The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to provide services necessary to two (2) of two (2) dialysis patients in the survey sample. (Patient #4 and Patient #13).

The findings included:

The clinical record for patient #4 contained documentation that the patient was admitted on [DATE]. Prior to the rehabilitation admission, Patient #4 received dialysis on 6/20/2021 as a hospital inpatient.

A physician order was entered on 6/22/2021 at 1:35 p.m. for hemodialysis.

A nephrology progress note on 6/23/2021 documented that the "pt [patient] didn't get hd [hemodialysis] as ordered yesterday". According to the note, Patient #4 denied having shortness of breath, chest pain, no worsening edema, and was making "some" urine. The plan documented by the physician said "spoke with [name of dialysis provider]" and the hemodialysis "must be done today" and "order is in...again".

A physician order was entered on 6/23/2021 at 9:54 a.m. for hemodialysis.

A nephrology progress note on 6/24/2021 documented that "hd attempted but failed b/c [because] cath [catheter] not working" and that staff "didn't come back yet". The patient denied shortness of breath, chest pain, no worsening edema, and was making "some" urine.

A nephrology progress note on 6/25/2021 documented that Patient #4 "still had no" hemodialysis. The note documented that the patient "has sob [shortness of breath] overnight req [required] oxygen". The physician discussed with nursing and documented that the patient had no worsening edema and was making "some" urine. The physician's plan stated "no hd [hemodialysis] again, need to do it today to see if cath [catheter] working and if not fix it asap [as soon as possible], had oxygen req [required] overnight which is new, rehab [rehabilitiation] nursing told me that HWS said they would be at bedside this am, I have asked admin [administration] to call me asap".

Based on the clinical record review for Patient #4, hemodialysis was performed on 6/20/2021 and not again until 6/25/2021.

The clinical record for Patient #13 was reviewed and contained documentation that the patient receives outpatient dialysis Monday, Wednesday, and Friday. An order was entered for hemodialysis on 8/28/2021. A nephrology progress note on 8/29/2021 documented that Patient #13 "didn ' t get uf [ultrafiltration] last night hd [hemodialysis] done last night as ordered acute need to run ...will run in am unless clinically [Patient #13] changes ...". A nursing note on 8/29/2021 documented that Patient #13 signed consent for dialysis, but "no dialysis was done". Physician order was entered but "not stat [immediately], no dialysis was done". An addendum to the nursing note documented a dialysis nurse contacted at 9:23 a.m. to ask about seeing patient for dialysis; per dialysis nurse, "cannot see patient as [nurse] is the only nurse and has multiple patients for dialysis today". The nursing supervisor was notified. A dialysis nurse called back and informed staff that a nurse "will be by later to run patient". The clinical record for Patient #13 documented that hemodialysis treatment was administered on 8/30/2021.

An interview was conducted on 9/1/2021 with SM #9. SM #9 confirmed the findings in the medical record and acknowledged patient #4's missed dialysis treatments.

The concern was discussed with SM #2 and SM #9 on 9/1/2021 and again at the exit conference on 9/2/2021.

A facility policy titled, Dialysis Scope of Service, was reviewed and read in part: "...The scope of services is defined as services provided for patients with chronic and acute renal failure within the hospital setting...Hemodialysis is a contracted service by [name of contracted group]...The Hemodialysis Unit is operational six days a week, Monday through Saturday 7:00 a.m. - 5:30 p.m. A Hemodialysis RN is on-call for emergency dialysis when the department is closed...The Divisional Director and market Manager for the contracted Hemodialysis service, has 24 hour responsibility for the overall leadership and direction of the unit and will partner with the facility dialysis liaison and Medical Director or Chief Medical Officer."