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)
V0147 IC-STAFF EDUCATION-CATHETERS/CATHETER CARE
CFR(s): 494.30(a)(2)

Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].


This STANDARD is not met as evidenced by:
Based on review of facility policy, observation, and staff interview, it was determined the facility failed to ensure staff performed Central Venous Catheter (CVC) exit site care per facility policy. This affected Patient Identifier # 7 in one of two observations of CVC exit site care and had the potential to negatively affect all patients dialyzing with a CVC at this facility. Findings Include: Facility Policy: Dialysis Catheter CVL Maintenance and Dressing Change Policy Number: 18388 Revision: 1 Date Published: Not listed CVL dressing change with a dialysis catheter ...3. Procedure ...p. With the Chlorhexidine (CHG) sponge, scrub the exit site for 30 seconds. Use a gentle back and forth diagonal motion when you scrub. 1. An observation was conducted on 2/27/25 at 9:58 AM with Employee Identifier (EI) # 6, Registered Nurse, performing CVC exit site care for PI # 7 at station 4. EI # 6 failed to scrub the exit site in a back-and-forth motion. An interview was conducted on 2/27/25 at 12:19 PM with EI # 1, Director of Nursing, who confirmed staff failed to perform CVC exit site care per facility policy.