Childrens Hospital of Kings Daughters

“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: 34452 Based on observation, document review and interview, it was determined that the facility staff failed to ensure persons [Family] assisting in Patient care wear gloves during termination of the treatment while while holding the Patient’s arms for one (1) of one (1) Patient’s (P) [Family] (P # 1). The findings include: On January 10, 2024 at 1:45 p.m., Staff Member (SM) # 3 was observed during the termination of the treatment for seven year old P # 1. P # 1 [family] assisted with P # 1 by holding arms during the termination. SM # 3 failed to provide [family] gloves to wear. P # 1 [family] did not perform hand hygiene after holding P # 1 arms. On January 11, 2024 at 12:30 p.m., the facility policy titled “Infection Control” reads in part “PPE (personal protective equipment) used in the hemodialysis unit. During direct patient care: wears fluid resistant apron/gown. Wears gloves, masks, face shield for anticipated exposure to body substances.” “Hand Hygiene” reads in part “Use alcohol based hand rub in the following situations for routinely decontaminating. Before direct contact with patients. After contact with a patient.” On January 11, 2024 at 12:45 p.m., the findings were discussed with SM # 1 and # 2 during the exit interview.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility staff failed to ensure persons [family] assisting in Patient care wear gowns, face shields, eye wear or masks to protect during termination of the treatment for one (1) of one (1) Patient’s (P) [Family] (P # 1). The findings include: On January 10, 2024 at 1:45 p.m., Staff Member (SM) # 3 was observed during the termination of the treatment for pediatric patient, P # 1. P # 1 [family] assisted with P # 1 by holding arms during the termination. SM # 3 failed to provide [family] a gown and face shield or face mask to wear. On January 11, 2024 at 12:30 p.m., the facility policy titled “Infection Control” reads in part “PPE (personal protective equipment) used in the hemodialysis unit. During direct patient care: wears fluid resistant apron/gown. Wears gloves, masks, face shield for anticipated exposure to body substances.” On January 11, 2024 at 12:45 p.m., the findings were discussed with SM # 1 and # 2 during the exit interview.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to complete the Plan of Care by the interdisciplinary team (IDT) including the Patient for one (1) of four (4) Patients (Patients # 1). The findings include: On January 11, 2024 between 9:00 a.m. and 12:30 p.m., Clinical Record review revealed the following: Patient # 1- There was no documented Patient’s Plan of Care meeting. On January 1, 2024 at 1:00 p.m. the facility policy provided by Staff Member (SM) # 1 titled “Patient comprehensive assessment and plan of care” reads in part “the comprehensive assessment and plan of care for new Patient should be completed within 30 days of admission to facility.” On January 11, 2024 at 12:45 p.m., the findings were discussed with SM # 1 and # 2 during the exit interview.”