| 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) |
| V0143 | IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This STANDARD is not met as evidenced by: Based on review of policy and procedure, observation and interviews, it was determined the facility failed to ensure staff labeled opened multidose medication vials per policy. This affected 2 of 6 opened vials observed, and had the potential to affect all patients served by this facility. Findings include: Policy: Medication Policy Policy Number: 1-06-01 Revision Date: April 2019 Purpose: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of all medications. Policy: ...28. Medications containing a preservative must be discarded 28 days after opening or accessed... Each vial is labeled with the initials of the person opening the vial and the expiration date. 1. During observation of the medication preparation area on 1/6/2020 at 11:55 AM the surveyor observed 1 of 5 opened vials of Epogen 20,000 units/ 2 ml (milliliters) with no date or initials, and 1 of 1 opened vials of Hectoral 4 mcg (micrograms)/ 2 ml with no date or initials. Employee Identifier (EI) # 5, RN (Registered Nurse), who was present during the observation, confirmed the vials should have been labeled. |