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)
V0726 MR-COMPLETE, ACCURATE, ACCESSIBLE
CFR(s): 494.170

The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.


This STANDARD is not met as evidenced by:
Based on observations, review of facility policies, review of Early Termination of Treatment Against Medical Advice forms, and interview it was determined the facility failed to ensure: 1. The facility policy for Early Termination of Treatment Against Medical Advice was followed. This affected 6 of 6 records reviewed including Patient Identifier (PI) # 14, #8, # 9, # 4, # 13 and # 12. 2. Treatment notes included documentation of Oxygen administered during treatments. This affected 3 of 3 patients receiving oxygen therapy including PI # 3, # 13 and # 16. These deficient practices had the potential to negatively affect all patients receiving dialysis at this facility. Findings include: Facility Policy: Early Termination of Treatment Against Medical Advice Policy #: 1-01-09 Revision Date: October 2019 Purpose: To provide requirements for teammates to follow when a patient's treatment is terminated early or extended. Policy: A. Completion of the Early Termination of Treatment Against Medical Advice Form. 1. The RN will verify that a patient signs the Early Treatment Against Medical Advice (ETAMA) form any time the patient requests to terminate their treatment earlier than the prescribed run time... 3. If a patient's treatment is terminated early, the RN (Registered Nurse) will obtain the patient's signature on the ETAMA form prior to the patient being rinsed back from their treatment. If unable to obtain the patient's signature prior to rinse-back from their treatment, the RN will obtain the patient's signature on the form prior to the patient's departure from the facility... B. Prescribed Treatment Time Not Met... 3. If a patient's treatment is shortened/ early terminated... - The amount of time by which the treatment was shortened; - A description of why the treatment was shortened... Facility Policy: Medication Policy Policy #: 1-06-01 Revision Date: April 2019 Purpose: To provide guidance for medication management in the facility... Policy: ...9. Medications are administered as prescribed and then documented in the patient's medical record... 1. During the flash tour of the facility conducted on 12/10/19 at 7:45 AM, the surveyor observed a stack of incomplete Early Termination of Treatment forms on the nurse's desk. The forms had a purple sticky note with, "Need to be signed (Employee Identifier [EI] # 7, RN )" Review of the ETAMA form printed on 11/15/19 for PI # 14 revealed no documentation for the: Prescribed treatment time, Shortened treatment by ___ minutes, and the Reason (specify): were all blank. Further review of the form revealed no signature by the patient, witness, or nurse and the date was blank. The RN failed to complete the ETAMA form per policy. Review of the ETAMA form printed on 11/21/19 for PI # 8 revealed no documentation for the: Prescribed treatment time, and the Reason (specify): was blank. Further review of the form revealed no signature by the patient, or nurse and the date was blank. The RN failed to complete the ETAMA form per policy. Review of the ETAMA form printed on 11/21/19 for PI # 9 revealed no patient and nurse signature, and the date was blank. The RN failed to complete the ETAMA form per policy. Review of the ETAMA form printed on 11/22/19 for PI # 8 revealed the following were blank: Prescribed treatment time; Reason treatment was shortened; Patient Signature and Licensed Nurse Signature. The RN failed to complete the ETAMA form per policy. Review of the ETAMA form printed on 12/619 for PI # 4 revealed no documentation for the prescribed treatment time, shortened treatment time, reason for shortened treatment and no signature and date by the Licensed Nurse. The RN failed to complete the ETAMA form per policy. Review of the ETAMA form printed on 12/6/19 for PI # 13 revealed no signature and date by the Licensed Nurse. The RN failed to complete the ETAMA form per policy. Review of the ETAMA form printed on 12/7/19 for PI # 12 revealed no signature for the Licensed Nurse and the date was blank. The RN failed to complete the ETAMA form per policy. In an interview conducted on 12/11/19 at 11:11 AM, EI # 2, Manager Clinical Services, confirmed the RN failed to complete ETAMA forms per policy. 40119 2. During an observation of the diaylsis floor conducted on 12/11/19 at 8:00 AM the following patients were observed by the surveyor to have oxygen administration during the treatment: PI # 3, with oxygen concentrator set on 2 Liters. PI # 13, with oxygen concentrator set between 1.5 and 2 Liters PI # 16, with oxygen concentrator set at 2 Liters. Review of the Post Treatment Notes for PI # 3, PI # 13, and PI # 16 dated 12/11/19 revealed no documentation of the oxygen administration during the treatment. An interview was conducted on 12/12/19 at 9:56 AM with EI # 1, who confirmed the above findings.