Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 852569	(X3) Date Survey Completed 07/23/2025
Name of Provider or Supplier Dialysis Center Of Athens	Street Address, City, State 210 Hawthorne Park, Athens, 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:
1. Based on observation, staff interview, medical record review, and a review of the facility's Policies and Procedures (P&P), it was determined that the Medical Director failed to ensure that one of one Registered Nurse (RN AA) observed, adhered to the facility's established P&P relative to pre-dialysis assessment of two of two patients (P) (P#2 and P#3), observed. Failure to perform a thorough nursing pre-dialysis assessment such as assessing both patients' (P#2's and P#3's) lung sounds by auscultation (method used to listen to the sounds of the lungs to detect abnormal sounds such as rales, rhonchi, wheezes, or diminished lung sounds using a stethoscope), to help determine P#2's and P#3's fluid overload status, (along with their pre-dialysis weight and Estimated Dry Weight [EDW] or target weight), had the potential to incorrectly determine or miscalculate the amount of fluid to be removed during hemodialysis - either removing too much or too little. This deficient practice had the potential to negatively affect the health and safety of P#2 and P#3. The facility census was 10. Findings include: During observation in the Patient Treatment Room on 7/23/25 between 5:00 a.m. and 6:40 a.m., the following was revealed: - P#2 entered the Patient Treatment Room at 5:03 a.m., and hemodialysis treatment was initiated at 5:10 a.m., by Patient Care Technician (PCT) AA, at Station (S) 7. At 5:11 a.m., RN AA was observed while she performed patient assessment. RN AA asked P#2 how she felt, but did not listen to P#2's lung sounds per facility P&P. - P#3 entered the Patient Treatment Room at 5:07 a.m., and hemodialysis treatment was initiated at 5:15 a.m., by PCT CC at S6. Again, RN AA performed patient assessment at 5:16 a.m. by asking P#3 how he felt, but did not listen to P#3's lung sounds to assess P#3's pulmonary status per facility P&P. - P#2's and P#3's heart sounds were not assessed for irregular rate and rhythm and murmur either. During an interview on 7/23/25 at 6:29 a.m., RN AA acknowledged the above observation and stated that she relied on her findings from the verbal assessment to determine whether the patient required further evaluation. A review of P#2's and P#3's dialysis treatment records dated 7/23/25, showed that P#2's and P#3's pre-dialysis assessments were both marked completed and finalized at 5:00 a.m, (which was before P#2 and P#3 even entered the Patient Treatment Room), by RN AA. Additionally, RN AA documented "no abnormal findings", prior to RN AA's actual (verbal) assessments of both patients. - A review of facility Policy: (no number), titled, "Monitoring and Care of the Patient on Hemodialysis", with no effective or revision date, stated: 1. Each patient will have a pre-dialysis assessment to include the following: a. Physical assessment by the RN or LPN (Licensed Practical Nurse) h. Pulmonary- rales, rhonchi, wheezes, diminished sounds. 2. Based on observation, a review of medical records and a review of facility Policies and Procedures (P & P), it was determined that the Medical Director (MD) failed to ensure that five of five patients (P) (P#1, P#2, P#3, P#4, and P#5) sampled, received medical care appropriate to their dialysis needs as evidenced by a lack of a prescription for their dialysis composition of bicarbonate value, for the Direct Patient Care (DPC) Staff (nurses and patient care technicians) to follow during each patient's hemodialysis treatments. In hemodialysis, bicarbonate is crucial for correcting metabolic acidosis (build up of acid in the blood due to low bicarbonate levels) or metabolic alkalosis (blood is too alkaline due to high levels of bicarbonate), by acting as a buffer to help maintain a healthy acid-base balance in the blood, which is often disrupted in chronic kidney disease. Metabolic acidosis can cause muscle wasting and bone loss, while metabolic alkalosis can increase the risk of hypokalemia (low potassium), hypocalcemia (low calcium), and hemodynamic instability. This deficient practice had the potential risk to negatively affect the health and safety of P#1, P#2, P#3, P#4, and P#5. The facility census was 10 in-center hemodialysis patients. Findings include: During observation in the Patient Treatment Room on 7/23/25 between 5:00 a.m. and 6:40 a.m., the following was revealed: - P#1's hemodialysis machine showed that the bicarbonate was set at 36 milliequivalents per liter (mEq/L). - P#2's hemodialysis machine showed that the bicarbonate was set at 37 mEq/L. - P#3's hemodialysis machine showed that the bicarbonate was set at 38 mEq/L. - P#4's hemodialysis machine showed that the bicarbonate was set at 38 mEq/L. - P#5's hemodialysis machine showed that the bicarbonate was set at 32 mEq/L. P#1's, P#2's, P#3's, P#4's and P#5's dialysis prescription lacked an order for dialysis composition of bicarbonate value for the DPC staff to follow, when setting up each patient's hemodialysis machine for treatment. - A review of P#1's, P#2's, P#3's, P#4's and P#5's medical records showed the following CO2 (carbon dioxide - blood test to measure bicarbonate levels), results: NOTE: The laboratory's Reference Range for CO2 was 22.0 - 29.0 mEq/L P#1: - On 3/28/25 - CO2 - 25.0 mEq/L - On 4/16/25 - CO2 - 18.0 mEq/L (L - low) - On 5/5/25 - CO2 - 15.0 mEq/L (L) - On 6/6/25 - CO2 - 17.0 mEq/L (L) - On 7/9/25 - CO2 - 15.0 mEq/L (L) P#2: - On 4/4/25 - CO2 - 24.0 mEq/L - On 5/5/25 - CO2 - 19.0 mEq/L (L) - On 5/9/25 - CO2 - 18.0 mEq/L (L) - On 6/4/25 - CO2 - 1223.0 mEq/L (H - high). There was no documentary evidence of a repeat CO2 blood test to verify validity of very high abnormal result or follow up. - No current CO2 results at the time of this review (7/23/25). P#3: - On 5/7/25 - CO2 - 18.0 mEq/L (L) - On 6/6/25 - CO2 - 17.0 mEq/L (L) - On 7/9/25 - CO2 - 16.0 mEq/L (L) P#4 and P#5 were admitted to this facility on 6/30/25, and their CO2 results were not available at the time of the survey. Note: The ideal range for pre-dialysis bicarbonate levels is often considered to be between 20-22 mEq/L, with a target post-dialysis level around 24 mEq/L. - A review of facility Policy: (no number), titled, "Dialysis Prescription", (no effective/ revision dates), stated: 1. Prescription Content The dialysis prescription should include (as applicable): " Dialysate composition (e.g., sodium, calcium, potassium, bicarb) 2. Order Validity and Communication " Prescriptions must be documented and reviewed regularly by the nephrologist. - During a telephonic interview on 7/23/25 at 12:31 p.m., the Medical Director stated that he did not realize the five sampled patients were missing a prescribed bicarbonate order.