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 852555 (X3) Date Survey Completed 03/21/2019
Name of Provider or Supplier Quitman Dialysis Street Address, City, State 101 E. Davis Street, Quitman, 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 observations, a review of the facility's policy and procedure ( P&P) and staff interviews, it was determined that the Medical Director (MD) failed to ensure that two of two licensed staff, (Registered Nurse - RN BB and Licensed Practical Nurse - LPN AA) observed, adhered to the facility's policy and procedure relative to extracorporeal circuit preparation (all the apparatus connected to the dialysis machine used to perform dialysis), prior to the initiation of dialysis, using the Fresenius 2008 K and 2008 T dialysis machines. This deficient practice could negatively affect all 39 hemodialysis (HD) patients who dialyze at this facility. Findings include: During observations in the patients' treatment room on 3/20/19 between 9:50 a.m. and 12:00 p.m., the following was observed: - LPN AA and RN BB were preparing and initiating hemodialysis treatments on patients at Stations (S), (S2 & S3; and S9 & S13), respectively. Both employees did not flush or prime the arterial and venous blood lines before initiating patient treatment. A review of the facility's policy and procedure #1 -03 -08F, titled, "Treatment Initiation Utilizing Fresenius 2008 Series Dialysis Delivery Systems with All Single Use Dialyze Types and Streamline or Combiset or Nipro Bloodlines", page #3, stated: Step #9 - Clamp arterial and venous bloodlines, leaving the recirculation connector on the end of the venous blood line. Open the clamp on the arterial line and flush for 25 seconds (approximately 50 ml of saline)... Step #10 - Hold end of venous line over priming container... Step #11 - Unclamp venous line, turn blood pump on and flush 250 ml of normal saline (NS) into priming container... During a telephonic interview with the Medical Director on 3/20/19 at approximately 2:00 p.m., and during a discussion with the Facility Administrator on 3/21/19 at 2:35 p.m., both stated that the staff should follow the facility's policy and procedure regarding flushing of lines or refreshing lines before initiating hemodialysis treatment.