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 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)
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 review of facility policy, medical record (MR), and interviews, it was determined the staff failed to ensure the MR contained complete and accurate documentation of patient symptoms and therapeutic effectiveness for PRN (as needed) medication use. This affected Patient Identifier (PI) # 6, PI # 4, PI # 8 in 3 of 4 records reviewed in which staff administered PRN medications. Finding include: Facility Policy: Medication Preparation and Administration Published: 04/05/2021 Version: 6 Purpose: To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control. ...Documentation Document all patient symptoms leading to PRN drug administration and patient's response to the PRN medication on treatment sheet or electronic medical record... 1. PI # 6 was admitted to the facility on 6/2/17 with diagnoses including Diabetes Mellitus with Diabetic Nephropathy and ESRD (End Stage Renal Disease). Review of the Treatment Sheet dated 7/12/21 revealed treatment initiation at 7:44 AM. At 7:50 AM, Ondansetron HCL (hydrochloride) 4.000/mg (milligram) was administered IVP (intravenous push) prn (as needed). There were no patient symptoms documented as why Ondansetron HCL was administered and no documentation of the patient response to the Ondansetron HCL. An interview was conducted with EI (Employee Identifier) # 1, Director of Operations on 7/14/21 at 12:56 PM CST (Central Standard Time) who confirmed staff failed document the reason for the IVP medication and the patient response. 2. PI # 4 was admitted to the facility 5/15/2020 with diagnoses including ESRD. Review of the Treatment Sheet dated 7/6/21 revealed at 2:47 PM Acetaminophen 650.000 mg oral (by mouth) prn was administered. There were no patient symptoms documented as why Acetaminophen was administered and no documentation of the patient response to Acetaminophen. During an interview conducted on 7/14/21 at 1:28 PM CST EI # 1 confirmed the staff failed to document all patient symptoms leading to PRN drug administration and the patient's response to the PRN medication on treatment sheet. 34107 3. PI # 8 was admitted to the facility 10/4/14 with diagnoses including ESRD. Review of the Treatment Sheet dated 6/30/21 revealed at 9:50 AM, Acetaminophen 650.000 mg oral/prn was administered. There were no patient symptoms documented as why the Acetaminophen was administered. During an interview conducted on 7/14/21 at 1:06 PM CST, EI # 1 confirmed the staff failed to document the reason why the PRN medication was administered.