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 852582 (X3) Date Survey Completed 04/26/2023
Name of Provider or Supplier West Clayton Dialysis Street Address, City, State 100 Promenade Pkwy Suite C, Fayetteville, 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)
V0115 IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK
CFR(s): 494.30(a)(1)(i)

Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory.


This STANDARD is not met as evidenced by:
Based on observation, a review of the facility's Policy, and staff interview, it was determined that the facility failed to ensure that all Direct Patient Care (DPC) Staff (Registered Nurse, (RN) AA, Licensed Practical Nurse, (LPN) AA, and Patient Care Technicians, (PCTs) AA, BB, and CC) who were working in the Patient Treatment Room, did not carry or keep their drink or drink containers in the Patient Treatment Room. This deficient practice had the potential for cross contamination and negative effect on the health and safety of five of five DPCs who were working in the Treatment Room at the time of this observation. Findings include: During observation in the Patient Treatment Room on 4/26/23 at 12:05 p.m., there was a green drink container that was placed next to the DPCs' computer. PCT BB stated on 4/26/23 at approximately 12:40 p.m., that she didn't know who's drink container it belonged to. A second observation in the Patient Treatment Room was conducted on 4/26/23 at 3:00 p.m. A clear water bottle/container was kept at the Charge Nurse's desk. A review of the facility's Policy: 1-05-01, titled, "Infection Control for Dialysis Facilities", with latest revision date of April 2023, stated: 17. Food and drinks in the treatment area will be limited to patients. Sharing and storage in the treatment area is not allowed.