Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 852539	(X3) Date Survey Completed 08/02/2024
Name of Provider or Supplier Eatonton Kidney Center	Street Address, City, State 103 N Washington Avenue, Eatonton, GA
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)

V0547

POC-MANAGE ANEMIA/H/H MEASURED Q MO
CFR(s): 494.90(a)(4)

The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient's hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient's anemia management needs.

This STANDARD is not met as evidenced by:
Based on a review of medical records, facility's anemia protocol, and staff interview, it was determined that the interdisciplinary team (IDT) failed to implement the plan of care and facility guidelines for anemia (lower-than-normal number of red blood cells), to meet the patients' anemia management needs in order to attain and maintain appropriate blood levels of Hemoglobin (Hgb - protein in red blood cells that carries oxygen) of two of two sampled patients (P#1 and P#2) whose Hgb levels were consistently below the clinically acceptable Hgb value of 10 g/dL (grams/deciliter). The accepted clinical practice standard for Hgb levels for dialysis patients was 10-12 g/dL. Anemia in dialysis patients could cause fatigue, shortness of breath, chest pain, dizziness, fainting, and increased risk of hospitalization and longer hospital length of stay. This deficient practice had the potential to negatively affect the health and safety of P#1 and P#2. The facility census was ten. Findings were: A review of "Rounding Report" for P#1 and P#2 revealed the following: P#1: P#1's Hgb and ferritin lab (laboratory) results showed the following: - 2/7/24: Hgb 8.0 g/dL -2/21/24: Hgb 8.0 g/dL - 3/13/24: Hgb 8.2 g/dL - 3/27/24: Hgb 8.0 g/dL - 4/10/24: Hgb 7.5 g/dL and ferritin was 1428 - 4/24/24: Hgb 8.7 g/dL - 5/15/24: Hgb 8.3 g/dL - 5/29/24: Hgb 7.8 g/dL - 6/12/24: Hgb 8.6 g/dL - 6/26/24: Hgb 8.0 g/dL A review of P#1's CIPA/POC (Comprehensive Interdisciplinary Patient Assessment/Plan of Care) dated 11/8/23 showed a goal of 9.0 g/dL - 11.5 g/dL... During an interview with the Facility Administrator (FA) on 8/2/24 at 8:10 a.m., the FA confirmed that the P#1 received Aranesp (medication used to treat anemia) on the following dates: - 1/24/24: Aranesp 40 mcg (microgaram) - 4/10/24: Aranesp 20 mcg. P#1's Hgb dropped from 8.2 g/dL on 3/13/24 to 8.0 g/dL on 3/27/24, and further dropped down to 7.5 g/dL on 4/10/24. However, the dose of Aranesp was decreased by 50% on 4/10/24 from 40 mcg to 20 mcg. - 5/29/24: Aranesp 60 mcg P#2: P#2's Hgb and ferritin lab results showed the following: - 5/29/24: Hgb 9.5 g/dL and ferritin was 377 - 6/21/24: Hgb 9.2 g/dL - 7/10/24: Hgb 8.8 g/dL and ferritin was 643 - 7/24/24: Hgb 8.0 g/dL There was a lack of documented evidence that Aranesp was administered when P#2's Hgb continued to drop from 9.5 g/dL to 8.0 g/dL. A review of P#2's CIPA/POC dated 6/3/24 showed a goal of 9.0 g/dL - 11.5 g/dL... During an interview with the FA on 8/2/24 at 8:15 a.m., the FA confirmed that P#2 has not received a dose of Aranesp since admission on 5/24/24. The FA stated it takes the physician two weeks after lab results were received to order or make changes to Aranesp to improve patients' Hgb. A review of undated facility "Guidelines for Dosing Aranesp" showed the following: Dose Adjustments: The dose should be adjusted for each patient to achieve and maintain Hgb within the range of 10 g/dL to 12 g/dL. Dose adjustment is made every four (4) weeks. If ferritin levels are adequate (500 - 800), the dose of Aranesp may be increased by 25% of the previous dose. Increase Dose: - If the increase in Hgb is less than 1 g/dL over 4 weeks and the ferritin level is adequate, the dose of Aranesp may be increased by 25% of the previous dose. - Further increases may be made at 4 week intervals until the specified Hgb is obtained. - Increase in dosage should not be made no more than once a month.