Dci Birmingham

“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: 22676 Based on observation, interview, and policy review, the facility failed to ensure proper hand hygiene was performed during central venous catheter access for one of one patient (Patient (P) 7) observed with a central venous catheter. Failure to perform proper hand hygiene has the potential to place all patients and visitors at risk for cross contamination. Findings include: During an observation on 05/19/25 at 11:15 AM, Registered Nurse (RN) 9 was observed accessing P7’s central venous catheter for dialysis treatment. RN9 repeatedly used the hand sanitizer that was mounted on the patient’s dialysis machine at Station 4 instead of using the hand sanitizer mounted on P7’s dialysis machine. During an interview on 05/19/25 at 11:30 AM, RN 9 confirmed the above findings. During an interview on 05/19/25 at 11:15 AM, Nurse Manager 3, who was present during the observation, confirmed the above findings. Review of the facility’s policy titled, “General Facility Infection Control,” dated 03/12/19 revealed, “. . . Items taken into the dialysis station should either be disposed of, dedicated for use on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient . . .””

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 22676 Based on observation, interview, and policy review, the facility failed to ensure the hemostats and clamps used in patient care were disinfected appropriately. This increased the risk of cross contamination for 36 of 36 patients receiving care at the facility. Findings include: During an observation on the treatment floor on 05/21/25 at 9:30 AM, the hemostats used in patient care were observed to be soaking in the disinfectant in the closed position versus the open position to ensure adequate disinfection of the interior surface of the clamp. During an interview on 05/21/25 at 9:40 AM, the Nurse Manager confirmed the clamps were to be in the open position when places in the disinfectant to ensure the inside of the clamps were adequately disinfected. Review of the facility’s policy titled, “Disinfection of Clamps,” dated 04/36/10, revealed, “ . . . As the clamps are used open them and observe for blood. If blood is found rinse them with tap water, place the clamps in the bucket of bleach . . .””

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 22676 Based on observation, interview, and policy review, the facility failed to sanitize and disinfect trash receptables and empty trash bags between patients at five of five treatment stations (Stations 3, 4, 5, 6, and 8) observed. This had the potential to lead to cross contamination between all patients who dialyze at the dialysis stations. Findings include: During observation in the dialysis treatment room on 05/19/25 between 9:45 AM-11:30 AM, it was noted that the outside of the trash receptacles were not sanitized and disinfected between patients at Stations 3, 4, 5, 6, and 8. These trash receptacles were located at each station, touching each station between the chair and in front of dialysis machine. It was noted the trash bags were not emptied between patients. During an interview on 05/19/25 at 11:45 AM, the Nurse Manager, who was present during the observation, confirmed that the outside of the trash receptacles were not cleaned between patients and the trash bags were not emptied or changed between patients. Review of the facility’s policy titled, “General Facility Infection Control,” dated 03/12/19, revealed, “. . . Items taken into the dialysis station should either be disposed of, dedicated for use on a single patient. Or cleaned and disinfected before being taken to a common clean area or used on another patient . . .””

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 22676 Based on observation and interview, the facility failed to maintain the water room floor in a safe and clean condition to ensure the safety of the patients and staff and reduce the risk of infection for 36 of 36 patients receiving care at the facility. Findings include: Observations of the water room on 05/19/25 at 9:30 AM revealed the floor of the water room had rust stains, a black substance, and was partially sealed. The unsealed portion was porous concrete. An area approximately one foot by three feet in the center of the room was porous concrete with rust stains and a black substance. During an interview on 05/19/25 at 9:30 AM, Biomedical Technician 6 confirmed the flooring was porous concrete with black substance. During an interview on 05/21/25 at 9:30 AM, the Administrator stated the facility did not have a specific policy that covered the water room.”