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 012306 (X3) Date Survey Completed 06/24/2021
Name of Provider or Supplier Childrens Hospital Of Alabama Esrd Street Address, City, State 1600 7th Avenue South, Birmingham, AL
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)
V0113 IC-WEAR GLOVES/HAND HYGIENE
CFR(s): 494.30(a)(1)

Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.


This STANDARD is not met as evidenced by:
Based on observations, review of facility procedure and interview, it was determined the facility failed to ensure staff followed their procedure for cannulation of AV (Arteriovenous) Graft/Fistula and perform hand hygiene after access site evaluation. This affected 1 of 2 patient observations for access site cannulation that included Patient Identifier (PI) # 8, and this had the potential to negatively affect all patient who dialyzed at this facility. Findings include: AV (arteriovenous) Fistula-Assessment, Cannulation, De-cannulation and Lab Draw Departmental Procedure No. 18335 Last Revised/Reviewed: 1/29/2020 I. Purpose The purpose of this procedure is to provide guidelines for routine AV Fistula/Graft cannulation, decannulation, and assessment of the AV Fistula/Graft. VI. Procedure E. Cannulation of a New AV Fistula/Graft (AVG) 2. Procedure d. Assess the Fistula/Graft i. Determine the directional flow ii. Check the bruit and thrill... f. Wash hands. Apply gloves. g. Prep site... i. Cannulate at a 25 degree angle... An observation of care on 6/23/21 at 9:05 AM for treatment initiation using an AVG with EI (Employee Identifier) # 4, RN (Registered Nurse) was conducted. At station 2, EI # 4 evaluated the AVG site, first by palpation with gloved hands, and then with a stethoscope. EI # 4 applied alcohol wipes to the AVG access site of PI # 8, an unsampled patient, then cannulated the access site. EI # 4 failed to remove gloves and perform hand hygiene after AVG site evaluation and prior to cannulation. In an interview on 6/23/21 at 9:25 AM following the observation, EI # 2, RN, Charge Nurse, also present during the procedure, verified the observation and confirmed staff failed to follow the facility procedure and perform hand hygiene after access evaluation.