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)
V0130 IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES
CFR(s): 494.30(a)(1)(i)

Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients.


This STANDARD is not met as evidenced by:
Based on observations, review of facility policy and interview, it was determined the facility failed to ensure: 1. All equipment used in the isolation room was designated and labeled for "isolation" only. 2. Infectious Waste in the red bag was removed from the HBsAg (Hepatitis B surface Antigen) positive patient treatment isolation unit each day. This had the potential to negatively affect all Hepatitis B susceptible patients, visitors, and facility staff. Findings include: Facility Policy: Dialyzing Patients with Positive Hepatitis B Antigen Published: 3/20/13 Version: 7 Purpose: To prevent the transmission of Hepatitis B. Policy: ...all patients with hepatitis B infection treated in the dialysis facility require additional infection control precautions... Isolation of Hepatitis B virus positive (HBsAg+) patients. All patients who are HBsAg positive must dialyze under isolation precautions. Equipment and Supplies Separated dedicated supplies and equipment... must be used to provide care to the HBsAg positive patient. ...All supplies used in the isolation room/ area such as clamps, blood pressure cuffs, testing reagents, etc. (etcetera), should be labeled "isolation" and not routinely removed... All disposable items, including the patient's dialyzer, shall be considered infectious, and shall be red-bagged, labeled as Infectious Waste and removed from the HBsAg positive patient care room/area each day using Standard Precautions. 1. On 9/14/21 at 2:40 PM the surveyor toured the isolation room with Employee Identifier (EI) # 6, RN (Registered Nurse) Charge Nurse. The following items were in the isolation room and not labeled/dedicated for "isolation" use only: 3 Hemodialysis machines 4 patient treatment chairs 1 set of Tri-Station reagents for Myron L D-6 meter 1 biohazard waste container 1 privacy screen The biohazard container was not emptied following for the 9/13/21 isolation unit dialysis treatment and was 1/2 full of red-bagged hazardous waste. During the tour an interview was conducted on 9/14/21 at 2:48 PM with EI # 6 who confirmed the equipment should have been designated labeled "isolation" and the red-bagged hazardous waste should have been emptied on 9/13/21.