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 852555 (X3) Date Survey Completed 03/21/2019
Name of Provider or Supplier Quitman Dialysis Street Address, City, State 101 E. Davis Street, Quitman, 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 observations, a review of the facility's policies and procedures (P & P), a review of the Center for Disease Control and Prevention (CDC) recommendations, and staff interviews, it was determined that the Infection Control Committee failed to ensure that three of three licensed personnel (Registered Nurse - RN AA, RN BB, and Licensed Practical Nurse - LPN AA), and one of one Patient Care Technician (PCT AA) observed, utilized appropriate techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of 12 of 12 Patients (P), (P#1 - P#12) who were undergoing hemodialysis (HD) treatment at the time of this observation and all the other 27 patients who dialyze at this facility. Findings include: During observation in the patients' treatment room on 3/19/19 between 11:00 a.m. and 11:50 a.m., the following was observed: PCT AA did not clean and disinfect P#11's HD chair at Station (S3), after P#11 completed his/her HD treatment and left the treatment room. There were reddish-brown stains on the chair's right side table. The Charge Nurse (CN) - RN AA, was notified of this observation on 3/19/19 at 11:40 a.m. and she stated that PCT AA should have cleaned and disinfected P#11's HD chair before PCT AA left the treatment room. During observations in the patients' treatment room on 3/20/19 between 9:50 a.m. and 12:00 p.m., the following was observed: RN AA and LPN AA were observed testing the pH (acidity) and Conductivity (ability of the dialysate to conduct electricity) of the dialysate at Stations (S1 and S2), respectively, using a Phoenix Meter (a device used to measure pH and Conductivity). Both employees did not disinfect the exterior of the Phoenix Meter after using them (at the above mentioned stations), before returning them to the clean area, at the counter. RN BB was observed during initiation of HD treatment on P#12 with a central venous catheter (CVC), at the Isolation Room. RN BB opened two sterile 10-cc syringes without needles, removed them from the packaging and laid them in an unsterile blue liner, then used both contaminated syringes to draw the old blood from P#12's catheter limbs. RN BB was observed during initiation of HD treatment on P#4 at S9. RN BB handed the Heparin (anticoagulant) syringe for maintenance dose back to RN AA since the amount of Heparin in the syringe was not enough. RN AA used the same contaminated Heparin syringe and needle to draw more Heparin (sterile) from the Heparin Multi-dose Vial, thus causing cross-contamination. During an interview with RN AA on 3/20/19 at 10:40 a.m., she stated that she should have discarded the contaminated Heparin syringe and needle and used a new, sterile syringe and needle to obtain the correct dose of Heparin for maintenance from a multi-dose Heparin vial. During an interview with RN BB on 3/21/19 at 1:50 p.m., she stated that she should have kept the sterile syringes in their package and kept them sterile until used, to avoid cross contamination. A review of the facility's Policy # 1-05-01, titled, "Infection Control For Dialysis Facilities", with revision date, December 2018, page 6 of 11, stated: 44. Teammates will thoroughly wipe down all non-disposable items and equipment such as ..., with an appropriate disinfectant after every treatment. 51. Equipment ..., the dialysis chair and side tables..., will be wiped clean with a bleach solution of the appropriate strength after completion of procedures, before being used on another patient..., and after each treatment. A review of the facility's Policy # 1-06-01, titled, "Medication Policy", with revision date, June, 2017, stated: 8. All teammates administering medications must utilize aseptic technique. 26. Multi-dose vials used for IV (intravenous) administration must be entered each time with a new sterile syringe and needle... - According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area) without proper disinfection, could cause the spread of bacteria/infection. During a discussion with the Facility Administrator on 3/21/19 at 2:35 p.m., she stated that the staff should utilize appropriate infection control techniques to prevent cross contamination.