Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012306	(X3) Date Survey Completed 02/27/2025
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 review of facility policy, observations, and staff interview, it was determined the facility failed to ensure staff followed policies related to infection prevention and control which could result in transmission of bacteria and poor patient outcomes. This affected Patient Identifier (PI) # 9, in one of two observations of discontinuation of dialysis with a Central Venous Catheter (CVC), in one of two observations of cleaning and disinfection of the dialysis station, one of two medication preparation and administration observations, which included PI # 8, and one of two observations for preparation of the hemodialysis (HD) machine. This had the potential to negatively affect the 17 incenter patients dialyzing at the facility, staff, and visitors. Findings include: Facility Policy: Hand Hygiene Policy Number: 12020 Revision: 9 Date Published: Not listed Purpose: Hands are the most common way in which microorganisms might be transported and cause infection. When to Perform Hand Hygiene: Before and after patient contact, even if the patient's skin is intact. Before and after touching any items in the patient's room... Before and after wearing gloves. Before and after handling dressings, body secretions and body excretions. After entering and/or working in an area that is likely to be highly contaminated, i.e. patient room... Hand Hygiene Technique: ...Alcohol-Based Instant Hand Sanitizer ...The efficacy of alcohol-based products depends on the technique of the user. If not enough product is dispensed or...not applied to all parts of the hand...efficacy may be limited. I. Put hands together spreading the...sanitizer onto fingertips, cuticles, and nails up to wrists. Rub palms against each other. II. Rub...sanitizer into back of hand, into the web spaces between fingers and on both thumbs. Repeat procedure for the other hand. III. Rub hand surfaces together UNTIL THEY ARE DRY... 1. An observation was conducted on 2/25/25 at 10:37 AM with Employee Identifier (EI) # 3, Registered Nurse (RN), performing discontinuation of dialysis with a CVC for PI # 9 at station 3. EI # 3 entered the patient station, and without performing hand hygiene, retrieved clean gloves from the box of clean gloves, and donned them. EI # 3 then removed one glove, exited the patient station, retrieved clean supplies from the drawer at the supply cabinet, re-entered the patient station, and without performing hand hygiene, retrieved a glove from the box of clean gloves, and donned it. After reinfusing the extracorporeal circuit, EI # 3 failed to remove his/her gloves and perform hand hygiene. An interview was conducted on 2/27/25 at 12:19 PM with EI # 1, Director of Nursing, who confirmed staff failed to perform hand hygiene per facility policy. 2. An observation was conducted on 2/25/25 at 10:56 AM with EI # 5, Unit Support Specialist, cleaning and disinfecting dialysis station 3. After emptying the prime waste container, EI # 5 failed to remove gloves and perform hand hygiene before completing the disinfection of the station. An interview was conducted on 2/27/25 at 12:19 PM with EI # 1, who confirmed staff failed to perform hand hygiene per facility policy. 30952 3. An observation of medication preparation and administration was conducted on 2/25/25 at 11:20 AM with EI # 4, RN, in the medication room, and at station 6, for PI # 8. During the observation, EI # 4 performed hand hygiene using hand sanitizer on multiple occasions for less than 4 seconds before donning gloves. EI # 4 failed rub hands together briskly until dry. An interview was conducted on 2/27/25 at 12:18 PM with EI # 1 who confirmed staff must apply adequate amount of product, briskly rub hands together, an allow sanitizer to dry before donning clean gloves. 4. An observation of care was conducted on 2/25/27 at 11:55 AM at station 4, with EI # 3, for preparation of the HD machine for treatment for an unsampled patient. EI # 3, gloved, placed saline solution bag, dialyzer, and bloodlines on the HD machine. EI # 3 removed gloves but failed to perform hand hygiene after glove removal. An interview was conducted on 2/27/25 at 12:18 PM with EI # 1 who confirmed staff must perform hand hygiene after glove removal.