| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 012515 | (X3) Date Survey Completed 04/20/2023 |
| Name of Provider or Supplier Fresenius Medical Care Opelika | Street Address, City, State 2609 Village Professional Drive, Suite 2, Opelika, 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 policies, and staff interviews, it was determined the facility failed to ensure : 1. Patients performed hand hygiene after holding exit sites prior to exiting the clinic. This included two of three observations for discontinuation of dialysis and post dialysis access care for AV (arteriovenous) fistula or graft which included Patient Identifier (PI) # 16, and PI # 17. 2. Staff performed hand hygiene before administering IV (intravenous) medication, in one of four observations for medication preparation and administration which included PI # 13. This had the potential to negatively affect all patients who dialyze at the facility, staff, and visitors. Findings include: Facility Policy: Hand Hygiene Published: 11/4/19 Version: 6 Purpose: The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. Responsibility All staff, patients...must follow the same requirements for hand hygiene. 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... Hand Hygiene: Patients Patients should perform hand hygiene if able, prior to and after each dialysis treatment. ...Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids, such as...holding access sites post treatment to achieve hemostasis. To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed. Facility Policy: Medication Preparation and Administration Published: 4/5/21 Version: 6 Purpose: To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control. ...Infection Control Perform hand hygiene prior to accessing supplies, handling vials and IV solutions and preparing or administering medications Aseptic technique will be used to prepare and administer IV medications. 1. During observations of care on the treatment floor on 4/18/23 from 9:20 AM to 10:27 AM for discontinuation of dialysis and post dialysis access care for AV Fistula or Graft the following were observed: a. PI # 16 held pressure over his/her access site with a gloved hand. Once hemostasis was achieved, PI # 16 removed his/her glove and exited the treatment area at 9:35 AM without performing hand hygiene. b. PI # 17 held pressure over his/her access site with a gloved hand. Once hemostasis was achieved, PI # 17 removed his/her glove and exited the treatment area at 10:27 AM without performing hand hygiene. The facility staff failed to have PI # 16 and PI # 17 perform hand hygiene per policy. In an interview conducted on 4/20/23 at 10:40 AM, Employee Identifier (EI) # 1, Director of Operations (DO), confirmed the dialysis patients should have performed hand hygiene before exiting the facility per policy. 2. During an observation of medication preparation and administration on 4/18/23 at 11:12 AM, EI # 3, Registered Nurse, prepared IV medication for PI # 13. EI # 3 sanitized his/her hands, donned gloves, and prepared IV Venofer 50 mg (milligram), exited the medication preparation area and entered station 10. EI # 3 administered the IV Venofer wearing the same gloves as used during medication preparation. EI # 3 failed to remove his/her gloves, perform hand hygiene before IV Venofer administration. An interview was conducted on 4/20/23 at 10:40 AM with EI # 1, who confirmed staff must perform hand hygiene prior to administering IV medication. 30952 |