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 09/12/2023
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 review of medical records, facility policy, and interviews, it was determined the facility failed to ensure staff documented the care provided to CVC (Central Venous Catheter) per policy. This affected two of two records reviewed with CVC accesses, and did affect Patient Identifier (PI) # 1, PI # 2, and had the potential to affect all patients dialyzing with CVC's. Findings include: Facility Policy: Central Venous Catheter Care Policy number: 1-04-02 Revision date: October 2022 Purpose: To reduce the risk of infection in the patient and to reduce trauma to the catheter and exit site while minimizing blood loss. Policy: 1. Only non-occlusive dressing, such as sterile gauze pads, will be used. ...2. Dressings are changed every dialysis treatment on: -Newly inserted cuffed catheters. -Cuffed catheter exit sites that are not well healed. -Exit sites with signs and symptoms of infection. -All CVCs not in use. ...4. Cuffed catheters with well-healed exit sites... still require examination and cleaning of exit site each treatment. 10. Acceptable germicidal/disinfectant solutions may include: a. Isopropyl alcohol b. Povidone iodine... c Hypochlorite...only for skin... d. Chlorhexidine Gluconate 2%...only for skin e. Alcavis 50...for CVC caps... 11. CVC capping devices include...Clearguard..end caps... ...15. Document findings and interventions in patient's medical record. 1. PI # 1 was admitted to the facility on 1/13/23 with a primary diagnosis of End Stage Renal Disease (ESRD). Review of the IDT (Interdisciplinary Team) Rounding Worksheet revealed PI # 1 was allergic to Chlorhexidine. Review of the Treatment Detail Reports (TDR's) dated 8/18/23, 8/21/23 and 8/25/23 revealed access type: CVC ...Dressing Change: Yes. There was no documentation of the disinfectant used for the CVC exit site care. An interview was conducted on 9/12/23 at 11:36 AM with Employee Identifier (EI) # 1, Facility Administrator, who confirmed there was no documentation of the disinfectant used for the CVC exit site care. 2. PI # 2 was admitted to the facility on 3/29/22 with a primary diagnosis of ESRD. Review of the IDT Rounding Worksheet revealed PI # 2 had no known allergies to disinfectant's. Review of the TDR's dated 8/31/23, 9/2/23 and 9/5/23 revealed access type: CVC ...Dressing Change: Yes. There was no documentation of the disinfectant used for the CVC exit site care. An interview was conducted on 9/12/23 at 11:45 AM with EI # 1, who confirmed there was no documentation of the disinfectant used for the CVC exit site care.