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Tag No.: A0084
Based on review of the clinical record, facility documentation, and staff interviews, the hospital failed to ensure that the services performed under a contract were provided in a safe and effective manner. The finding includes the following:
Patient #1 was admitted to the hospital on 11/21/09 with diagnoses that included pneumonia, compression fractures of multiple vertebrae and a history of end stage renal disease (ESRD) on hemodialysis. On 12/8/09 the patient had surgery, remained in PACU overnight and went directly to hemodialysis on the morning of 12/9/09. Interview with RN #1 (charge nurse) on 12/16/09 at 10:45 AM identified she placed the patient in a private room as she was unsure of the patient's stability and needs and wanted the patient close to the nurse's station. RN #1 stated following the prescribed dialysis treament, she rinsed back the patient's blood, the arterial and venous lines were clamped and syringes filled with normal saline applied to the end of the extension set. RN #1 stated at this point another patient in the unit started to yell and complained of not feeling well. RN #1 stated she left the room to attend to the other patient and informed Patient #1 that the needles would not be removed at that time. RN #2 entered Patient #1's room to remove the needles and immediatley summoned help. Interviews with RN #1 and RN #2 on 12/16/09 identified that blood was observed on the pad and on the floor and that the arterial clamp was open and the syringe removed. A code was immediately called however resuscitation was unsuccessful. RN #1 and RN #2 stated that they were able to visualize the patient's head but not the access site when not in the room. According to the CMS Federal Regulations, Conditions for Coverage for ESRD Facilities, patients must be in view of staff during hemodialysis treatment to ensure safety. The interpretative guidelines stated that the each patient's vascular access site must be seen by a staff member throughout the dialysis treatment.
The hospital failed to ensure that the patient's access site was visible at all times. Review of the hospitals action plan dated 1/11/10 identified that a staff member would be assigned to the private room with staff educated on this process.