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 852557 (X3) Date Survey Completed 03/22/2023
Name of Provider or Supplier Fresenius Kidney Care Glynn County Street Address, City, State 3150 Glynn Avenue, Brunswick, 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)
V0121 IC-HANDLING INFECTIOUS WASTE
CFR(s): 494.30(a)(4)(i)

[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- (i) Handling, storage and disposal of potentially infectious waste;


This STANDARD is not met as evidenced by:
Based on observation, a review of facility policies and procedures and Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, it was determined that the Infection Control Committee failed to ensure that the staff followed the facility's infection control policies, to prevent cross contamination and the spread of infections. The facility failed to clean and disinfect multiple blood splatters on the outside of six of 17 sharps containers that were attached to the hemodialysis machines at Stations (S) 2, 4, 5, 8, 15 and 16 in one of one patient treatment room. Findings include: During a tour of the patient treatment room on 3/20/23 between 1:30 p.m. - 2:30 p.m., it was observed that the sharps containers attached to the side of the hemodialysis machines in S2, S4,S5, S8, S15, and S16, were more than 2/3 full and had multiple blood splatters on the outside of the containers. The blood splatters were not cleaned and wiped with a disinfectant cloth during the observation. A review of policy titled, "Medical Waste Management Plan" dated 7/31/21 stated that all sharps container must be replaced when they are 2/3 to 3/4 full. A review of policy FMS-CS-11-155-110A titled, "Cleaning and Disinfection of Dialysis Station" dated July 1, 2019 paragraph titled, "Work Surface Cleaning and Disinfection with Visible Blood" stated that after cleaning up all visible blood, use a new cloth wet with 1:100 bleach solution for a second cleaning of the surface. According to CDC guidelines, failures 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 patient chair or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces) must be performed between patients uses to prevent transmission of dangerous pathogens. During an interview with the Clinic Manager on 3/21/23 at approximately 4:00 p.m., she stated that the staff should have used a separate bleached cloth to clean and disinfect the surfaces of the sharps containers at the patient stations and emptied the containers.