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 852560 (X3) Date Survey Completed 02/22/2024
Name of Provider or Supplier Poplar Dialysis Street Address, City, State 2301 Newnan Crossing Blvd, Ste 180, Newnan, 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)
V0147 IC-STAFF EDUCATION-CATHETERS/CATHETER CARE
CFR(s): 494.30(a)(2)

Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].


This STANDARD is not met as evidenced by:
Based on observation, a review of policy, and staff interviews, it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN NN) observed during initiation of dialysis through a Central Venous Catheter (CVC - a large plastic tube placed in a vein in the neck or groin for exchange of blood to and from the hemodialysis machine during the hemodialysis treatment) access, adhered to facility policy pertaining to CVC. This deficient practice increased the relative risk for bacteremia in patients with dialysis catheters, and had the potential to affect all current and future facility patients with CVC. Findings were: During observation in the Patient Treatment Room on 2/21/24 between 11:00 a.m. and 12:00 p.m, the following was revealed: - At 11:08 a.m., RN NN initiated dialysis treatment on Patient (P) #21 with a CVC access at Station (S) 6. When cleansing the CVC limb hubs (end of CVC that connects to the blood lines or cap), RN NN scrubbed each hub for 4 seconds only. - At 11:40 a.m., RN NN changed the CVC dressing of P#15 at S 8. She cleaned the exit site with 2% Chlorhexidine Gluconate 70% Isopropyl Alcohol swab for 10 seconds only. - At 11:45 a.m., RN NN initiated dialysis treatment on P#15 via CVC. When cleansing the CVC limb hubs, RN NN scrubbed each hub for 10 seconds only. A review of Policy 1-04-02B titled, "Central Venous Catheter (CVC) with Cleaguard HD Antimicrobial End Caps and Tegaderm CHG Dressing Procedure" dated October 2023 stated: For initiation of hemodialysis: Scrub each hub for 15 seconds including the sides, threads and end of hub thoroughly. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate 70% Isopropyl Alcohol swab for a minimum of 30 seconds. The Facility Administrator was informed of the above findings on 2/21/24 at approximately 12:35 p.m. The findings were discussed with RN NN on 2/21/24 at 12:45 p.m.