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 852542 (X3) Date Survey Completed 08/08/2018
Name of Provider or Supplier Red Hills Dialysis Street Address, City, State 201 Old Albany Road, Thomasville, 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)
V0715 MD RESP-ENSURE ALL ADHERE TO P&P
CFR(s): 494.150(c)(2)(i)

The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;


This STANDARD is not met as evidenced by:
Based on a review of patients' records, facility records, policies and procedures, and interviews with facility staff and patients, it was determined that the medical director failed to ensure that one (1) of (1) one employee (staff #4), adhered to the facility policies and procedures and standing orders for one (1) of one (1) sampled patient (Patient #1 ). Findings were: A review of patient and facility records, revealed the following: A review of the facility adverse occurrence report for the incident that occurred on 7/28/18 revealed the following: - Patient #1 complained for weakness, back pain and was lethargic. He/She ws started on dialysis at 11: 16 a.m.. His/Her heart rate increased forty five minutes into the treatment. Heart rate remained elevated while on the dialysis machine. The patient became unresponsive and CPR (Cardio- pulmonary Resuscitation) was initiated at 1:25 p.m. - A review of the treatment sheet for patient #1 for 7/28/18 revealed the following: The pretreatment assessment at 11:16 a.m., revealed that the patient was lethargic and complained for back pain. The patient was asked by the charge nurse who did the assessment, if he/she felt as though he/she needed to be evaluated at the emergency room (ER). Patient refused to go to the ER, stated that was his/her baseline condition. The flow sheet revealed that the patient was placed on dialysis at 11:16 a.m. and at 12:02 p.m., the patient's pulse rate doubled to 124 beats per minute (BPM). The pulse rate remained elevated for 45 minutes, fluctuating between 120 and 136 beats a minute. At 12:48 p.m., the treatment was terminated, pulse at 115 BPM and the patient was given 800 cc of normal saline from 12:48 to 12:50 p.m. The pulse rate increased from 133 BPM after treatment was discontinued to 171 BPM at 1:19 p.m. The patient became unresponsive at 1:24 p.m., the pulse rate dropped to 54 BPM at 1:25 p.m., at which time there was no pulse and CPR was initiated. A blood pressure and heart rate of 107/81 and 142, were recorded while CPR was in progress. Emergency Medical Services EMS arrived at 1:40 p.m. Patient did not have a recorded heart rate. - A review of the Policy #1-03-08, "Pre-Intra-Post treatment Data Collection, Monitoring and Nursing Assessment" revision date 4/17, revealed that the nurse was responsible for monitoring the patient during dialysis and should use his/her clinical judgement when a patient's condition changes during dialysis. If a patient's vital signs were out of range it should be addressed by staff and the physician should be notified of any concerns that may preclude the initiation of dialysis. - A review of the facility's Procedure :1 -10-06 A ; Title: Resuscitation in the Event of a Cardio/Pulmonary Arrest, #5 stated to notify nephrologist and #9 administer oxygen as ordered. An interview with staff #1 the clinic manager on 8/7/18 at 1:30 p.m. revealed that the charge nurse was responsible for that section of patients in POD 6 and POD 7. He/She stated that although there were two staff members that called in, that there was replacement staff. Further stated that the patient in question complained for weakness, the pulse increased, the patient was given saline and taken off the dialysis machine. He/She became unresponsive and was given CPR until the EMS arrived. When asked if the patient's doctor was called or if the patient was given oxygen, staff #1 replied, "no". - Interviews with staff #5 (the patient's PCT- patient care technician at the time of the incident) on 8/7/18 at 2:20 p.m. revealed that 30 minutes into dialysis treatment the pulse was rapidly increasing and that he/she notified the charge nurse (staff #4). . The patient informed staff #5 that he/she had dialysis five times already for the week, during hospital stay and that he/she felt very weak. Staff #5 stated that he/she turned down the blood flow rate from 450 ml/hr to 200 ml/hr and discontinued the use of the ultrafiltration (fluid removal mechanism of the dialysis machine). - An interview with (staff #4) charge nurse on 8/7/18 at 2:15 p.m., revealed that patient #1 complained for weakness and back pain, but refused to go to the emergency room. He/She stated that the patient pulse rate continued to increase during treatment, the patient was taken off the machine and became unresponsive. CPR was initiated and the EMS was called. When asked if the doctor was called, staff #4 replied, "no". - Interviews with staff #3 and #6 on 8/7/18, between 2:00 p.m. and 3:00 p.m., revealed that they were not sure what happened as they were giving care in a different Pods. They came to help the other staff when there was a call for the crash cart and the patient was placed on the floor to begin CPR until the EMS came. - There was no documented evidence that the above policies were followed by the staff on 7/28/18, as related to the care given to Patient #1. Staff #4 did not follow the facility's policy and procedures for monitoring, nursing assessment for pre intra and post dialysis as well as emergencies. The facility administrator, group facility administrator, and educator were informed of the above findings. The facility administrator stated on 8/7/18 at 5:00 p.m., that the above identified facility's policies were not followed by staff #4.