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 012502 (X3) Date Survey Completed 01/08/2020
Name of Provider or Supplier Tuscaloosa University Dialysis Street Address, City, State 220 15th Street, Tuscaloosa, 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 procedures and interviews, it was determined the facility failed to ensure staff 1. Wore/changed gloves as directed per the facility policy. 2. Performed hand hygiene after removing gloves. This did affect 1 of 2 observations conducted for Discontinuation of Dialysis and Post Dialysis Access Care for AV (Atrioventricular) Fistula or Graft and 2 of 2 observations conducted for Parental Medication Preparation and Administration. This affected Patient Identifier (PI) # 12, PI # 13, PI # 14 and had the potential to negatively affect all patients served by the facility. Findings include: Policy: 1-05-01 Title: Infection Control For Dialysis Facilities Revision Date: October 2019 Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Teammate Hygiene 1. Hand hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves... after patient and dialysis delivery system contact...before touching clean areas such as supplies, and on exiting the patient treatment area. Teammate/Patient Safety 11. Teammates will wear gloves when caring for the patient or touching the patient's equipment at the dialysis station, and will remove gloves and wash hands or perform hand hygiene between each patient and/or station. 12. Gloves should be worn when: ...Administering medications, checking vital signs. Policy: 1-06-01 Title: Medication Policy Revision Date: April 2019 Purpose...To provide guidance for medication management...aspect technique for preparation of all medications. 8. All teammates administering medications must utilize aseptic technique... Procedure: 1-06-04A Title: Preparation and Administration of Intravenous Epogen With All Dialyzer Types Revision Date: April 2017 Preparation of Epogen dose ...2. Perform hand hygiene. Put on PPE (Personnel Protective Equipment). 3. Prior to each medication preparation, disinfect medication preparation surface area... Remove PPE. ...5. Perform hand hygiene prior to medication preparation. ...16. Distribute the medication to the patient station in an aseptic manner... Administration of Epogen ...3. Perform hand hygiene. Put on PPE. 1. During observation of Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft on 1/6/2020 at 10:07 AM, the surveyor observed Employee Identifier (EI) # 4, Certified Clinical Hemodialysis Technician (CCHT), removed the first needle from PI # 12, proceeded to the clean counter top, obtained a glove and the thermometer. Holding the thermometer with the glove, hand EI # 4 returned to station # 16 and assessed PI # 12's temperature. EI # 4 failed to apply gloves as directed per the facility policy. 2. During observation of Parenteral Medication Preparation and Administration on 1/6/2020 at 11:05 AM, the surveyor observed EI # 5, Registered Nurse (RN), prepare two (2) intravenous (IV) medication's for PI # 13. EI # 5 withdrew the medication into the syringe and removed his/her gloves without performing hand hygiene. 3. During observation of Parenteral Medication Preparation and Administration on 1/6/2020 at 12:15 PM, the surveyor observed EI # 3, RN, prepare and administer three (3) IV medication's, including Epogen, for PI # 14 at station # 11. EI # 3 withdrew the medications into the syringes and wearing the same gloves proceeded to station # 11. EI # 3, holding medications in 1 gloved hand retrieve a large sharps container located on the treatment floor and place the large sharps container in a rolling cart with the both gloved hands. EI # 3 then rolled the sharps container closer to station # 11 and proceeded to administer the IV medications, including Epogen, to PI # 14 without changing gloves and performing hand hygiene. An interview was conducted on 1/8/2020 12:05 PM with EI # 1, Facility Administrator, who confirmed the staff failed to follow facility infection control policies and procedures for gloving and hand hygiene.