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)
V0147 IC-STAFF EDUCATION-CATHETERS/CATHETER CARE
CFR(s): 494.30(a)(2)

Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].


This STANDARD is not met as evidenced by:
Based on observation, review of policy and procedure, and interview, it was determined the facility failed to ensure staff performed initiation of dialysis with a Central Venous Catheter (CVC) per policy. This affected 2 of 2 observations of initiation of dialysis with CVC, including Patient Identifiers (PI) # 15, PI # 16, and had the potential to affect all patients dialyzing at this facility. Findings include: Policy: Central Venous Catheter (CVC) Care Policy Number: 1-04-02 Revision Date: October 2019 Purpose: To reduce the risk of infection in the patient... Policy: Central Venous Catheter (CVC) Procedure Policy Number: 1-04-02A Revision Date: April 2019 ...21. Remove attached Curos for TEGO Caps from each TEGO connector and discard. 22. Scrub CVC TEGO connectors or caps with LARGE alcohol prep pad, one (1) per TEGO connector or cap, for 60 seconds. 1. During observations of care on 1/6/2020 at 10:05 AM, the surveyor observed Employee Identifier (EI) # 5, RN (Registered Nurse), perform initiation of dialysis with a CVC on PI # 15. During disinfection of the CVC hubs, EI # 5 used an alcohol pad and wiped the threads of the blue port for 5 seconds, and the red port for 3 seconds. EI # 5 failed to scrub the connector caps for 60 seconds, per policy. 2. During observations of care on 1/6/2020 at 11:35 AM, the surveyor observed EI # 5, perform initiation of dialysis with a CVC on PI # 16. During disinfection of the CVC hubs, EI # 5 used an alcohol pad and wiped the threads of the blue port for 10 seconds, and the red port for 10 seconds. EI # 5 failed to scrub the connector caps for 60 seconds, per policy. An interview was conducted on 1/8/2020 at 11:35 AM with EI # 5, who confirmed she/he failed to clean the CVC hubs per policy.