Statement of Deficiencies

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)

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 observations, review of facility policies and procedure, staff interviews, it was determined the facility failed to ensure: 1. Patient's performed hand hygiene when entering the treatment floor 2. Staff performed hand hygiene before preparing Intravenous (IV) medications. 3. Staff sanitized hands for at least 20 seconds as per facility procedure. This did affect Patient Identifier (PI) # 12, 1 of 2 patients observed for Access of AV (Atrioventricular) Fistula or Graft, and PI # 2, PI # 14, 2 of 3 observations conducted for medication preparation and administration. This had the potential to negatively affect all patient's dialyzing at this facility. Findings include: Facility Policy: Hand Hygiene Published: 11/4/19 Version: 6 Purpose: The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. Responsibility All staff, patients...must follow the same requirements for hand hygiene. Policy: Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content... ...below identifies when hands should be washed specifically with soap and water or when alcohol-based hand rubs can be used: ...Entering and leaving the treatment room. Before performing any invasive procedure such as vascular access cannulation or administration of parental medications. Facility Hand Hygiene Procedure Published: 9/16/18 Reference Nunmber: 47665 Procedure for Decontaminating Hands with Alcohol Based Hand Rubs 2. Apply Alcohol-based hand rubs to the palm of one hand... 3. Rub hands together covering all surfaces of the hands and fingers until hands are dry. Allowing alcohol to dry completely allows adequate contact time to kill germs... Note: Duration of the entire procedure: 20-30 seconds Facility Policy: Medication Preparation and Administration Published: 04/05/2021 Version: 6 "Purpose: To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control. Infection Control Perform hand hygiene prior to accessing supplies, handlings vials and IV solutions and preparing and administering medications. Aseptic technique will be used to prepare and administer IV medications. 1. During observations of care on 9/14/21 at 9:35 AM station 15, Employee Identifier (EI) # 4, Registered Nurse (RN), reinfused the extracorporeal circuit, removed gloves and sanitized hands for 7 seconds before donning clean gloves. EI # 4 failed to sanitize hands for at least 20 seconds per the facility hand hygiene procedure. 2. During observations of care on 9/14/21 at 10:20 AM at station 8, EI # 10, Certified Clinical Hemodialysis Technician (CCHT), disinfected the dialysis machine, removed gloves, and sanitized hands for 8 seconds before retrieving gloves from the clean glove supply. EI # 10 failed to follow the facility hand hygiene procedure. 3. During observations of care on 9/14/21 at 10:35 AM station 15 , EI # 4 removed the old CVC (central venous catheter) dressing, discarded the dressing, removed/discarded gloves and sanitized hands for 10 seconds and not at least 20 seconds per the facility hand hygiene procedure. 4. During observations of care on 9/14/21 at 10:46 AM at station 16, EI # 5, Patient Care Technician (PCT), removed needle 1 from the access site, removed/discarded gloves then sanitized hands for 8 seconds before retrieving gloves from the clean gloves supply. EI # 5 failed to sanitize hands per the facility hand hygiene procedure. An interview was conducted on 9/16/21 at 8:45 AM and EI # 1, Clinic Manager, confirmed staff failed to follow the facility hand hygiene procedure. 5. An observation was conducted on 9/14/21 at 11:15 AM to observe EI # 8, CCHT, initiate dialysis on PI # 12. EI # 8 opened the treatment floor door and PI # 12 entered the treatment floor. PI # 12 weighed his/herself and proceeded to station 20 without performing hand hygiene as directed per the facility policy. 6. An observation was conducted on 9/14/21 at 11:50 AM to observe EI # 4 prepare and administer an IV medication (Heparin) to PI # 2 at station 19. EI # 4 failed to perform hand hygiene prior to accessing supplies and handling medication vials as directed per the facility policy. 7. An observation was conducted on 9/14/21 at 12:09 PM to observe EI # 9, RN, prepare and administer an IV medication (Venofer) to PI # 14 at station 8. EI # 9 failed to perform hand hygiene prior to accessing supplies and handling medication vials as directed per the facility policy. An interview was conducted on 9/16/21 at 8:40 AM with EI # 1 who verified the staff failed to ensure the patient's performed hand hygiene when entering the treatment floor as per the facility policy. EI # 1 also verified the staff to perform hand hygiene before preparing IV medications as directed per the facility policy. 30952