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 012505 (X3) Date Survey Completed 07/21/2022
Name of Provider or Supplier Physicians Choice Dialysis-Montgomery Street Address, City, State 1001 Forest Avenue, Montgomery, 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)
V0120 IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED
CFR(s): 494.30(a)(1)(i)

Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines' pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between 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 staff followed the policy for wet transducers. This had the potential to affect all patients dialyzing at this facility. Findings include: Facility Policy: Changing the Transducer Protectors Policy number: 1-03-11 Revision date: April 2021 Purpose: To provide guidance for changing transducer protectors and preventing cross contamination. Policy: 1. This policy is intended for all dialysis systems that utilize blood tubing sets with external pressure transducer protectors in the arterial and venous pressure monitoring system. ...3. External transducer protectors will be inspected for presence of blood or saline every 30 minutes during patient treatment and included as part of the monitoring process. 4. The external transducer protector will be replaced: - Prior to each patient use. -Whenever blood or saline is observed in contact with the patient side of the transducer protector. 5. If the external transducer protector becomes contaminated with blood or saline, the teammate will replace the external transducer protector... 1. During observations of care on the treatment floor on 7/19/22 at 9:03 AM, the surveyor observed a transducer wet with blood at station 3. The surveyor confirmed the wet transducer with Employee Identifier (EI) # 8, CCHT (Certified Clinical Hemodialysis Technician). EI # 8 changed the transducer at 9:05 AM, and immediately, the transducer became wet with blood again. The surveyor observed the transducer wet until dialysis was completed at 10:35 AM. An interview was conducted on 7/21/22 at 1:05 PM with EI # 1, Facility Administrator, who confirmed staff failed to monitor and change the wet transducer, per policy.