| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852604 | (X3) Date Survey Completed 02/17/2025 |
| Name of Provider or Supplier Bellemeade Dialysis | Street Address, City, State 3240 S Cobb Drive Se Suite 800, Smyrna, 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) |
| V0684 | PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This STANDARD is not met as evidenced by: Based on a review of records, staff interview, and a review of facility Policy and Procedures (P&P) it was determined that the facility failed to ensure that this facility had a full-time registered nurse (RN) who was responsible for nursing services, to provide oversight and direction to five of five direct patient care staff (one registered nurse [RN AA] and four Patient Care Technicians [PCT AA, PCT BB, PCT CC and PCT DD], who provided nursing care and dialysis care to 36 in-center hemodialysis patients who were receiving dialysis at this facility. Findings include: - A review of facility's Governing Body Meeting minutes dated September 2024, revealed that the facility appointed a Nurse Manager who was a full-time employee at the facility. However, there was no documentary evidence that the facility discussed or appointed a new Nurse Manger after the former nurse manager resigned in January 2025. - During an interview on 2/17/25 at 5:00 p.m., the Facility Administrator stated that the facility currently has not filled the position of a nurse manager and planned on discussing who would be placed into the nurse manger position on 2/26/25, in the facility's upcoming Governing Body meeting. The FA confirmed that the facility has not had a NM within the last few weeks. A review of the facility's Policy: 8-02-01 titled, "Teammate Qualifications Licensure and Adequate Teammate Staffing" with latest revision date of October 2017 showed: 10. The facility will have a Registered Nurse identified who is responsible for nursing services in the facility who will: Be a full-time employee of the facility and Have at least 12 months of experience in clinical nursing and an additional six months of experience in providing nursing care to patients on maintenance dialysis. |