| 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) |
| 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 observations, review of the facility's procedure and interviews, it was determined the facility failed to ensure the staff followed the procedure for medication administration and storage during one of three in-center medication administration and preparation (prep) observations. This affected PI (Patient Identifier) # 19 had the potential to negatively affect all patients who dialyzed at this facility. Findings include: Facility Procedure: 1-0601A Title: Preparation and Administration of Parental Medications (Non-EPO, Non-parsabiv) With all Dialyzer Types Revision Date: October 2021 Procedure: 1. Perform hand hygiene... 2. Prior to each medication preparation, disinfect the medication preparation surface with 1:100 (1 bleach/100 parts water) solution and disposable wipes. Remove gloves...Perform hand hygiene. 4. Place required supplies in disinfected medication preparation area. 17. Distribute the medication to the patient station in an aseptic manner. For example, place patient's syringe(s) in a reclosable bag if medication is not administered immediately. Do not place medication(s) directly on top of patient machine... 1. Observations on the in-center treatment floor were conducted on 7/20/22 from 9:25 AM to 11:30 AM. At 9:29 AM, the surveyor observed one bag of IDPN (intradialytic parental nutrition) laying on a counter next to a printer, a thermometer, and a rusty hole punch. At 11:30 AM, the IDPN bag was still laying on the counter next to the printer and the rusty hole punch. Staff failed to store the IDPN in a disinfected medication preparation area. 2. On 7/20/22 at 10:20 AM, EI # 7, RN entered station 3 with two IV (intravenous) heparin filled syringes, saline syringes, and central venous catheter (CVC) supplies (alcohol pads, catheter hubs) and placed the supplies on top of the dialysis machine. EI # 7 completed CVC exit care including saline flush and administered IV heparin to PI # 19 using the medication and supplies placed on top of the dialysis machine. An interview was conducted on 7/21/22 at 12:10 PM, EI # 1, Facility Administrator confirmed medications and supplies were to be stored in a designated clean area and not on top of the dialysis machine. 39098 3. On 7/20/22 at 2:35 PM, EI # 7, RN, was observed discontinuing dialysis with CVC on PI # 19. EI # 7 placed the supplies, including the saline flush syringes, on top of the dialysis machine. EI # 7 performed hand hygiene and donned gloves. With gloved hands, EI # 7 pulled a rolling chair up to the station. With the same gloves, EI # 7 retrieved saline flush syringes from the top of the machine, disconnected the blood lines and attached syringes and flushed both lines. EI # 7 retrieved alcohol swabs and caps from the top of the machine and cleaned the hubs and placed the caps on the CVC lines. EI # 7 then retrieved the ziplock bag with the barrier still folded inside and placed in the garbage. EI # 7 failed to place the saline flush syringes and supplies on a clean barrier. An interview was conducted on 7/21/22 at 1:05 PM with EI # 1, who confirmed staff failed to maintain or store supplies and medications in an aseptic manner and not place supplies on top of the dialysis machine. |