed with a new AVF/AVG including PI #1. This had the potential to negatively affect all patients with a new AVF/AVG (arteriovenous fistula/graft). Findings Include: Policy Title: Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Access Care Policy #: 1-04-01 Revision Date: April 2018 "Purpose: To reduce the risk of infection in the patient, to reduce trauma to the fistula or graft while minimizing blood loss and to maximize the lifetime of each access. Policy: 1. Inspection of the AVF or AVG access includes the following: ... Presence/absence of thrill and/or bruit ... Physical location of the access ... ... Condition of incision(s) especially in newly placed access or revised access ... 1. PI # 1 was admitted to the facility on 9/23/19 with the diagnosis of End Stage Renal Disease. Review of the 11/15/19 Hospital Operation Note revealed documentation a left arm fistula was placed in the cephalic vein and radial artery. Further documentation revealed a 3 centimeter incision and an excellent thrill noted. Review of the 11/26/19, 11/29/19, 12/2/19, 12/4/19, 12/6/19, and 12/9/19 Post Treatment sheets revealed no documentation the staff assessed the newly placed left AVF for bruit and thrill or signs /symptoms of infection. In an interview conducted on 12/12/19 at 9:36 AM, Employee Identifier (EI) # 1, Facility Administrator, confirmed the staff failed to document the assessment of the newly placed AVF.