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 852550 (X3) Date Survey Completed 10/29/2019
Name of Provider or Supplier Dublin Kidney Institute Street Address, City, State 207 Industrial Blvd Ste 2, Dublin, 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)
V0117 IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS
CFR(s): 494.30(a)(1)(i)

Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients.


This STANDARD is not met as evidenced by:
Based on observation, a review of the Center for Disease Control and Prevention (CDC) guidelines, review of facility's Policies and Procedures (P & P), and staff interview, it was determined that the facility failed to ensure that one of three Patient Care Staff, (RN AA) observed, used alcohol wipe/swab to disinfect the contaminated arterial bloodline tip and the Normal Saline (NS) port, prior to the reinfusion of blood of a patient (P) (P#2), to prevent cross contamination. This breach in infection control technique could negatively affect the health and safety of one of two patients (P#2), who were dialyzing at a Skilled Nursing Facility (SNF) and who were under the care of this facility. Findings include: During observation in the dialysis treatment room at a SNF on 10/29/19 between 11:10 a.m. and 12:45 p.m., the following was observed: - RN AA was observed discontinuing dialysis treatment on P#2. She disconnected the arterial AVF needle (dialysis needle) from the arterial bloodline tubing and attempted to connect the arterial bloodline tip to the NS port (hanging freely from the pole) with one hand (right hand), while she held the arterial AVF needle with her left hand. It took four attempts to align and insert the tip of the bloodline tubing into the NS port. In the process, the tip of the arterial tubing accidentally touched the outside surfaces of the NS port with each attempt, that caused contamination to the arterial bloodline tip and the NS port. - RN AA did not use alcohol wipe/swab to disinfect the contaminated arterial bloodline tip and the NS port after each attempt and prior to the reinfusion of blood of P#2. According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area) without proper disinfection, could cause the spread of pathogens/infection. A review of the facility's P & P, titled, "Infection Control Manual" with effective date of 1/14, stated: Use Aseptic Technique. During an interview on 10/29/19 at 4:30 p.m., the Facility Administrator (FA) stated that she also saw RN AA's breach of infection control technique when she used a "one-hand technique" to connect the bloodline to the NS bag. The FA stated that she inquired RN AA about it and RN AA told her that she didn't know why she did it that way.