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 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)
V0147 IC-STAFF EDUCATION-CATHETERS/CATHETER CARE
CFR(s): 494.30(a)(2)

Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].


This STANDARD is not met as evidenced by:
Based on observations, review of the facility procedure, and staff interviews, it was determined the facility failed to ensure staff performed Central Venous Catheter (CVC) exit site care according to facility procedure in two of two CVC observations. This affected Patient Identifier (PI) # 4, and PI # 11 and had the potential to negatively affect all patients with CVC's who dialyze at this facility. Findings include: Facility Procedure: Changing the Catheter Dressing Published: 05/02/2022 Reference Number: 45664 Version: 7 Purpose: The purpose of this policy is to provide instruction for cleaning the hemodialysis catheter exit site... Supplies ...1 package-2% chlorhexidine (CHG) 70% isopropyl alcohol swabs stick... Cleaning the Site: Follow the steps below to clean the catheter exit site: ...2. Remove swab stick from package... 2% CHG and 70% alcohol (Chloraprep): Using gentle back and forth friction, clean the exit site beginning in the center...and continuing outward....for 30 (thirty) seconds and allow to dry a minimum of 30 seconds... 1. During an observation of CVC exit site care conducted at station 4 on 4/18/23 at 12:10 PM, Employee Identifier (EI) # 4, Registered Nurse (RN) cleaned PI # 4's CVC exit site with one Chloraprep swab stick for five seconds, utilized a second Chloraprep swab stick and cleaned the exit site again for an additional eight seconds, cleaning the exit site for a total of 13 seconds. EI # 7 failed to clean the exit site with Chloraprep for 30 seconds. An interview was conducted on 4/20/23 at 10:40 AM with EI # 1, Director of Operations (DO), who confirmed staff failed to follow the CVC exit care procedure. 30952 2. During an observation of care on 4/18/23 at 12:12 PM, the surveyor observed EI # 3, RN, perform CVC exit site care and initiation of dialysis on PI # 11. During exit site care, EI # 3 cleansed the CVC exit site with Chloraprep antiseptic swab stick for 20 seconds. EI # 3 failed to clean the CVC exit site with Chloraprep for 30 seconds per facility procedure. An interview was conducted on 4/20/23 at 10:40 AM with EI # 1, who confirmed staff failed to follow the CVC exit site care procedure.