Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 012500 (X3) Date Survey Completed 09/16/2021
Name of Provider or Supplier Fmc Capitol City Street Address, City, State 255 South Jackson Street, Montgomery, AL
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)
V0111 IC-SANITARY ENVIRONMENT
CFR(s): 494.30

The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas.


This STANDARD is not met as evidenced by:
Based on observation, review of facility policy and procedures and interviews, it was determined the facility failed to ensure the staff: 1. Completed vascular access care according to facility procedure. 2. Emptied the prime bucket in the utility hopper or dirty sink according to facility policy. 3. Covered the bleach container with an opaque lid and discarded bleach solution daily at the end of the treatment day per facility procedure. This did affect Patient Identifier (PI) # 12, 1 of 2 patients observed for Access of AV (Atrioventricular) Fistula or Graft, and 1 of 2 observations conducted for cleaning and disinfection of the dialysis station and had the potential to affect all patients in this facility. Findings Include: Facility Procedure: Access Assessment and Cannulation Published: 8/22/2018 Version: 1 Purpose: The purpose of this procedure is to provide guidance for placement of needles in an AV (Arteriovenous) Fistula or AV Graft to obtain access to the circulatory system for hemodialysis. Assessment of Vascular Access... Step 1. Prior to treatment, ask your patient to wash access area with liquid soap for one minute, rinsing well... Wash access (per above), if patients unable to clean their access. Facility Policy: Use of Priming Buckets Published: 07/17/2017 Version: 4 Purpose: All facilities will utilize a priming bucket or approved container to collect the Normal Saline prime pretreatment. Policy: A priming bucket or other approved removable container will be used to collect the normal saline prime pretreatment... Procedure: Step 4: At the completion of the patient treatment, remove the priming bucket or approved removable container, and dispose of the Normal Saline in the utility room hopper or dirty sink. Facility Procedure: Mixing Bleach Published: 08/25/2020 Version: 4 Procedure: 5. Cover opaque container with lid. 6. Discard solution daily at end of treatment day or more often if needed. 1. During observations of care on 9/14/21 from 10:25 AM until 11:15 AM at POD (section) 6, the surveyor observed the 1:100 (1 part bleach 100 parts water) bleach container uncovered. Staff had failed to secure the bleach container lid. In an interview on 9/16/21 at 10:30 AM, Employee Identifier (EI) # 1, Clinic Manager, confirmed staff failed to follow the facility bleach procedure. 2. An observation was conducted on 9/14/21 at 10:15 AM to observe EI # 7, Registered Nurse (RN), perform cleaning and disinfection of dialysis station 27. EI # 7 removed all bloodlines from the dialysis station and discarded in the biohazardous waste container. EI # 7 proceeded to remove his/her gloves, perform hand hygiene, and apply new gloves. EI # 7 then removed the prime bucket from station 27 and emptied the Normal Saline in the prime bucket into the wall drain behind the dialysis station. EI # 7 failed to empty the Normal Saline in the utility room hopper or dirty sink as directed per the policy. An interview was conducted on 9/16/21 at 8:40 AM with EI # 1 who stated the prime bucket should be emptied in the dirty sink. EI # 1 verified the staff failed to follow the facility policy for disposing of Normal Saline in the prime bucket. 3. During observation of care on 9/14/21 at 11:15 AM, the surveyor observed PI # 12 enter the treatment floor, walk to the scales, then walk directly to station 20. EI # 8, Certified Clinical Hemodialysis Technician, palpated the access site, then cleaned the area with alcohol, and cannulated the site. EI # 8 failed to wash the access with soap and water prior to starting the procedure, per policy. During an interview on 9/16/21 at 8:40 AM with EI # 1 verified the staff failed to complete vascular access care according to facility procedure. 30952 4. On 9/14/21 at 2:45 PM a tour of the isolation unit and interview was conducted with EI # 6, RN, Charge Nurse. The surveyor observed a bleach container 1/2 full of a clear liquid solution. The surveyor asked EI # 6 when staff should discard the bleach solution? EI # 6 reported bleach should be discarded at the end of the day. EI # 6 confirmed staff failed to discard the bleach Monday 9/13/21. EI # 6 promptly discarded the bleach solution from the bleach container into the dirty sink. In an interview on 9/16/21 at 10:30 AM, EI # 1 confirmed staff failed to follow the facility bleach procedure.