| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852539 | (X3) Date Survey Completed 07/26/2023 |
| Name of Provider or Supplier Eatonton Kidney Center | Street Address, City, State 103 N Washington Avenue, Eatonton, 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) |
| E0000 | A Recertification Survey was conducted at Eatonton Kidney Center from July 24, 2023 through July 26, 2023. The survey revealed that the facility was in compliance with 42 CFR Part 494.62, Conditions for Coverage for Emergency Preparedness Plan for End Stage Renal Disease facilities. No deficiencies were cited. |
| V0000 | A Recertification Survey [CORE] was conducted at Eatonton Kidney Center from July 24, 2023 through July 26, 2023. The survey revealed that the facility was in substantial compliance with 42 CFR Part 494 Conditions for Coverage for End Stage Renal Disease Facilities. However, the following deficiencies resulted from the facility's noncompliance related to the survey: |
| V0117 | IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This STANDARD is not met as evidenced by: Based on observation, a review of the Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN AA) observed, utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of one of one patient (P#4), who was undergoing hemodialysis (HD) treatment with central venous catheter (CVC - dialysis access) at the time of this observation. Findings include: During observation in the patient treatment room on 7/26/23 between 9:30 a.m. and 10:00 a.m., the following was observed: - RN AA was observed during initiation of HD treatment on P#4 with a CVC at Station 1. She placed the used syringes, gauzes and alcohol wipes (contaminated) on the blue liner that stored clean/sterile supplies such as Heparin-lock syringes, clean gauze pads, and clean alcohol pads. According to the CDC, measures to prevent contamination of clean or sterile items include not storing potentially contaminated (used) supplies in areas where clean (unused) supplies are handled. During an interview with the Facility Administrator on 7/26/23 at approximately 10:30 a.m., she stated that the nurse should have separated the clean supplies from the dirty/contaminated supplies to prevent cross contamination. |
| V0401 | PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to ensure that there was a safe environment for all 10 in-center hemodialysis patients as evidenced by eight of 10 dialysis chairs that were not capable of placing a patient on Trendelenburg position (flat on the back with feet higher than the head by 15-30 degrees - a position that helps improve a patient's extremely low blood pressure). This environmental concern was observed in one of one in-center hemodialysis patient treatment room. Findings include: During a tour of the facility on 7/24/23 between 10:30 a.m. and 11:30 a.m., the following was observed: In the Patient Treatment Room: - Eight of 10 patient hemodialysis chairs were too low for the staff and did not provide the staff the ability to place chairs in a trendelenburg position when necessary, to improve the patient's blood pressure when low. During an interview on 7/11/23 at approximately 11:30 a.m., when this surveyor asked if the dialysis chairs could recline in trendelenburg position, the Charge Nurse answered no. She also stated that the staff will have to push the head of the chairs back as far as they can. |
| V0403 | PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations. This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to have a system in place to ensure that 10 of 10 hemodialysis machines (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) were maintained and free of unsanitary substances. Findings were: During a tour of the facility on July 24, 2023 between 11:00 a.m. - 12:00 p.m., the following was observed: - Machines #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 had peeling paint and rust colored stains covering the lower surfaces of the machines. During an interview with the Administrative Assistant on 7/24/23 at approximately 2:00 p.m., she stated that the machines needed to be painted. |
| V0633 | QAPI-INDICATOR-VASCULAR ACCESS CFR(s): 494.110(a)(2)(v) The program must include, but not be limited to, the following: (v) Vascular access. This STANDARD is not met as evidenced by: Based on a review of the 2022 Dialysis Facility Report (A report prepared by the Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients), facility records review, and staff interview, it was determined that the facility failed to track, measure, and analyze vascular access (access used for dialysis) for six of six months (January 2023 to June 2023) of Quality Improvement Program/Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed, to decrease the use of catheters. This deficient practice increased the risk for incidence of infection related to catheter use for 26% of patients, who used catheter as their only vascular access for dialysis. The facility census was 10. Findings were: A review of the 2022 Dialysis Facility Report revealed that the US average for Central Venous Catheters (CVC) only, that had been in place for 90 days or more, should not exceed 10.3%. - The facility had 26% of patients who had CVC only, as their dialysis access. A review of the QAPI meeting minutes from January 2023 - June 2023 revealed no documentary evidence that the QAPI team conducted a comprehensive review of the patients with vascular access to decrease the use of catheters. - The QAPI meeting minutes revealed a lack of documented evidence that aggregate data had appropriate action plans, root cause analysis, and follow-up evaluations to ensure improvement and decrease the use of catheters. During an interview with the Facility Administrator on 7/26/23 at approximately 11:00 a.m., she stated that the information was reviewed. However, root causes, action plans, and evaluations should have been completed for the reduction of catheters. |