| 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) |
| V0550 | POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This STANDARD is not met as evidenced by: Based on observations, review of medical record (MR), policy and procedure, and staff interviews, it was determined the facility failed to ensure the staff followed their own policy and procedure for care of an AVF/AVG (Arteriovenous Fistula/Graft). This affected PI's (Patient Identifier) # 7, PI # 8, PI # 10, in 3 of 6 records reviewed for patients with an AVF/AVG (arteriovenous fistula/graft and this had the potential to affect all patients with an AVF/AVG. Findings Include: Facility Policy: Access Assessment and Cannulation Published: 08/22/2018 Version: 1 Purpose...of this procedure...provide guidance for placements of needles in an AV Fistula or AV Graft...for hemodialysis. ...Skin Disinfection Step 1. Disinfect cannulation site as follows using any of the disinfectants below: 70 % isopropyl alcohol pad... Povidone Iodine pad... 2% Chlorhexadine and 70% alcohol... 1. PI # 7 was admitted to the facility 9/7/17 with diagnoses including End Stage Renal Disease(ESRD). Review of the Treatment Sheets dated 9/2/21, 9/9/21, 9/11/21, and 9/14/21 revealed staff documented the AVF was "Cleaned with chlorhexidine." MR review revealed no physician's order for chlorhexadine. There was no reason documented why 70 % isopropyl alcohol, Povidone Iodine, or 2% Chlorhexadine and 70% alcohol was not used in 4 of 6 treatment sheets reviewed. In an interview on 9/16/21 at 8:59 AM, EI (Employee Identifier) # 2, Director of Operations reported chlorhexadine was not an accepted AVF site skin disinfectant. Staff failed to follow the facility procedure for AVF skin disinfection. 28327 2. PI # 8 was admitted to the facility 4/6/17 with diagnoses including ESRD. Review of the Treatment Sheets dated 9/10/21 and 9/13/21 revealed staff documented the AVF was "Cleaned with chlorhexidine." MR review revealed no physician's order for chlorhexadine. There was no reason documented why 70 % isopropyl alcohol, Povidone Iodine, or 2% Chlorhexadine and 70% alcohol was not used in 2 of 6 treatment sheets reviewed. In an interview on 9/16/21 at 9:10 AM, EI # 1, Clinic Manager, reported chlorhexadine was not an accepted AVF site skin disinfectant. Staff failed to follow the facility procedure for AVF skin disinfection. 3. PI # 10 was admitted to the facility 8/26/19 with diagnoses including ESRD. Review of the Treatment Sheets dated 9/1/21, 9/3/21, 9/6/21, 9/8/21, 9/10/21 and 9/13/21 revealed staff documented the AVF was "Cleaned with chlorhexidine." MR review revealed no physician's order for chlorhexadine. There was no reason documented why 70 % isopropyl alcohol, Povidone Iodine, or 2% Chlorhexadine and 70% alcohol was not used in 6 of 6 treatment sheets reviewed. In an interview on 9/16/21 at 9:14 AM, EI # 1 reported chlorhexadine was not an accepted AVF site skin disinfectant. Staff failed to follow the facility procedure for AVF skin disinfection. |