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 012508 (X3) Date Survey Completed 12/12/2019
Name of Provider or Supplier Birmingham East Dialysis Street Address, City, State 1105 East Park Drive, 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 interviews with the staff it was determined the facility failed to ensure staff followed the facility policy for: 1. Performing hand hygiene including sanitizing hands and changing gloves. This deficient practice had the potential to negatively affect all patients, visitors and staff. Findings include: Policy: Infection Control For Dialysis Facilities Policy Number: 1-05-01 Revised Date: April 2019 Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Policy: The centers for Disease Control (CDC) recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients... Teammate Hygiene 1. Hand hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, before touching clean areas such as supplies and on exiting the patient treatment area... 2. If hands are not visibly contaminated, use of alcohol-based hand rub may be substituted for handwashing... Teammate/Patient Safety 11. Teammates will wear disposable gloves when caring for patient or touching the patient's equipment at the dialysis station, and will remove gloves and wash hands or perform hand hygiene between each patient and/or station... 13. Gloves should be changed when: ...When going from a "dirty" area or task to a "clean" area or task. ...After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient's dialysis delivery system. ChairSideSnappy Terminal and Cart 71. The ChairSideSnappy cart, monitor and keyboard are considered clean areas. 72. Gloves are to be removed and hands washed or alcohol based hand rubs used before and after touching the keyboard. 1. During an observations of care conducted on 12/10/19 at 7:45 AM to 10:15 AM, the surveyor observed the following: At 8:02 AM, Employee Identifier (EI) # 5, Patient Care Technician (PCT), entered the treatment floor and went to station 1, applied gloves and reset the dialysis machine alarm. EI # 5 removed gloves and obtained face shield, reapplied gloves and addressed the alarms on the dialysis machine at station 3. EI # 5 failed to perform hand hygiene when entering the treatment floor, after removing gloves, and between touching different patient dialysis machines. At 8:30 AM after cleaning the dialysis station 7, EI # 4, PCT, removed gloves, obtained a clean dialysis set up for the next patient. EI # 4 failed to perform hand hygiene after removing gloves and before obtaining clean supplies. In an interview conducted on 12/10/19 at 10:00 AM, EI # 9, Facility Administrator # 2, confirmed the staff failed to follow facility policy for hand hygiene.