Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012513	(X3) Date Survey Completed 07/14/2021
Name of Provider or Supplier Bma Langdale	Street Address, City, State 8 Medical Park North, Valley, 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 interviews, it was determined the facility failed to ensure staff: 1. Prepared and labeled bleach solutions daily. 2. Cleaned and disinfected the dialysis station after patient treatments per its own policy. This affected 4 of 4 dialysis station disinfection observations and had the potential to negatively affect all patients dialyzed by this facility. Findings include: Facility Procedure: Mixing Bleach Published: 8/25/2020 Version: 4 2. Pour measure amount of water needed into labeled opaque container... 4. Label opaque container with "Bleach Solution", strength of solution, date, and time prepared, and your initials. Facility Policy: Cleaning and Disinfection of the Dialysis Station Published: 11/02/2020 Version: 11 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 ...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...and attachment such as (IV) intravenous pole... General Cleaning The dialysis station could become contaminated with blood and other body fluids during treatment... After use, all equipment and supplies must be considered as potentially blood contaminated, and should be separated, handled with caution and either disinfected or discarded. Work Surface Cleaning and Disinfection without Visible Blood using Bleach Solutions. All work surfaces shall be cleaned and disinfected with 1:100 (1-part bleach, 100 parts water) bleach solution after completion of procedures. Make the surface glistening wet and let air dry unless otherwise specified by the manufacturer... During observations of the care from 10:00 AM CST (Central Standard Time) to 3:30 PM CST, the surveyors observed the following: 1. At 10:00 AM CST, 4 containers filled with liquid were observed 2 on each end of the treatment floor with white disposable cloths beside them. The surveyor asked Employee Identifier (EI) # 7 Certified Clinical Hemodialysis Technician (CCHT) what was in the containers. EI # 7 stated, "It's our bleach solution for cleaning." EI # 7 confirmed the containers were not labeled with type of bleach solution, date, time, or initials of the staff who prepared the solution. 2. At 10:15 AM CST at station 12 the surveyor observed Patient Identifier (PI) # 18 was dialyzing with the plumbed bath of 2.0 K (Potassium) 2.0 Ca (Calcium) 1.0 Mg (Magnesium) (2201). The surveyor noted a dialysate container labeled as 3.0 K, 2.5 Ca, 1 Mg (3231) sitting on the base of the dialysis machine. The surveyor asked EI # 7, "Is this for PI # 18?" EI # 7 stated, "No, I just didn't move it." EI # 7 failed to ensure all supplies were either disinfected or discarded. 3. At 12:25 PM CST at station 3, EI # 5, PCT (Patient Care Technician), disinfected the HD (hemodialysis) machine top, and HD right side but failed to disinfect the hand sanitizer container. In addition, EI # 5 failed to disinfect the Hansen connector. 30952 4. At 2:35 PM CST at station 2, EI # 5, PCT removed the bath jug from the base of the HD machine then placed the jug on the staff stool seat. EI # 5 disinfected the HD top, and HD right side but failed to disinfect the inside of wire BP (blood pressure) cuff basket and hand sanitizer container also inside the basket. In addition, EI # 5 failed to disinfect the Hansen connector. 5. EI # 5 completed disinfection of station 2 and at 2:45 PM CST, EI # 5 exited the treatment floor with the bath jug. EI # 5 failed to disinfect the staff stool after removing the bath jug from the stool. 6. At 2:55 PM CST at station 10 during the dialysis treatment of an unsampled patient, the surveyor observed 2 syringes that contained 1.5 ml- 2 ml dark substances in each lying on the chairside table. The surveyor asked EI # 7, CCHT what was in the 2 syringes on the patient chairside table. EI # 7 confirmed blood was in the syringes and disposed of the 2 syringes into the sharps container. EI # 7 failed to follow standard infection precautions and discard the syringes that contained visible blood from the chairside table. 7. At 3:00 PM CST at station 4 during an observation of care, the surveyor observed white crystals on the staff stool that were from the bath jug placed on the stool during station 2 disinfection and not disinfected by EI # 5. 8. On 7/13/21 at 10:45 AM CST at station 17, EI # 11 PCT, disinfected the top of the HD machine and while disinfecting the IV pole, removed the blue clip from the IV pole and placed the clip in the bleach solution. EI # 11 failed to remove all reusable equipment before beginning disinfection. EI # 11 then returned to station 17 and completed disinfection of the HD machine, and failed to clean the back of the station or the arm of the TV. In an interview on 7/14/21 at 11:25 AM, EI # 1, Director of Operations confirmed the observations were breaches in the facility infection control policies and procedures.