Children’s Hospital of Philadelphia

“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: 46632 Based on observation of the clinical area, facility policy and an interview with the Administrator, Clinical Nurse Expert and Manager of Regulatory & Accreditation, the facility did not ensure infection control procedure regarding glove removal and handwashing for three (3) of seven (7) observations (OBS). (OBS# 1, 2 and 3). Findings include: A review of policy “Hand Hygeine” on April 9, 2024 at 12:30 PM states: “It is the policy of the Children Hospital of Philadelphia that employees shall follow the World Health Organization’s Five Moment for Hand Hygeine during patient care and perform hand hygeine: 1) Before patient contact, 2) Before an aseptic procedure, 3) After contact with body substances, 4) After patient contact and 5) After contact with patients environment”. Observation of the clinical area was conducted on April 8, 2024 between 9:30 am-12:24 pm. OBS # 1 Machine 45 RN 1, Initiation of Dialysis with Central Venous Catheter, after disinfecting the CVC hub touched patients shirt and then connected the sterile syringe the RN did not discard gloves, perform hand hygiene and don new gloves. The RN then touched the dialysis machine screen and connected the blood lines to the CVC port, did not discard gloves, perform hand hygiene and don new gloves. OBS # 2 Machine 41 RN 2 , Discontinuation of Dialysis with Central Venous Catheter, closed CVC clamps touched patient shirt and preceded to disinfect hub, did not discard gloves, perform hand hygiene and don new gloves. OBS # 3 Machine 45 RN 2, Discontinuation of Dialysis with Central Venous Catheter, removed blood lines, discarded in biohazard waste, removed gloves and donned new gloves, did not perform hand hygeine. Removed crib sheet and disinfected the crib. An interview with the Administrator, Clinical Nurse Expert and Manager of Regulatory & Accreditation conducted on April 10, 2024 at 11:45 am confirmed the above findings.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 46632 Based on a review of policies, medical records (MR), interview with the Administrator, Clinical Nurse Expert and Manager of Regulatory & Accreditation the agency failed to provide the necessary care and services to manage a patient’s volume status for one (1) of five (5) medical records reviewed (MR # 1). Findings include: Review of facility policy “- Post-Dialysis Documentation on April 9, 2024 at approximately 1:00 p.m. 1. Enter Post weight and complete hemodialysis treatment record portion. 2. Post HCT/HGB, BV, SVO2, and minimum O2. 3. Vascular Access- assessment, ....... 4. Post Dialysis assessment comments”. Review of medical records on 4/9/24 at approximately 10:30 a.m. revealed the following: MR # 1 admission date 7/28/2022. Treatment Flow sheet for 3/25/24, revealed undocumented post dialysis assessment comments. An interview with the Administrator, Clinical Nurse Expert and Manager of Regulatory & Accreditation conducted on April 10, 2024 at 11:45 am confirmed the above findings.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 46632 Based on a review of patient medical records, and an interview with Administrator and Manager of Regulatory &Accreditation, the facility failed to ensure the standardized mental and physical assessment tool (PedsQL) was administered annually for one (1) of five (5) patient medical records (MR) reviewed (MR# 3). Findings: An interview with the Manager, Regulatory & Accreditation on April 10, 2024 at approximately 12:43 pm stated there is no policy related to the standardized mental and physical assessment tool being performed yearly only PedsQL module. A review of patient medical records conducted on April 9, 2024 at approximately 12: 46 pm revealed the following: MR# 3 Date of admission: 7/11/2022 No documentation of a 2023 annual PedsQL. An interview with the Administrator and Manager, Regulatory & Accreditation on April 10, 2024 at approximately 12:00 p.m. confirmed the above findings.”