| 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) |
| 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 review of facility policies, observations, and staff interview, it was determined the facility failed to ensure staff donned Personal Protective Equipment per facility policy. This did affect two of two observations of cleaning and disinfection of the dialysis station, Patient Identifier (PI) # 10 in one of two observations of access of the Arteriovenous Fistula/Arteriovenous Graft (AVF/AVG) for initiation of dialysis, and PI # 9 in one of two observations of discontinuation of dialysis with a Central Venous Catheter (CVC) and had the potential to negatively affect the 17 incenter patients dialyzing at the facility and staff performing care. Findings include: Facility Policy: Infection Control of Dialysis Equipment Policy Number: 18640 Date Published: Not Listed Purpose: The purpose of this policy is to provide current infection prevention and control guidelines regarding cleaning and disinfecting of patient care equipment and surrounding environment to prevent cross-contamination between patients and care providers: Precautions: All personnel will follow Standard Precautions for all...chemicals. Barriers will be selected based on likelihood of exposure. Appropriate personal protective equipment (PPE) utilized based on exposure risk may include gloves, gown...goggles or face shields. Facility Policy: Dialysis Catheter CVL Maintenance and Dressing Change Policy Number: 18388 Revision: 1 Date Published: Not Listed Precautions: All personnel will follow Standard Precautions for all patient specimens... Barriers will be selected based on likelihood of exposure. Appropriate personal protective equipment utilized based on exposure risk may include gloves, gown...goggles or face shields. 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 failed to don a face shield while discontinuing the dialysis treatment. An interview was conducted on 2/27/25 at 12:19 PM with EI # 1, Director of Nursing, who confirmed staff failed to don a face shield 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. EI # 5 failed to don a face shield while cleaning and disinfecting the dialysis station. An interview was conducted on 2/27/25 at 12:19 PM with EI # 1, who confirmed staff failed to don a face shield per facility policy. 3. An observation was conducted on 2/26/25 at 11:05 AM with EI # 5, during cleaning of dialysis station 5. EI # 5 failed to don a face shield while cleaning and disinfecting the dialysis station. An interview was conducted on 2/27/25 at 12:18 PM with EI # 1, who confirmed staff failed to follow the facility infection control policy during dialysis station disinfection. 4. An observation was conducted on 2/25/25 at 1:30 PM with EI # 7 accessing the Arteriovenous Graft (AVG) for PI # 10 at station 5. EI # 7 failed to don a face shield while accessing the AVG. An interview was conducted on 2/27/25 at 12:19 PM with EI # 1, who confirmed staff failed to don a face shield based on exposure risk per facility policy. 30952 |