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)
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 observations, facility policy, and interview, it was determined the facility failed to ensure staff cleaned and disinfected the dialysis station after patient treatments. This affected 2 of 2 observations of the cleaning and disinfection of the dialysis station and had the potential to affect all patients dialyzed by this facility. Findings include: Policy: Cleaning and Disinfection of the Dialysis Station Published: 11/02/2020 Version: 11 Purpose The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. Responsibility All dialysis facility staff Dialysis Station Area including the dialysis machine, chair/bed and other reusable equipment... General Cleaning The dialysis station could become contaminated with blood and other body fluids during treatment... After use, all non-disposable equipment and supplies must be disinfected with 1:100 bleach or manufacturer's recommendation or discarded. Work Surface Cleaning and Disinfection without Visible Blood using Bleach Solutions. All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. Make the surface glistening wet and let air dry unless otherwise specified by the manufacturer. 1. An observation was conducted on 9/14/21 at 10:15 AM to observe Employee Identifier (EI) # 7, Registered Nurse (RN), perform cleaning and disinfection of dialysis station 27. While disinfecting the dialysis station, EI # 7 failed to clean and disinfect underneath the chairside table tops and the exterior chair panels bilaterally. An interview was conducted on 9/16/21 at 8:40 AM with EI # 1, Clinic Manager who verified the staff failed to clean and disinfect the dialysis station as directed per the facility policy. 30952 2. During observations of care on 9/14/21 at 10:20 AM at station 8, EI # 10, Certified Clinical Hemodialysis (HD) Technician disinfected the patient treatment chair, blood pressure (BP) cuff and tubing then placed the clean BP cuff/tubing equipment inside the wire basket on the HD machine. EI # 10 had not yet disinfected the HD machine and placed the clean BP equipment into a contaminated surface. EI # 10 then disinfected the HD machine but failed to disinfect the IV (intravenous) pole hooks. In an interview on 9/16/21 at 8:45 AM, EI # 1 confirmed staff failed to follow the facility dialysis station disinfection policy.