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 852540 (X3) Date Survey Completed 01/06/2023
Name of Provider or Supplier Camilla Dialysis Street Address, City, State 251 Us 19 N, Camilla, 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)
V0543 POC-MANAGE VOLUME STATUS
CFR(s): 494.90(a)(1)

The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient's volume status;


This STANDARD is not met as evidenced by:
Based on a review of medical records and staff interviews, it was determined that the facility failed to ensure that one of one patient sampled (P#4) who had elevated blood pressure (BP) readings, was treated according to the physician's standing order. This deficient practice had the potential to negatively affect the health and safety of P#4 and the other 73 in-center hemodialysis patients who dialyzed at this facility. Findings include: A review of P#4's medical records revealed the following: - P#4 came to the facility for dialysis treatment on 12/29/22 with the following vital signs as recorded in P#4's treatment flowsheet: PRE-TREATMENT VITAL SIGNS: BP sitting - 230/129; standing BP 222/125; Pulse - 74; Temperature - 97.1; Pre-Weight - 103.0 kilograms (kg) POST-TREATMENT VITAL SIGNS: BP sitting - 208/110; BP standing - 190/109; Pulse - 81; Temperature - 98.2; Post-weight - 98.7 kg Target weight - 97.0 kg BP ranges during P#4's hemodialysis treatment on 12/29/22 fluctuated between 165/106 and 218/111. Documentation stated that P#4's BP reading was either trending up or trending down, but there was no documentation whether a PRN (as needed) medication was offered nor given and there was no documentation that the doctor was notified. - P#4's treatment flowsheet on 1/3/23 revealed the following: PRE-TREATMENT VITAL SIGNS: BP sitting - 187/112; standing BP 189/119; Pulse - 75; Temperature - 97.2; Pre-Weight - 101.7 kg POST-TREATMENT VITAL SIGNS: BP sitting - 191/109; BP standing - 191/111; Pulse - 86; Temperature - 98.0; Post-weight - 98.6 kg Target weight - 97.0 kg BP ranges during P#4's hemodialysis treatment on 1/3/23 fluctuated between 173/99 and 210/114. Documentation stated that P#4's BP reading was either trending up or trending down, but there was no documentation whether a PRN medication was offered nor given and there was no documentation that the doctor was notified. P#4 had missed treatment on 12/22/22, 12/27/22 and 12/31/22. The Facility Administrator and Regional Operations Director were notified of the above observation and the Regional Operations Director stated on 1/6/23 at 4:00 p.m. that P#4 did not have an individualized PRN medication order for Hypertension (HTN) but the facility had a general HTN standing order of: "Clonidine 0.10 mg by mouth. May give 1 tablet orally every 30 minutes up to 3 doses PRN". There were no specific parameters that was included in the medication order.