cms 2567 05-13-08

A. BUILDING(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X3) DATE SURVEYCOMPLETED

PRINTED: 06/05/2008FORM APPROVED

(X2) MULTIPLE CONSTRUCTIONB. WING _____________________________

______________________

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391

452639

05/13/2008

C

LUFKIN, TX 75904

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

LUFKIN DIALYSIS CENTER

700 S JOHN REDDITT

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

(X5)COMPLETIONDATE

IDPREFIXTAG(X4) IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)

V 000INITIAL COMMENTSV 000An entrance conference was conducted at thisend stage renal disease (ESRD) facility on April28, 2008, 2008 at 12:50 p.m. with the facility'sRegional Director and the Medical Director. Thepurpose of the survey and the survey processwas explained. An opportunity was provided for questions and answers.An onsite unannounced complaint investigationfor TX#00093935, TX#00094614 andTX00093224 was conducted per Section 2278,2700-2764, and Appendix H of the StateOperations Manual (CMS Pub. 100-7) todetermine the ESRD facility's compliance with therequirements at 42 CFR 405, SubpartU-Conditions for Coverage of suppliers of ESRDservices using the applicable survey report form.Complaint #00094614 and TX#00093935 werefound to be substantiated with related deficienciescited and an immediate jeopardy was identified.The facility voluntarily closed on a temporarybasis effective the last shift on 4/28/08, removingthe threat to the patient safety. The facilitysuccessfully transferred all patients on 4/29/08.This finding was considered an immediate jeopardy on 4/28/08 and the immediate jeopardywas removed with the voluntary closure of thefacility on 4/28/08 after the last patient shift.Recommend 90 day termination. The followingConditions for Coverage were not met. GoverningBody, (405.2136); Medical Records(405.2139);Physician Director of an ESRD Facility(405.2161); and Staff of a renal dialysis facility(405.2162).Complaint # TX 00093224 was found to be

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURETITLE

(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined thatother safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 daysfollowing the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continuedprogram participation.

FORM CMS-2567(02-99) Previous Versions ObsoleteINPH11

Event ID:

Facility ID:820110

If continuation sheet Page 1 of 41

A. BUILDING(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X3) DATE SURVEYCOMPLETED

PRINTED: 06/05/2008FORM APPROVED

(X2) MULTIPLE CONSTRUCTIONB. WING _____________________________

______________________

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391

452639

05/13/2008

C

LUFKIN, TX 75904

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

LUFKIN DIALYSIS CENTER

700 S JOHN REDDITT

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

(X5)COMPLETIONDATE

IDPREFIXTAG(X4) IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)

V 000Continued From page 1V 000unsubstantiated.Note: The Statement of Deficiencies is an official,legal document. All information must remainunchanged except for entering the plan of correction, correction dates, and the signaturespace. If information is inadvertently changed bythe provider, you should notify the State SurveyAgency. If the State Agency notices anydiscrepancy in the information related to scopeand severity assigned or the deficiency citation(s),the State Agency will report this occurrence to theDepartment. The Department will make a referralof possible fraud to the Office of the Inspector General (OIG).Definitions and Abbreviations:Access- An access is a route into thebloodstream that allows enough blood flow for hemodialysis. For permanent access, a surgeonconnects a vein to an artery. For temporaryaccess, a catheter may be placed in a largecentral vein, such as the internal jugular vein inthe neck.Administer (ADM) to give to a patientAdverse Occurrence Report: (AOR): reportsrequired to be completed by facility policy for certain events including emergency transfersfrom the facility to the hospital.As Needed (PRN) - to administer as needed, asdirected by the physician.Blood Flow Rate (BFR)- The blood pump pullsand returns the blood from the patient via thearterial and venous needles. The pump speed

FORM CMS-2567(02-99) Previous Versions ObsoleteINPH11

Event ID:

Facility ID:820110

If continuation sheet Page 2 of 41

A. BUILDING(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X3) DATE SURVEYCOMPLETED

PRINTED: 06/05/2008FORM APPROVED

(X2) MULTIPLE CONSTRUCTIONB. WING _____________________________

______________________

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391

452639

05/13/2008

C

LUFKIN, TX 75904

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

LUFKIN DIALYSIS CENTER

700 S JOHN REDDITT

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

(X5)COMPLETIONDATE

IDPREFIXTAG(X4) IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)

V 000Continued From page 2V 000and the resulting blood flow rate is adjustablefrom zero to about 600cc/min. The physicianprescribes the BFR for each patient.Blood Pressure (B/P)- According to theContemporary Nephrology Nursing: Principlesand Practice, Second Edition, Copyright 2006,page 257 states the following on blood pressuremanagement: " The National Kidney FoundationKidney Disease Outcomes Quality InitiativeClinical Practice Guidelines (NKF-K/DOQI) onBlood Pressure Management and use of Antihypertensive Agents in Chronic KidneyDisease (2004) state the goals of antihypertensive therapy in CKD (Chronic KidneyDisease) are to lower BP, slow the progression of kidney disease, and reduce the risk of CVD(cardiovascular disease)....Patients with CKDshould have a BP <(less than) 130/80 mmHg."The Core Curriculum for the Dialysis Technician,Third Edition, page 327, states "Hypotension islow blood pressure. In dialysis patients,hypotension occurs most often when too muchfluid is removed during dialysis, or when patientstake too many blood pressure drugs. Symptomsinclude severe muscle cramps, headache; feelingwarm, restless, dizzy, faint, or nauseated; or having visual disturbances. The Trendelenburgposition (raising the feet higher than the heart)and giving fluids(i.e. normal saline) help returnblood pressure to normal."c/o-complains of Clonidine- an oral medication used to treatelevated blood pressure during dialysis.CVC- Central Venous Catheter, used as vascular access for dialysis