Cardinal Glennon Childrens Hospital Dialysis

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility failed to ensure one of one dietician completed infection control and emergency preparedness training annually. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 13. Findings included: 1. Review of the facility personnel information showed the facility dietician last completed the infection control and emergency preparedness training in November of 2022. 2. During an interview on 2/27/24 at approximately 10:00 AM, the dietician said she had not completed the annual infection control or emergency preparedness training since November of 2022.”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 17026 Based on observations and staff interview, the facility staff failed to ensure one of two brine (water softener) tanks in the water room remained free of corrosion and discolored water, and failed to ensure two bolt connection areas in the water room remained free of rust. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 13. Findings included: 1. Observation on 2/26/24 at approximately 12:15 PM showed a water softener tank in the water room with corroded areas inside the tank and discolored water. 2. Further observation on 2/26/24 at approximately 12:17 PM of the water room showed two areas with rusted bolt connections that could potentially contaminate the water system. 3. During an interview on 2/26/24 at approximately 12:20 PM, the clinic manager said staff need to ensure the water room is maintained through their contracted company.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 17026 Based on observations and staff interview, the facility staff failed to ensure two of the conductivity solutions were not expired. This had the potential to effect all of the patients on dialysis and cause an increase in complications. The facility census was 13. Findings included: 1. Observation on 2/26/24 at approximately 12:30 PM showed a conductivity solution that expired 2/5/24. 2. Observation on 2/26/24 at approximately 12:31 PM showed a conductivity solution that expired 2/12/24. 3. During an interview on 2/26/24 at approximately 12:32 PM, the clinic manager said staff need to ensure the conductivity solutions are not expired.”