Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012513	(X3) Date Survey Completed 07/14/2021
Name of Provider or Supplier Bma Langdale	Street Address, City, State 8 Medical Park North, Valley, 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)

V0551

POC-VA MONITOR/PREVENT FAILURE/STENOSIS
CFR(s): 494.90(a)(5)

The patient's vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis.

This STANDARD is not met as evidenced by:
Based on review of facility policy, medical records (MR) and staff interviews, it was determined the facility failed to ensure staff: 1. Documented access assessment findings in 1 of 1 record with a maturing access site AVF (arteriovenous fistula), identify an infiltration, and provide care to the maturing access site per policy. 2. Documented the presence/absence of a bruit and thrill (B/T) in 4 of 7 records reviewed with an AVF/AVG (arteriovenous graft). This did affect PI (Patient Identifier) # 1, PI # 4, PI # 3, PI # 8 and had the potential to negatively affect all patients who dialyzed at the facility. Findings include: Facility Procedure: Access Assessment and Cannulation Published: 08/22/2018 Version: 1 Purpose ...of this procedure is to provide guidance for placement of needles in an AV (arteriovenous) Fistula or AV Graft... Policy New Access Care and Cannulation Evaluation and preparation of the access will be performed routinely prior to cannulation at each dialysis session. ...assign clinical staff for the initial cannulations based on experience and expertise. Check fistula for adequate bruit and thrill to confirm patency Check for signs of infection. ...Perform skin disinfection as outlined in policy... Assessment of Vascular Access Follow the steps below to access the vascular access: 5. LOOK: Skin Discoloration/Redness/Bruising/lesion Hematomas Extremity or Other Swelling ...Greater than expected redness...Swelling 6...LISTEN: Bruit high pitch/whistle Bruit not present throughout access ...Document in eCC ("e-cube"-the facility electronic medical record documentation software) 7. FEEL: Pulse not soft/not easily compressible Thrill not strong at anastomosis Thrill not present throughout access Document in eCC. 8. Note and report any unusual findings to Team Leader or Charge Nurse, before proceeding with needle insertion... 9. Remove gloves, perform hand hygiene. Don new gloves. Skin disinfection Step 1 Disinfect Cannulation site...using...disinfectants...70 % Isopropyl alcohol pad... Facility Policy: Complications of Hemodialysis (HD)-Management and Prevention of Needle Infiltration Published: 08/28/2020 Version: 5 ...The purpose of this policy is to provide guidelines for prevention, recognition, and appropriate treatment for needle infiltration. Policy Staff will be familiar with cannulation techniques used to prevent infiltration... Staff will monitor patients closely for signs and symptoms (s/s) of infiltration...Needle infiltration will be recognized, reported, and treated immediately when occurring while on HD, during needle insertion or needle removal. Background ...A quick response to a needle infiltration can help minimize damage to the access (2006 NKFK (National Kidney Foundation.../DOQI [Dialysis Outcomes Quality Initiative] Clinical practice Guidelines for Vascular Access) Possible Contributing Factors Access not cannulated properly... Patient movement causing needle to puncture vessel wall ...Immature access cannulated too early Inexperienced staff cannulating new...fistula/graft Prevention of Needle Infiltration ...Evaluate increased venous pressures or poor arterial flows Avoid premature cannulation of access Use expert cannulators to cannulate new...fistulas... Signs and Symptoms (s/s) of Needle Infiltration ...Staff may see: Swelling at the insertion site...above/or around the insertion site Hardness at the insertion site ...Staff may discover: Increased venous pressure Loss of arterial blood flow... Treatment of Needle Infiltration The following steps should be followed to treat needle infiltration: Step 1. Establish that an infiltration has occurred. 2. Turn off blood pump... ...3. Notify the RN (Registered Nurse) 5. If the infiltration has occurred after the administration of heparin...apply ice to the site of the infiltration... 7. Instruct pt (patient) to apply ice to the infiltrate for the first 24 hours and then warm compresses for the following 24 hours 8. Instruct the pt to watch for...complications and contact the physician...Pain at site Reoccurrence of bleeding... Temperature elevation Additional swelling of area Absence of thrill 1. PI # 1 was admitted to the facility 4/13/21 with diagnoses including Diabetic Glomerular Sclerosis and ESRD (End Stage Renal Disease). MR review revealed an operative report dated 5/20/21 for a right arm brachiocephalic fistula procedure and surgical clinic note documentation dated 6/29/21, "ok to use AV Fistula". Review of the Treatment Sheets dated 6/29/21 and 7/1/21 revealed the pt was dialyzed via a central venous catheter. There was no documentation staff assessed the condition of the maturing AVF for the presence of a B/T or abnormal findings. Review of the Treatment Sheet dated 7/3/21 failed to include documentation staff assessed the condition of the maturing AVF for the presence of a B/T or abnormal findings pre-treatment. Further review of the 7/3/21 Treatment Sheet revealed documentation at 12:03 PM Heparin 5000 unit bolus was administered. At 12:20 PM, the RN documented, "pt bent right arm access-no infiltration however arterial needle exceeded pressures-using both arterial and venous lines". There was no AVF assess site documentation post treatment and no documentation of the presence/absence of a B/T. There were no documentation staff provided infiltration care. There was no patient education for infiltration care or possible complications documented. Review of the Treatment Sheet dated 7/6/21 revealed documentation staff assessed the right AVF with skin discoloration/redness/bruising/extremity swelling. Interventions documented were use alternative access, apply cold compress to site (1st 24 hr-[hour]). There was no documentation the maturing AVF was assessed on 7/6/21 for the presence of a B/T. The staff failed to provide accurate instructions for care of an infiltrate greater than 24 hours per policy. Review of the Treatment Sheet dated 7/8/21 revealed the AVF status, redness, bruising, lesion, hematomas, use alternative active access. There was no documentation staff assessed the maturing AV Fistula for the presence of B/T. In an interview on 7/14/21 at 1:09 PM CST (Central Standard Time), EI (Employee Identifier) # 1, Director of Operations (DOO), confirmed staff failed to follow the facility procedure for AVF assessment and documentation. 2. PI # 4 was admitted to the facility 5/15/2020 with diagnoses including ESRD. Review of the Current Orders Report revealed dialysis treatments were provided via an AVF. Review of the Treatment Sheet dated 7/8/21 revealed no documentation of an AVF assessment which included the presence/absence of a B/T. During an interview conducted on 7/14/21 at 1:28 PM CST EI # 1 confirmed staff failed to document AVF assessment findings. 34107 3. PI # 3 was admitted to the facility 12/09/2020 with the primary diagnosis of ESRD. Review of the Current Orders Report revealed dialysis treatments were provided via an AVF. Review of the Treatment Sheets dated 6/30/21, 7/9/21 and 7/12/21 revealed no documentation of an AVF assessment which included the presence/absence of a B/T. In an interview conducted on 7/14/21 at 1:05 PM CST, EI # 1 confirmed 3 of the 6 treatments reviewed the staff failed to document the AVF assessment or B/T. 4. PI # 8 was admitted to the facility 10/4/14 with diagnosis including ESRD. Review of the Current Orders Report revealed dialysis treatments were provided via an AVF. Review of the Treatment Sheet dated 7/12/21 revealed no documentation of an AVF assessment which included the presence/absence of a B/T. In an interview conducted on 7/14/21 at 1:06 PM CST, EI # 1 confirmed the staff failed to document the AVF assessment or B/T.