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 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)
V0122 IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL
CFR(s): 494.30(a)(4)(ii)

[The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.


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 failed to follow infection prevention and control guidelines and facility policy regarding cleaning and disinfection of patient care equipment and surrounding environment in two of two observations of cleaning and disinfection of the dialysis station. This deficient practice had the potential to negatively affect the 17 incenter patients dialyzing at the facility. Findings include: Facility Policy: Infection Control of Dialysis Equipment Policy Number: 18640 Date Published: Not listed ...IV. Equipment 1. Each dialysis station is cleaned and disinfected prior to each patient's use. This includes, but is not limited to: Chair fully reclined, tables, TV, computers, dialysis machine, critline, containers, patient's blood pressure cuff, used clamps, Phoenix meter, acid wands, Hemachron Elite, and machine log clipboard. a. The exterior surfaces of the dialysis machine, care equipment and care area will be disinfected with a hospital approved germicidal disposable wipe. 1. An observation was conducted on 2/26/25 at 10:56 AM with Employee Identifier (EI) # 5, Unit Support Specialist, cleaning dialysis station 3. EI # 5 failed to disinfect all exterior surfaces of the dialysis machine, including all sides of the machine, basket, IV pole, Hansen Connectors, prime waste container, reusable clamps, and blood pressure cuff cord. EI # 5 failed to disinfect all surfaces in the patient care area, including the TV, wall behind the dialysis machine, sharps container, and chair used by the family during 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 clean and disinfect the dialysis station and surrounding areas per facility policy. 30952 2. 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 disinfect all exterior surfaces of the dialysis machine, including all sides of the machine, the IV pole, reusable clamps, and clip board on the pole. EI # 5 removed and emptied the prime waste container but failed to disinfect the inside and outside surfaces of the container before replacing the container onto the dialysis machine. EI # 5 failed to disinfect all surfaces in the patient care area, including the TV, and chair used by the family during the dialysis treatment. An interview was conducted on 2/27/25 at 12:18 PM with EI # 1, who confirmed staff failed to clean and disinfect the dialysis station and surrounding areas per facility policy.