| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852540 | (X3) Date Survey Completed 01/06/2023 |
| Name of Provider or Supplier Camilla Dialysis | Street Address, City, State 251 Us 19 N, Camilla, 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 | {CORE} A Recertification Survey was conducted at Camilla Dialysis from January 4, 2023 through January 6, 2023. The survey revealed that the facility was in substantial compliance with 42 CFR Part 494.62, Conditions for Coverage for Emergency Preparedness Plan for End Stage Renal Disease facilities. A standard level deficiency was cited. |
| E0040 | ESRD Patient Orientation Training The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This STANDARD is not met as evidenced by: Based on a review of facility records, it was determined that the facility failed to ensure that two of seven Patients (P#4 and P#5) sampled, who were admitted on 9/3/22 and 10/21/21, respectively, received Emergency Preparedness orientation and training. This failure had the potential to negatively affect the health and safety of P#4 and P#5. The facility census was 74. Findings include: During a review of the facility's Emergency Preparedness Program Orientation and Training Manual for all seven patients sampled, it was revealed that there were no records of training and orientation of the facility's Emergency Preparedness Program for P#4 and P#5. There were no records of training these patients regarding communication protocols for contacting the ESRD ( End Stage Renal Disease) facility and no records of identifying an alternate location for their treatment in the event of a facility closure or actions that patients would be required to take in case of an emergency in the facility. There were no documented evidences that a training and audit was done regarding emergency take off. The Facility Administrator stated on 1/6/23 at approximately 4:00 p.m., that they could not find any documented evidences of patient emergency training and orientation for P#4 and P#5. |
| V0000 | {CORE} A recertification survey was conducted at Camilla Dialysis from January 4, 2023 through January 6, 2023. The survey revealed that the facility was in substantial compliance with 42 CFR Part 494 Condition 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, staff interview, a review of facility Policy and Procedures (P & P), and a review of the Center for Disease Control and Prevention (CDC) guidelines, it was determined that the Infection Control Committee failed to ensure that one of one Patient Care Technicians (PCT AA) observed, performed hand hygiene (wash hands or use an alcohol-based hand sanitizer) after removal of gloves and before donning gloves. This breach in infection control techniques had the potential to cause the spread of infections, or bloodborne pathogens in the dialysis environment through cross contamination. The facility census was 74. Findings include: During observation in the patients' treatment room on 1/6/23 between 10:10 a.m. and 12:10 p.m., the following was revealed: - PCT AA was observed removing the used bloodlines and dialyzer off of the hemodialysis machine at Station 2. PCT AA changed gloves without performing hand hygiene between glove changes. - During an interview with PCT AA on 1/6/23 at approximately 1:10 p.m. regarding the above observation, she stated that she forgot or didn't realize that she didn't perform hand hygiene between glove changes. - A review of the facility's Policy: 1-05-01 titled, "Infection Control For Dialysis Facilities", with the latest revision date of October 2022, stated: 1. Hand hygiene is to be performed ... prior to gloving, after removal of gloves... 6. Alcohol-based hand rubs may be used: ... before gloving and after glove removal... According to CDC recommendations, 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... |
| V0122 | IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This STANDARD is not met as evidenced by: Based on observation, staff interview, a review of Centers for Disease Control and Prevention (CDC) guidelines, and a review of the facility's policies and procedures (P & P), it was determined that the facility failed to ensure that one of one Registered Nurse (RN AA), one of one Licensed Practical Nurse (LPN AA), and four of four Patient Care Technicians (PCTs AA, BB, CC, and DD), who were present during this observation, immediately and thoroughly cleaned and disinfected five of five blood-contaminated surfaces on the cover of sharps containers observed, between patient use. This failure could lead to the transmission of dangerous pathogens through cross contamination. This deficient practice had the potential to negatively affect the health and safety of 20 hemodialysis patients (P#8 - P#27), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 74. Findings include: During observation in the patients' treatment room on 1/4/23 between 1:45.m. and 2:45 p.m., the following was observed: There were blood splatters of different shapes and sizes on the covers of the sharps containers between Stations (S) 2 and S3, between S6 and S7, at S9, next to the document shredder, right under the fire extinguisher, between S13 and S14 and between S15 and S16. The Charge Nurse (RN AA) confirmed and acknowledged these observations and stated on 1/4/23 at approximately 2:45 p.m., that the dried blood should have been disinfected right away. According to CDC guidelines, failure in environmental cleaning and disinfection have led to transmission of bloodborne pathogens (e.g., Hepatitis B virus) and other infections from one patient to another in hemodialysis units. Correct cleaning and disinfection of environmental surfaces (including floors, patient chair or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces, etc., especially with blood splatters) must be performed between patient uses to prevent transmission of dangerous pathogens. A review of facility Policy: 1-05-01, titled, "Infection Control for Dialysis Facilities", with latest revision date of October 2022, stated: 45. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials ... After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time. |
| V0543 | POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient's volume status; This STANDARD is not met as evidenced by: Based on a review of medical records and staff interviews, it was determined that the facility failed to ensure that one of one patient sampled (P#4) who had elevated blood pressure (BP) readings, was treated according to the physician's standing order. This deficient practice had the potential to negatively affect the health and safety of P#4 and the other 73 in-center hemodialysis patients who dialyzed at this facility. Findings include: A review of P#4's medical records revealed the following: - P#4 came to the facility for dialysis treatment on 12/29/22 with the following vital signs as recorded in P#4's treatment flowsheet: PRE-TREATMENT VITAL SIGNS: BP sitting - 230/129; standing BP 222/125; Pulse - 74; Temperature - 97.1; Pre-Weight - 103.0 kilograms (kg) POST-TREATMENT VITAL SIGNS: BP sitting - 208/110; BP standing - 190/109; Pulse - 81; Temperature - 98.2; Post-weight - 98.7 kg Target weight - 97.0 kg BP ranges during P#4's hemodialysis treatment on 12/29/22 fluctuated between 165/106 and 218/111. Documentation stated that P#4's BP reading was either trending up or trending down, but there was no documentation whether a PRN (as needed) medication was offered nor given and there was no documentation that the doctor was notified. - P#4's treatment flowsheet on 1/3/23 revealed the following: PRE-TREATMENT VITAL SIGNS: BP sitting - 187/112; standing BP 189/119; Pulse - 75; Temperature - 97.2; Pre-Weight - 101.7 kg POST-TREATMENT VITAL SIGNS: BP sitting - 191/109; BP standing - 191/111; Pulse - 86; Temperature - 98.0; Post-weight - 98.6 kg Target weight - 97.0 kg BP ranges during P#4's hemodialysis treatment on 1/3/23 fluctuated between 173/99 and 210/114. Documentation stated that P#4's BP reading was either trending up or trending down, but there was no documentation whether a PRN medication was offered nor given and there was no documentation that the doctor was notified. P#4 had missed treatment on 12/22/22, 12/27/22 and 12/31/22. The Facility Administrator and Regional Operations Director were notified of the above observation and the Regional Operations Director stated on 1/6/23 at 4:00 p.m. that P#4 did not have an individualized PRN medication order for Hypertension (HTN) but the facility had a general HTN standing order of: "Clonidine 0.10 mg by mouth. May give 1 tablet orally every 30 minutes up to 3 doses PRN". There were no specific parameters that was included in the medication order. |