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 012506 (X3) Date Survey Completed 04/13/2023
Name of Provider or Supplier Dothan Dialysis Street Address, City, State 216 Graceland Drive, Dothan, 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)
V0115 IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK
CFR(s): 494.30(a)(1)(i)

Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory.


This STANDARD is not met as evidenced by:
Based on observations, review of facility procedure, and interview, it was determined the staff failed to properly wear face masks during one of three observations for Central Venous Catheter (CVC) Exit Site Care. This did affect Patient Identifier (PI) # 8 and had the potential to negatively affect all patients who dialyze at the facility. Findings include: Facility Procedure: Central Venous Catheter with Clearguard HD (Hemodialysis) Antimicrobial End Caps Procedure Procedure Number: 1-04-02B Revision Date: April 2023 Notes: Use Dialysis Precautions and aseptic techniques throughout procedure. Procedure: 1. ...Teammate and patient will wear masks covering the nose and mouth during this procedure ... These measures are vital to preventing the exposure of the catheter and exit site to nasal droplets and infectious bacteria ... 1. An observation was conducted on 4/11/23 at 11:25 AM at station 7 to observe Employee Identifier (EI) # 7, Registered Nurse (RN) perform CVC exit site care on PI # 8. EI # 7's face mask was worn below the level of the nose during the CVC site care and initiation of dialysis. EI # 7 failed to wear the face mask covering the nose and mouth per facility procedure. An interview was conducted on 4/13/23 at 11:04 AM with EI # 1, Facility Administrator, who confirmed the RN failed to properly wear face masks during CVC exit site care per facility procedure.