Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 852592	(X3) Date Survey Completed 07/16/2025
Name of Provider or Supplier Kidneyspa East Atlanta Dialysis, Llc	Street Address, City, State 2375 Metropolitan Pkwy Sw, Atlanta, 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 facility records, patient and staff interviews, and a review of the facility's Policies and Procedures (P&P), it was determined that the Medical Director failed to ensure that all Direct Patient Care (DPC) staff (Registered Nurses - RNs, and Patient Care Technicians - PCTs), consistently adhered to prescribed hemodialysis orders relative to ultrafiltration rate (UFR-the speed at which excess fluid is removed from the body during hemodialysis treatment which is at or below 13 mL/kg/hr [milliLiter per kilogram per hour] - the maximum safe rate for fluid removal during treatment), of three of three patients (P) P#1, P#2, and P#3, sampled. Excessive ultrafiltration (UF) during hemodialysis can lead to serious complications, including intradialytic hypotension (low blood pressure during treatment), muscle cramping, dizziness, and long-term cardiovascular risks, potentially leading to increased morbidity and mortality. In addition, one of the three patients (P#1) sampled, did not receive the correct dialysate (dialysis fluid - specially prepared sterile solution of electrolytes, glucose, bicarbonate or lactate) and did not have hourly blood glucose checks performed as ordered. This deficient practice had the potential to negatively impact the health and safety of P#1, P#2, and P#3. The facility census was 61. Findings include: During a review of facility records, the following was revealed: P#1: - P#1 had a hemodialysis order to run on a 1.0 potassium bath (potassium component of the dialysate) for the first hour of treatment, followed by a 2.0 potassium bath for the remaining 2 hours and 45 minutes of hemodialysis treatment. P#1 also had an active order for hourly blood glucose monitoring during dialysis. A review of P#1's hemodialysis orders dated July 9, 2025, confirmed this prescription, along with the blood sugar monitoring instructions. A review of P#1's hemodialysis treatment flowsheets revealed that on 6/17/25, 6/19/25, and 7/12/25, P#1 was dialyzed using a 2.0 potassium / 2.5 calcium bath or dialysate for the entire treatment, which was not in accordance with the prescribed staggered potassium bath order. Additionally, there was no documented evidence that hourly blood glucose checks were performed on any of the above mentioned dates as ordered. - A review of P#1's recent potassium lab values showed that P#1 has had consistently elevated potassium levels: 7.2 mEq/L on 6/19/25, 6.9 mEq/L on 6/26/25, and 6.0 mEq/L on 7/3/25 (normal range: 3.5-5.5 mEq/L). - A review of P#1's weight history from 6/24/25 to 7/15/25 showed an average weight of 79.23 kg (kilogram), while P#1's estimated dry weight (EDW) remained 73.0 kg. - On 6/19/25, P#1 weighed 81.5 kg, with a pre-BP of 201/116 mmHg and post-BP of 198/91 mmHg. The UFR was 16.34, no clonidine (treatment for high BP, as needed) was administered, and there was no documentation of physician notification. - On 7/12/25, P#1's weight was 84.6 kg, with a pre-BP of 216/107 mmHg and a post-BP of 188/92 mmHg. Clonidine 0.1 mg was given at 9:45 a.m., and the UFR was 14.28. No documentation was found indicating physician notification of elevated BP readings or of UFR (greater than) >13 mL/kg/hr. - On 7/17/25, P#1's pre-dialysis weight was 81 kg, with a blood pressure (BP) reading of 224/113 mmHg (millimeters of mercury) pre-hemodialysis treatment and 221/109 mmHg post-hemodialysis treatment. - The UFR was 19.81, and 0.1 mg of clonidine was given at 10:30 a.m. There was no documentation that the physician was notified of the elevated BP reading or high UFR. - On July 3, 2025, the Nurse Practitioner (NP- who made rounds in addition to the Nephrologist's monthly rounds) documented that the patient was stable and without complaints. In addition, the NP documented that the prescription, vital signs, and labs were reviewed, and the plan was to continue hemodialysis as instructed. The NP did not address the high BP readings, excessive weight gain, high UFR and high potassium levels. During an interview on 7/17/25 at 4:00 p.m., P#1 stated: The doctor walks in, gives us cookies, and walks out. I know some of this is my fault, but I only started feeling bad and cramping when they tried to pull all the fluid off of me. I can't remember the last time someone adjusted my dry weight, and the doctor seemed too overwhelmed with patients to really pay attention. I have not received a nutritional report from the dietitian in over three months, and I had to stop the dietitian (also the Facility Administrator) just to ask a question. I think the staff are doing the best they can with what they have, but they need better training. P#2: - On 7/1/25, P#2's pre-treatment weight was 89.4 kg. P#2's EDW was 86.6 kg. The ordered fluid removal for the treatment was 2.9 kg, with a scheduled dialysis session of 3 hours and 30 minutes. However, documentation showed that the treatment started at 8:53 a.m. and ended at 11:03 a.m., lasting only 2.0 hours and 4 minutes. Despite the shortened treatment time, the UFR for this session was 23.04 mL/kg/hr (well above the recommended maximum of 13 mL/kg/hr). - A review of P#2's weight history from 6/5/25 to 7/15/25 showed an average weight of 88.3 kg. During hemodialysis treatment, P#2's BP readings ranged from 127/77 to 159/92, and the pulse ranged from 115 to 105 beats per minute. - 0n 7/5/25 the NP documented: "Patient was stable and without complaints. Perscription, vitals and labs have been reviewed. Continue HD as instructed". - During an interview on 7/16/25 at 11:15 a.m., P#2 stated: I kept telling the nurse that I was being pulled too hard. I was cramping, and the staff did nothing. I made them take me off the dialysis machine (on 7/1/25). The doctor only cared about cookies. I was so sick when I got home that day-my heart was racing, and I told them that. They treat us like cattle-get us in and get us out. I can't remember the last time anyone sat down and talked to me about adjusting my dry weight or helping me understand the medications I'm taking. P#3: - On 6/17/25, P#3's pre-treatment weight was 81 kg. P#3's EDW was 78 kg. P#3's prescribed treatment time was 3 hours and 30 minutes, but the patient only dialyzed for 2 hours and 54 minutes. UFR was 14.18 mL/kg/hr, exceeding the recommended safe limit of 13 mL/kg/hr. P#3's post dialysis weight was 77.8 kg, which was slightly below the prescribed EDW. - On 6/19/25, P#3's UFR was 17 mL/kg/hr. Pre-hemodialysis treatment BP was 127/78 mmHg and post-treatment BP was elevated at 162/112 mmHg, and post-treatment weight was 78 kg. During an interview on 7/16/25 at 12:00 p.m., P#3 stated: "On 6/19/25, I made them take me off the dialysis machine because I started feeling bad, and I knew my blood pressure would go up These dumb people didn't know what to do. I was angry because I asked them to give me some fluid, and they just turned my UF off. On 6/16/25, they pulled me below my dry weight, and I was tired and sick all day. The doctor is a joke-if you don't take his cookies, he won't talk to you . He'll walk past you like he didn't even see you. Some of the techs (patient care technicians) are really good. They're the ones who actually go get what I need from the doctors and nurses". - On 7/3/25 the Nurse Practitiner documented: Patient is stable and without complaints. Prescription, Vitals, and labs have been reviewed. Continue HD as instructed. (The same exact wording as above for the other two patients). During an interview with the Facility Administrator on 7/16/25 at 9:44a.m., the Facility Administrator stated that she was a Deititian by profession, and any clinical issues must be addressed by Registered Nurse (RN AA) because she was adopted by the Governing Body on 4/25/25 as the Clinicical Coordinator and Nurse in Charge of Nursing Services. During an interview on 7/16/25 at 1:00 p.m., RN AA, (who was listed in the Governing Body meeting minutes as the nurse in charge of nursing services), stated: I work part-time. I am not the nurse in charge of nursing services. No one asked me, and I did not accept that responsibility. A review of policy #02.103, dated 10/20/20, titled, "Nursing Assessment Before, During, and after Hemodialysis", stated: Before beginning hemodialysis each patient should be evaluated by a registered nurse for the following data and sign and symptoms which, if abnormal, SHOULD be document and may need to be REPORTED to the patient's nephrologist as needed. A review of policy # 02.419, dated 5/22/22, titled " Utrafiltration (UF) Rate Verification" states: -The UF rate entered into the dialysis machine (in ml/hr) must be manually verified by the clinical team prior to the start of each treatment. -UF rate and removal accuracy must also be re-verified during every routine blood pressure and machine safety check throughout the treatment session.