| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852538 | (X3) Date Survey Completed 10/10/2024 |
| Name of Provider or Supplier Jesse Jewell Dialysis | Street Address, City, State 1475 Jesse Jewell Pkwy Ne, Ste 110, Gainesville, GA | |
| 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 observation, patient and staff interviews, a review of facility Policy and Procedures (P& P), facility records, and Centers for Disease Control and Prevention (CDC) Recommendations, it was determined that the Infection Control Committee failed to ensure that two of two patients (P), (P#6 and P#7) observed, performed hand hygiene (washed hands or used an alcohol-based hand sanitizer), after removal of contaminated gloves, and before leaving the Patient Treatment Room. Failure to perform hand hygiene, increased the risk for cross contamination with the potential to expose other patients and staff to bloodborne pathogens in the dialysis environment. The facility in-center census was ___. Findings were: During observation in the Patient Treatment Room on 10/8/24 between 10:15 a.m. and 11:45 a.m., the following was revealed: - P#6 at Station (S4) did not perform hand hygiene after holding his access site at the end of his treatment and before leaving the Patient Treatment Room. Patient Care Technician (PCT BB), who assisted P#6 to the weighing scale, did not remind P#6 to perform hand hygiene after removing his contaminated glove and before leaving the Patient Treatment Room. - P#7 at S7 held his access site without wearing a glove. This observation was brought to PCT AA's attention on 10/8/24 at 10:08 a.m., and he stated, "Oh, okay". PCT AA assisted P#7 to put on a glove (on P#7's right hand), without offering P#7 a hand sanitizer nor encouraging P#7 to wash his hands before putting on his glove. After holding his access site, P#7 left the Patient Treatment Room without performing hand hygiene and was not reminded by PCT AA. - P#8, P#9, and P#10, stated on 10/8/24 between 11:35 a.m. and 11:45 a.m., that they were told to wash their hands before and after treatment but sometimes forgot. - A review of the facility's Policy #1-05-01 titled, "Infection Control for Dialysis Facilities" with latest revision date of April 2023 stated: Hand Hygiene: 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area. - There was no documentary evidence that P#6 and P#7 received education regarding Hand Hygiene. According to CDC recommendations, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal ... |