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)
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 procedure, and interviews, it was determined the facility failed to ensure staff documented CVC (Central Venous Catheter) care per policy. This affected two of three records reviewed with CVC accesses, and did affect Patient Identifier (PI) # 5, and PI # 4, 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: April 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: ...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. ...16. Document findings and interventions in patient's medical record. Facility Procedure: Central Venous Catheter with Clearguard HD (Hemodialysis) Antimicrobial End Caps Procedure Policy number: 1-04-02B Revision date: None listed (Origination Date April 2019) ...Notes: Use Dialysis Precautions and aseptic technique throughout procedure. ...DaVita's first choice for CVC care is 2% Chlorhexidine/ 70% Alcohol swab... Perform 15 second hub scrub every time a CVC is connected or disconnected from the blood lines... Procedure: 1. Perform hand hygiene per procedure. 2. ...Set up clean field with all appropriate supplies on a clean, moisture proof barrier. 3. Place patient in comfortable position... 4. Remove old dressing and discard. 5. Observe site for signs and symptoms of infection... 7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 8. Holding catheter... clean exit site with 2% Chlorhexidine Gluconate/ 70% Isopropyl Alcohol swab for a minimum of 30 seconds... then wait 60 seconds for air dry time. 9. Clean each CVC limb/ cap... 10. Remove gloves and discard, perform hand hygiene... re-glove. ...12. Place sterile 2 (two) x (by) 2 (two) gauze over catheter exit site... 14. Remove gloves and discard, perform hand hygiene... 1. PI # 5 was admitted to the facility on 7/12/22 with diagnoses including ESRD (End Stage Renal Disease). Review of two Treatment Detail Reports dated 7/12/22 and 7/14/22 revealed access type: CVC ...Dressing Change: Yes. There was no documentation of what CVC care was performed, per policy. An interview was conducted on 7/21/22 at 10:26 AM with Employee Identifier (EI) # 10, Manager, Clinical Services, who confirmed staff failed to document the CVC care performed. 2. PI # 4 was admitted to the facility on 5/16/22 with diagnoses including ESRD. Review of 5 Treatment Detail Reports dated 7/5/22, 7/7/22, 7/9/22, 7/12/22, and 7/14/22 revealed access type: AV (Atrioventricular) Graft, Additional Access Type: CVC ...Dressing Change: Yes. There was no documentation of what CVC care was performed on each of the treatment dates, per policy. An interview was conducted on 7/21/22 at 10:48 AM with EI # 1, Facility Administrator, who confirmed staff failed to document CVC care, per policy.