| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852539 | (X3) Date Survey Completed 08/02/2024 |
| 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 | An unannounced Recertification survey was conducted at Eatonton Kidney Center from July 31, 2024 through August 2, 2024. 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 | {CORE} An unannounced Recertification survey was conducted at Eatonton Kidney Center from July 31, 2024 through August 2, 2024. 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 standard level deficiencies were cited which resulted from the facility's noncompliance related to the survey: |
| V0113 | IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This STANDARD is not met as evidenced by: Based on observation, a review of Centers for Disease Control and Prevention (CDC) Recommendations, and staff interview, it was determined that the Infection Control Committee failed to ensure that three of three patients (at Station (S) #3, S4, and S7) observed, who held pressure to their access sites for hemostasis (stopping of the flow of blood) after dialysis, performed hand hygiene (wash hands with soap and water or use an alcohol based hand sanitizer) after glove removal and prior to leaving the facility. This deficient practice had the potential for cross contamination and increased risk of infection. The facility census was 10. Findings were: During observation in the patient treatment area on 7/31/24 between 10:41 a.m. and 11:58 a.m., the following was observed: - Patients who were seated at S3, S4, and S7 held pressure to their dialysis access sites and left the facility without performing hand hygiene. The patients were not reminded by staff to wash their hands nor were offered to use hand sanitizer after glove removal. According to the CDC, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal. A review of undated facility policy titled, "Handwashing Technique" under Handwashing Procedure showed the following: Indications for handwashing and hand antisepsis: " ...Decontaminate hands after removing gloves". The above findings were discussed with the Facility Administrator on 7/31/24 at 1:00 p.m. and did not offer any comments. |
| V0115 | IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to ensure that one of one Registered Nurse (RN BB) observed, properly wore personal protective equipment during the initiation and termination of hemodialysis treatment. This deficient practice presented a potential to expose RN BB to blood-borne pathogens. Findings were: During observation in the patients' treatment room on 7/31/24 between 10:41 a.m. and 11:58 a.m. and on 8/2/24 between 6:39 a.m. and 7:15 a.m., the following was revealed: - On 7/31/24 at 10:55 a.m., RN BB did not wear a face shield or eye goggles during termination of hemodialysis on Patient (P) #1 who had a catheter access at Station (S) 10. RN BB wore her prescription eyeglasses which did not completely cover her eyes from potential blood or body fluid splatters during the procedure. - On 8/2/24 at 6:39 a.m., RN BB did not wear a face shield or eye goggles during initiation of hemodialysis on P#4 who had a catheter access at S5. RN BB wore prescription eyeglasses which did not completely cover her eyes from potential blood or body fluid splatters during the procedure. The above findings were discussed with the Facility Administrator on 8/2/24 at 1:00 p.m. and did not offer any comments. |
| 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 one of one double doors at the back of the building, was maintained to prevent entry of insects and vermin; and to provide a safe environment for 10 patients who were dialyzing at this facility. Findings were: During a tour with the Facility Administrator (FA) on 7/31/24 between 11:58 a.m. and 1:15 p.m. the following was observed in the supply delivery area: - The front double doors leading to the outside had approximately 1/4 inch - 1/2 inch gap between the double doors and the floor (24 inches width across the left door, 1/2 inch in the middle, and 12 inches across the right door) that could allow insects and vermin to enter the building. The FA was present during the tour and confirmed the above findings on 7/31/24 at 12:15 p.m. and stated that they need to apply a weatherstrip to the door. |
| V0402 | PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. 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 clean, orderly, and safe environment for 10 patients and all staff as evidenced by holes in the walls; powdery substance, debris, and broken baseboard strips on the floor; and scratched up/paint peeling on the walls. These environmental concerns were observed in one of one treatment area, one of one patient bathroom, one of one water treatment room, one of one lobby, one of one office, one of one corridor, and one of one delivery area. Findings were: During a tour with the Facility Administrator (FA) on 7/31/24 between 11:58 a.m. and 12:57 p.m., the following was observed: - The isolation room had holes in the wall. There were debris/plaster fragments/flakes and powdery substance on the floor. - A 4 - 5 inch in diameter hole was observed in the wall at Station (S) 1 with plaster fragments and debris on the floor. - The baseboard strips in the patient bathroom and in the treatment area had pulled/separated from the wall and were left on the floor. - The walls in the treatment area, water treatment room, lobby, office, and corridor were scratched up with paint peeling and patched areas with paint that did not match. - The area where supplies were delivered was dirty with white powdery substance and debris scattered all over the floor. There were multiple salt bags that were piled up in the corner near delivery door. The FA stated that they don't use this area except for deliveries. The FA confirmed the above findings on 7/31/24 at 12:57 p.m. and stated an acid leak from the water treatment room seeped through the wall and created holes in the wall in the isolation room. FA also indicated this building was the old health department and needed some repairs. |
| 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 maintain equipment in safe and functional working condition as evidenced by broken mechanisms on two of nine adjustable television (TV) arms and torn leather upholstery on five of nine patient treatment chairs in the patient treatment area. This failure could hinder effective cleaning and disinfection of the surfaces, thus had the potential for microbial growth. Findings were: During a tour with the Facility Administrator (FA) on 7/31/24 between 11:58 a.m. and 12:57 p.m., the following was observed in the patient treatment area: - The adjustable TV arms were broken at S3 and S9. The TV were propped up and could not be straightened for patient viewing. - The hemodialysis chairs at Station (S) 2, S4, S5, S8, and S9 had torn upholstery ranging from approximately 2 inches to 8 inches in length and diameter, along the sides and top of the armrests, and/or on the seats and backrests. The FA was present during the tour and confirmed the above findings on 7/31/24 at 12:57 p.m. |
| V0547 | POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient's hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient's anemia management needs. This STANDARD is not met as evidenced by: Based on a review of medical records, facility's anemia protocol, and staff interview, it was determined that the interdisciplinary team (IDT) failed to implement the plan of care and facility guidelines for anemia (lower-than-normal number of red blood cells), to meet the patients' anemia management needs in order to attain and maintain appropriate blood levels of Hemoglobin (Hgb - protein in red blood cells that carries oxygen) of two of two sampled patients (P#1 and P#2) whose Hgb levels were consistently below the clinically acceptable Hgb value of 10 g/dL (grams/deciliter). The accepted clinical practice standard for Hgb levels for dialysis patients was 10-12 g/dL. Anemia in dialysis patients could cause fatigue, shortness of breath, chest pain, dizziness, fainting, and increased risk of hospitalization and longer hospital length of stay. This deficient practice had the potential to negatively affect the health and safety of P#1 and P#2. The facility census was ten. Findings were: A review of "Rounding Report" for P#1 and P#2 revealed the following: P#1: P#1's Hgb and ferritin lab (laboratory) results showed the following: - 2/7/24: Hgb 8.0 g/dL -2/21/24: Hgb 8.0 g/dL - 3/13/24: Hgb 8.2 g/dL - 3/27/24: Hgb 8.0 g/dL - 4/10/24: Hgb 7.5 g/dL and ferritin was 1428 - 4/24/24: Hgb 8.7 g/dL - 5/15/24: Hgb 8.3 g/dL - 5/29/24: Hgb 7.8 g/dL - 6/12/24: Hgb 8.6 g/dL - 6/26/24: Hgb 8.0 g/dL A review of P#1's CIPA/POC (Comprehensive Interdisciplinary Patient Assessment/Plan of Care) dated 11/8/23 showed a goal of 9.0 g/dL - 11.5 g/dL... During an interview with the Facility Administrator (FA) on 8/2/24 at 8:10 a.m., the FA confirmed that the P#1 received Aranesp (medication used to treat anemia) on the following dates: - 1/24/24: Aranesp 40 mcg (microgaram) - 4/10/24: Aranesp 20 mcg. P#1's Hgb dropped from 8.2 g/dL on 3/13/24 to 8.0 g/dL on 3/27/24, and further dropped down to 7.5 g/dL on 4/10/24. However, the dose of Aranesp was decreased by 50% on 4/10/24 from 40 mcg to 20 mcg. - 5/29/24: Aranesp 60 mcg P#2: P#2's Hgb and ferritin lab results showed the following: - 5/29/24: Hgb 9.5 g/dL and ferritin was 377 - 6/21/24: Hgb 9.2 g/dL - 7/10/24: Hgb 8.8 g/dL and ferritin was 643 - 7/24/24: Hgb 8.0 g/dL There was a lack of documented evidence that Aranesp was administered when P#2's Hgb continued to drop from 9.5 g/dL to 8.0 g/dL. A review of P#2's CIPA/POC dated 6/3/24 showed a goal of 9.0 g/dL - 11.5 g/dL... During an interview with the FA on 8/2/24 at 8:15 a.m., the FA confirmed that P#2 has not received a dose of Aranesp since admission on 5/24/24. The FA stated it takes the physician two weeks after lab results were received to order or make changes to Aranesp to improve patients' Hgb. A review of undated facility "Guidelines for Dosing Aranesp" showed the following: Dose Adjustments: The dose should be adjusted for each patient to achieve and maintain Hgb within the range of 10 g/dL to 12 g/dL. Dose adjustment is made every four (4) weeks. If ferritin levels are adequate (500 - 800), the dose of Aranesp may be increased by 25% of the previous dose. Increase Dose: - If the increase in Hgb is less than 1 g/dL over 4 weeks and the ferritin level is adequate, the dose of Aranesp may be increased by 25% of the previous dose. - Further increases may be made at 4 week intervals until the specified Hgb is obtained. - Increase in dosage should not be made no more than once a month. |