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)
V0550 POC-VASCULAR ACCESS-MONITOR/REFERRALS
CFR(s): 494.90(a)(5)

The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.


This STANDARD is not met as evidenced by:
Based on review of facility procedure, observations, and staff interview, it was determined the facility failed to ensure staff performed Arteriovenous Fistula/Arteriovenous Graft (AVF/AVG) site preparation for cannulation accroding to facility procedure in two of two observations of accessing the AVF/AVG for initiation of dialysis. This affected Patient Identifier (PI) # 10, and PI # 12, and had the potential to negatively affect all patients dialyzing with an AVF/AVG at this facility. Findings include: Facility Procedure: AV (Arteriovenous Fistula)-Assessment, Cannulation, De-cannulation and Lab Draw Procedure Number: 18335 Date Published: Not listed ...The purpose of this procedure is to provide guidelines for routine AVF/AVG cannulation... 5. Cannulation of a New AVF/AVG ...b. Procedure ...vii. Prep (prepare) site ...II. Scrub site with chloraprep (Chlorhexidine Gluconate 2% and isopropyl alcohol 70%, a topical skin antiseptic solution used to disinfect the skin before surgical and medical procedures) for 30 seconds and allow to air dry... 1. An observation was conducted on 2/25/25 at 1:30 PM with Employee Identifier (EI) # 7, Registered Nurse (RN), accessing the AVG and initiating dialysis for PI # 10 at station 5. EI # 7 failed to scrub the arterial and venous cannulation sites for 30 seconds each prior to cannulation. An interview was conducted on 2/27/25 at 12:19 PM with EI # 1, Director of Nursing, who confirmed staff failed to perform site preparation for AVF/AVG cannulation per facility procedure. 30952 2. An observation was conducted on 2/26/25 at 7:30 AM with EI # 2, RN, to prepare, cannulate, and initiate dialysis for PI # 12 at station 6. EI # 2 used a Chloraprep sponge, and scrubbed access site one for 20 seconds, scrubbed access site two for 5 (five) seconds, allowed both sites to dry, and cannulated the sites. EI # 2 failed to scrub the access cannulation sites for 30 seconds each prior to cannulation. An interview was conducted on 2/27/25 at 12:18 PM with EI # 1, who confirmed staff failed to follow the facility procedure for AVF/AVG assessment, and cannulation.