| 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) |
| 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 observation, staff interviews, a review of Centers for Disease Control and Prevention (CDC) guidelines, and a review of the facility's policies and procedures (P & P), it was determined that the Infection Control Committee failed to ensure that all Direct Patient Care (DPC) Staff, (Registered Nurse - RN BB, and Patient Care Technicians - PCTs AA and BB), who were present during this observation, immediately and thoroughly cleaned and disinfected blood-contaminated surfaces on the covers of four of six sharps containers observed, between patient use; and to ensure that one of one Patient Care Technician (PCT AA) observed, utilized appropriate infection control techniques to prevent cross contamination. This failure could lead to the transmission of dangerous pathogens through cross contamination; and had the potential to negatively affect the health and safety of nine of nine patients (P), (P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 47. 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 observed: - The covers of Sharps Containers located at Stations (S1, and S6), next to the laboratory area, and next to the dirty sink , had spattered droplets of dried blood on the top covers of the Sharps Containers. RN BB was notified of this observation on 10/8/24 at approximately 10:50 a.m., which she acknowledged. - PCT AA transferred the TV (television) remote control from S1 to S5 without first disinfecting the surface of the TV control for patient, (P#6) at S5 to use. - When this breach in infection control practice was brought to PCT AA's attention on 10/8/24 at approximately 11:00 a.m., he stated, "Oh, okay". According to CDC guidelines, failure in environmental cleaning and disinfection have led to transmission of bloodborne pathogens (e.g., Hepatitis B virus) and other infections from one patient to another in hemodialysis units. Correct cleaning and disinfection of environmental surfaces (including floors, patient chair or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces, etc., especially with blood splatters) must be performed between patient uses to prevent transmission of dangerous pathogens. A review of facility Policy: 1-05-01, titled, "Infection Control for Dialysis Facilities" with latest revision date of April 2023, stated: 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials... ... iii. Cleaning of visible blood should be performed when first observed... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station... |