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)
V0715 MD RESP-ENSURE ALL ADHERE TO P&P
CFR(s): 494.150(c)(2)(i)

The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;


This STANDARD is not met as evidenced by:
Based on a review of facility records and staff interviews, it was determined that the Medical Director (MD) failed to ensure that all three Patient Care Staff, (RN AA, RN BB, and LPN AA), who administered home hemodialysis treatments to patients, (P#1, P#2, and P#3), who were residents at a Skilled Nursing Facility, adhered to the facility's policy and procedure (P&P) relative to infection control techniques. This deficient practice had harmed P#1, and had the potential to negatively affect the health and safety of the other two patients (P#2 and P#3), after P#1's Hepatitis C Seroconversion was discovered. Findings include: Cross reference the following cited deficiencies: V 113 - Failure of the Medical Director to ensure that staff followed P & P regarding hand hygiene and glove use and glove changes. V 115 - Failure of the Medical Director to ensure staff followed P & P regarding wearing appropriate personal protective equipment (PPE) during potential exposure to blood and body fluids. V 117 - Failure of the Medical Director to ensure staff followed P & P regarding infection control techniques to avoid cross contamination.