Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012512	(X3) Date Survey Completed 11/17/2022
Name of Provider or Supplier Fmc Dialysis Services Selma	Street Address, City, State 905 Medical Center Parkway, Selma, 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)

V0113

IC-WEAR GLOVES/HAND HYGIENE
CFR(s): 494.30(a)(1)

Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.

This STANDARD is not met as evidenced by:
Based on observations, review of the facility hand hygiene policy and staff interviews, it was determined the facility failed to ensure the staff followed the facility policy for hand hygiene in 6 of 16 observations conducted. This had the potential to negatively affect all patients who dialyze at the facility. Findings include: Facility Policy: Hand Hygiene Date: 11/4/19 Reference Number: 47664 Policy: Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content. Hands will be: Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water. When: Before and after direct contact with patients. Entering and leaving the treatment area. Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications. Immediately after removing gloves. After contact with inanimate objects near the patient. When moving from a contaminated body site to a clean body site of the same patient. Procedure for Decontaminating Hands With Alcohol Based Hand Rubs: Procedure: 1. If gloves are worn, remove and discard... 2. Apply alcohol-based hand rub to the palm of one hand using the amount recommended... 3. Rub hands together covering all surfaces of the hands and fingers, until hands are dry. Allowing alcohol to dry completely allows adequate contact time to kill germs... 1. An observation was conducted on 11/15/22 at 9:15 AM with Employee Identifier (EI) # 5, Registered Nurse (RN), to observe a single dose medication being drawn up from the vial and taken to station # 16. After drawing up the medication in a syringe, EI # 5 removed gloves and donned clean gloves, failed to sanitize hands prior to donning gloves and preceded to station # 16. Once at the station EI # 5 documented on the machine. After completing documentation with the same gloves on, EI # 5 gave the medication to the patient, and documented on the machine. EI # 5 then removed gloves and washed hands. An interview was conducted on 11/17/22 at 10:50 AM with EI # 1, Clinic Manager, who confirmed the nurse failed to sanitize hands prior to donning clean gloves after drawing up the medication. EI # 1 also stated EI # 5 should have removed gloves after documentation on the machine and sanitized hands, donned clean gloves prior to giving the medication and EI # 5 failed to follow facility policy. 2. An observation was conducted on 11/15/22 at 10:20 AM with EI # 3, Certified Clinical Hemodialysis Technician (CCHT) to observe procedure for a water check. Once the water check was complete EI # 3 removed gloves and failed to sanitize or wash hands. An interview was conducted on 11/17/22 at 10:50 AM with EI # 1 who confirmed the CCHT failed to remove gloves and sanitize hands after completing the water check. 3. An observation was conducted on 11/15/22 at 11:30 AM to observe the discontinuation of a Central Venous Catheter (CVC) at station # 3 with EI # 5. After the blood lines were disconnected EI # 5 failed to remove gloves and sanitize hands and flushed line with Heparin, documented on the machine and with same gloves obtained 4 by 4 gauze and wrapped the CVC lines and taped with gauze. An interview was conducted on 11/17/22 at 10:55 AM with EI # 1 who confirmed the nurse failed to remove gloves and sanitize hands and don clean gloves after heparin flush and prior to documentation on the machine. EI # 5 also failed to sanitize hands and don clean gloves prior to obtaining four by four gauze, wrapping the CVC lines and taping in place. 4. An observation was conducted on 11/15/22 at 9:30 AM with EI # 3 to observe the cleaning of the dialysis station # 14. During the cleaning at station # 14, the dialysis machine at station # 15 began to alarm. EI # 3, removed gloves, donned clean gloves and did not sanitize hands prior to donning clean gloves, went to station # 15, reset the alarms and documented on the machine. EI # 3 removed gloves and did not sanitize hands and obtained clean supplies from the supply cart. EI # 3 then donned clean gloves did not sanitize hands and took clean supplies to station # 15. An interview was conducted on 11/17/22 at 10:57 AM with EI # 1 who confirmed the CCHT failed to follow the facility policy for glove change and sanitizing hands. 5. An observation was conducted on 11/15/22 at 9:45 AM with EI # 3 at station # 15 to observe the discontinuation of an AV (arterial venous) fistula or graft. During the observation EI # 3 removed the blood lines and with the same gloves on, documented on the machine. EI # 3 then removed gloves, donned clean gloves and failed to sanitize hands prior to donning clean gloves. An interview was conducted with EI # 1 on 11/1722 at 11:00 AM who confirmed the CCHT failed to follow the facility policy and procedure for hand hygiene and glove change. 40119 6. An observation was conducted on 11/15/22 at 2:00 PM at station # 1 to observe the discontinuation of CVC. During the observation EI # 4, CCHT, obtained alcohol pads then entered station # 1 and handed the alcohol pads to the nurse without performing hand hygiene prior to obtaining clean supplies and entering station # 1. An interview was conducted with EI # 1 on 11/17/22 at 11:30 AM who confirmed the tech failed to follow the facility policy and procedure for hand hygiene.