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 012501 (X3) Date Survey Completed 06/30/2021
Name of Provider or Supplier Gadsden Dialysis Street Address, City, State 409 South First Street, Gadsden, 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)
V0116 IC-IF TO STATION=DISP/DEDICATE OR DISINFECT
CFR(s): 494.30(a)(1)(i)

Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other 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 the staff cleaned and disinfected equipment before returning it to a common clean area or being used on another patient. This did affect 1 of 2 observations conducted for preparation of the hemodialysis machine and perform conductivity testing using the Myron L meter and 1 of 3 observations conducted for initiation of dialysis and exit site care of patients with a Central Venous Catheter (CVC). This did affect Patient Identifier (PI) # 7, PI # 1, and 1 unsampled patient. This had the potential to negatively affect all patients served by this facility. Findings Include: Policy: Infection Control for Dialysis Facilities Policy Number: 1-05-01 Date Revised: October 2020 Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. ...Teammate/Patient Safety ...25. Non-disposable items are to be disinfected between patients. 26. Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred) bleach solution... ...Dialysis Station Management ...65. Items taken into the dialysis station will be... cleaned and disinfected before taken to a common area or used on another patient... 66. Teammates will thoroughly wipe down all non-disposable items and equipment...with an appropriate disinfectant... Chairsidesnappy Terminal and Cart 71. The ChairSideSnappy cart, monitor and keyboard are considered clean areas. 1. An observation was conducted on 6/28/21 at 8:15 AM to observe Employee Identifier (EI) # 6, Certified Clinical Hemodialysis Technician (CCHT) prepare the dialysis machine and perform the conductivity using the Myron L meter for PI # 7 at station 6. EI # 6 obtained the Myron L meter from the clean supply countertop and proceeded to station 6. EI # 6 obtained the dialysate solution from the dialysis machine and then placed the Myron L meter on PI # 6's flowsheet which was lying on top of the ChairSideSnappy cart. After performing the conductivity testing PI # 6 retrieved the Myron L meter and returned the meter to the clean supply countertop without cleaning the meter after use as directed per the facility policy. 2. During observations of care on 6/28/21 at 10:10AM the surveyor observed EI # 6 retrieve the thermometer from the ChairSideSnappy cart at station 22 and proceed to an unsampled patient at station 20. EI # 6 obtained the unsampled patient's temperature at station 20 then proceeded to station 5. EI # 6 placed the thermometer on the ChairSideSnappy cart at station 5 without cleaning the thermometer after use as directed per the facility policy. 3. An observation was conducted on 6/28/21 at 10:42 to observe EI # 5, Registered Nurse, perform exit site care and initiate dialysis on PI # 1 with a CVC at station 21. EI # 5 retrieved the thermometer from the clean supply countertop and obtained PI # 1's temperature. EI # 5 then placed the thermometer on the ChairSideSnappy cart without cleaning the thermometer after use as directed per the facility policy. EI # 5 then performed a pre-assessment with a stethoscope on PI # 1. EI # 5 hung the stethoscope around his/her neck and failed to disinfect the stethoscope after use as directed per the facility policy. An interview was conducted on 6/30/21 at 11:50 AM with EI # 1, Facility Administrator, who confirmed the staff failed to clean and disinfect equipment before returning it to a common clean area or before being used on another patient.