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 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)
V0143 IC-ASEPTIC TECHNIQUES FOR IV MEDS
CFR(s): 494.30(b)(2)

[The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and


This STANDARD is not met as evidenced by:
Based on observation, review of the CDC (Centers for Disease Control) Injection Safety Information for Providers, facility policy, and interview, it was determined Registered Nurse (RN), Employee Identifier (EI) # 3 failed to use a sterile syringe and needle when entering the medication vial. This affected unsampled Patient Identifier (PI) # 10, 1 of 2 observations of multidose vial medication preparation/administration and had the potential to negatively affect all patients who dialyzed at the facility. Findings include: CDC Injection Safety Information for Providers FAQ's (Frequently Asked Questions) Regarding Safe Practices for Medical Injections ....1. How should I draw up medications? Parental medications should be accessed in an aseptic manner...includes using a new sterile syringe and sterile needle to draw up medications... Medication Administration Questions ...The safest practice is to always enter a medication vial with a sterile needle and sterile syringe, even when obtaining additional doses of medication for the same patient. This adds an extra layer of safety in case...the medication vial is not discarded at the end of the procedure...and is inadvertently used on a subsequent patient... Facility Policy: Medication Preparation and Administration Published: 4/5/21 Version: 6 Purpose: To administer medication with the goals of staff and patient safety...and infection control. ...Infection Control The following steps must be taken to ensure infection control. Always use a sterile syringe and needle when entering a vial...If either vial is multi-use a different syringe must be used for entry into each vial... 1. During an observation of care on 7/13/21 at 12:30 PM CST (Central Standard Time) at the medication preparation counter, EI # 3 prepared Heparin from an opened multidose vial and withdrew 6 ml (milliliter) into a needle and syringe, which was insufficient for the ordered Heparin. EI # 3 then opened an unused multidose Heparin vial. Using the same syringe and needle, EI # 3 withdrew an additional 1 ml to 1.5 ml Heparin into the syringe. EI # 3 labeled the multidose Heparin vial and placed the vial in the locked medication cabinet. EI # 3 failed to use a sterile needle and syringe for parental medication preparation per CDC recommendations and facility policy. In an interview on 7/14/21 at 11:10 AM CST, EI # 1, Director of Operations, confirmed medication vials must be entered each time with a sterile needle and syringe.