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 05/18/2021
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)
V0504 PA-ASSESS B/P, FLUID MANAGEMENT NEEDS
CFR(s): 494.80(a)(2)

The patient's comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs.


This STANDARD is not met as evidenced by:
Based on interview, record review, and policy review, the facility failed to ensure one of eight patients (Patient (P) 4), was monitored every 30 minutes as required. The failure to monitor patients every 30 minutes had the potential to not capture an adverse event in a timely manner and could affect 85 incenter patient. Findings include: Review of the medical record for P4 revealed the facility admitted the patient on 01/28/19 with diagnosis including end stage renal disease. Review of six dialysis flow record for P4 from 04/30/21- 05/14/21 revealed on 05/03/21 the patients treatment was initiated at 7:08 AM. The patients' blood pressure was not checked again until 8:32 AM. One hour and 24 minutes later. On 05/07/21 The patients blood pressure was checked at 8:00 am and not again until 9:30 AM. One hour and thirty minutes later. The blood pressure was checked at 10:00 AM and not again until 11:00 AM. One hours later. During an interview on 05/18/21 at 1:20 AM, the Clinic Coordinator Registered Nurse stated patients should be always monitored and documented every 30 minutes to ensure patients are safe. Review of the facility's policy titled, "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment," revised April 2021, revealed the following, "Vital Signs and treatment monitoring: For non-nocturnal treatments is completed at least every 30 minutes. . ."