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 02/28/2024
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)
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 observation, a review of facility policy, and staff interview, it was determined that the medical director failed to ensure that all Direct Patient Care Staff (DPCS) adhered to facility policy pertaining to vascular access care. This failure could lead to infection of the vascular access of seven of seven patients (P#4, P#6, P#8, P#9, P#10, P#12, and P#13) observed during discontinuation of treatment. The facility census was 35. During observation in The Patient Treatment Room on 2/27/24 between 8:30 a.m. - 10:30 a.m. and 11:30 a.m. - 12:30 p.m., the following was observed: - After dialysis, fistula needles were removed from P#4, P#6, P#8, P#9, P#10, P#12, and P#13's cannulation (needle insertion) sites. - The sites were covered with gauze and tape, and pressure was applied to the cannulation sites. -After hemostasis (stopping of the flow of blood) was attained, the DPCS who were assigned to care for P#4, P#6, P#8, P#9, P#10, P#12, and P#13 did not discard the used gauze dressings but reinforced them with tape. - The DPCS did not apply new band-aid, adhesive dressing or gauze dressing over cannulation sites per facility policy, before the above mentioned patients were discharged. A review of Policy 1-04-01B titled, "Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles" dated April 2023, stated: 13. Once bleeding has stopped, discard gauze or band-aid used to hold site. Inspect site for any trauma and for hemostasis. 14. Apply band-aid or sterile dressing over cannulation site. The above findings were discussed with the Facility Administrator on 2/27/24 at approximately 1:00 p.m.