| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 012509 | (X3) Date Survey Completed 03/30/2023 |
| Name of Provider or Supplier North Alabama Nephrology Center | Street Address, City, State 1311 North Memorial Parkway #200, Huntsville, 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) |
| V0122 | IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This STANDARD is not met as evidenced by: Based on observations, facility policy and procedure, and interview, it was determined the facility failed to ensure staff cleaned and disinfected the dialysis station after patient treatments. This affected two of two observations of the cleaning and disinfection of the dialysis station. Findings include: Facility Policy: Cleaning and Disinfection of the Dialysis Station Reference Number: 47806 Published: 11/07/2022 Version: 13 Purpose The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. Responsibility All dialysis facility staff Background The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent contamination, a dialysis station must be cleaned and disinfected between dialysis patients... Definition Dialysis Station: Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment... Equipment in the dialysis station may include... the following: Dialysis machine/cycler and attachments such as IV (Intravenous) pole, B/P (Blood Pressure) cuff... Chair/bed General Cleaning The dialysis station could become contaminated with blood and other body fluids during treatment. Work Surface Cleaning and Disinfection without Visible Blood using Bleach Solutions. All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. Make the surface glistening wet and let air dry unless otherwise specified by the manufacturer. Procedure Follow the steps below to disinfect the dialysis station after each dialysis treatment: Step: ...3. Use a cloth wetted with 1:100 bleach solution... to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff... wall behind chair... 4. Clean all surfaces... 1. An observation was conducted on 3/29/23 at 9:22 AM to observe EI (Employee Identifier) # 6, Certified Clinical Hemodialysis Technician (CCHT), perform cleaning and disinfection of station 4. EI # 6 removed the television remote from the wire basket on the side of the dialysis machine, cleaned the remote then placed the clean remote back in the wire basket which had not been cleaned. EI # 6 failed to disinfect the wire basket and the surface inside the basket. EI # 6 failed to disinfect the sharps container on the dialysis machine. In an interview conducted on 3/30/23 at 10:05 AM with EI # 1, Facility Administrator, the surveyors reviewed observations for dialysis station cleaning and disinfection. EI # 1 confirmed staff failed to follow the facility policy for dialysis station cleaning/disinfection. 2. An observation was conducted on 3/29/23 at 9:35 AM to observe EI # 8, Certified Clinical Nephrology Technician (CCNT), perform cleaning and disinfection of dialysis station 17. EI # 8 first cleaned the dialysis chair with bleach cloths and failed to ensure all surfaces were visibly wet. EI # 8 failed to clean and disinfect underneath the chairside tabletops bilaterally. EI # 6 then proceeded to unplug the chair and failed to the clean and disinfect the cord and placed the chair cord in the chair. EI # 8 failed to re-clean the chair after placing the dirty chair cord in the chair. EI # 8 then began cleaning and disinfection of the dialysis machine and equipment. EI # 8 cleaned and disinfected the B/P cuff and placed the B/P cuff in the dirty chair without first re-cleaning the chair. Further observations revealed EI # 8 failed to clean and disinfect the front surfaces of the dialysis machine (Heparin pump and Venous chamber), the side surfaces (IV pole, wire basket, television remote, sharps container, dialysate hoses, Hansen connectors), and the counter top behind the dialysis station. An interview was conducted on 3/30/23 at 10:01 AM, with EI # 1, who confirmed the staff failed to follow the facility policy for cleaning and disinfection of the dialysis station. 30952 |