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Based on observation, interview and record review, the facility failed to ensure the dialysis equipment storage room was maintained clean and secure by Contractor Q.

This deficient practice had the potential for cross contamination and unauthorized access to the dialysis supplies and machines.

Findings:

During a tour of the facility on April 2, 2019, from 9:36 a.m. - 10:08 a.m., the dialysis equipment room was located in the fourth floor. The following was observed:

1. The dialysis equipment room was located in room 407. The door was wide open. The dialysis machines and supplies were visible from the corridor and accessible to other staff and visitors. There was no staff in the room at the time of the observation.

2. There was a blanket warmer inside the room. There were clean blankets inside. The biomed technician was requested by the evaluator to run the top surface with a gloved hand. The top of the blanket warmer was dusty
At 9:45 a.m., the dialysis coordinator stated the steam warmer was used by the staff for patients in the 4th floor.

3. There were 4 dialysis machines- #4, 6, 7, 8. Machine #4 was labeled "Isolation Use Only."
At 9:50 a.m., the biomed technician stated they had 8 machines.
There was approximately 3-4 feet from the machine in the room to the entrance. Even without the additional four machines in the room, the door could not be closed. The door was approximately 4-5 feet wide.

4. At 10 a.m., there were 2 carbon tanks behind dialysis machine #6. Both carbon tanks were labeled "3/14/19."

5. The sink where the eyewash was located was dirty. On top of the sink counter, there was a plastic container with no cover filled with dry white clamps. The plastic container had openings so no solution could be placed inside.

At 10:03 a.m., during an interview, the biomed technician stated the white clamps in the plastic container were dirty. The biomed technician further stated he had another container for disinfection with 1:100 bleach. However, there was no plastic container labeled 1:100 bleach in the room.

6. There were two (2) bottles inside the sink labeled "disinfectant." One container had no cover. The second container was covered with a blue glove.
At 10:03 a.m., during an interview, the biomed technician stated they do not have caps to cover the bottles so a glove was used.

7. Under the sink, there was accumulation of greenish deposits.

8. The water drains rolled up behind the dialysis machines were covered with gloves.
At 10:05 a.m., during an interview, the biomed technician stated they ran out of caps to cover the drains to prevent water from leaking during treatment.

9. Along the wall, there was one, five (5)- shelf stainless steel storage rack. There were bags of saline solutions stored on the upper shelf and gallons of 2K 3 CA baths and diasol stored on the lower shelves. Next to the storage rack were more than 20 unopened boxes labeled "Diasol" and "Sodium Chloride" stored on top of a pallet.

According to the facility's "Service Agreement" with Contractor Q, made on 3/1/18:

2. Hospital's Obligations

a. Equipment, Facilities, Supplies, Utilities, and Services. Hospital shall, at no cost to OCmpany, provide all facilities, uitlities imcluding telephone service. and other services as hospital shall, in its sole discretion, determine from time to time to be necessary for the performance of the Services. ---."

"Exhibit A

Description of Duties and responsibilities

Contractor Q

Company shall:

7. Provide the following services free of charge:
d. Dialysis storage is to be maintained by company Staff to include cleanliness of environment, product storage and security."

Based on record review and interview, the facility failed to:

1. Identify the delayed acute HD (hemodialysis) as a quality indicator, and use collecting data to monitor effectiveness of acute HD.

2. Identify the acute HD outcome as a quality indicator, and use collecting data to monitor quality of care for acute HD.

Findings:

1. During an interview on April 2, 2019 at 11:45 a.m., CSC 1 (Contractor Service Coordinator) stated the acute HD hemodialysis contractor had identified delayed HD treatments in the contracted service as a quality indicator, collected data, and summarized the data in a table.

During the concurrent interview, CSC 1 stated the contractor had not integrated the delayed HD treaments as a quality indicator into the facility's QAPI program.

During an interview on April 2, 2019 at 12:05 p.m. , QAPI Coordinator stated the facility had not integrated the delayed HD treaments as a quality indicator into the facility's QAPI program, and collected data, measured, analyzed, and tracked the delayed HD treaments.

During an interview on April 3, 2019 at 11:22 a.m., MD 1 stated the acute HD treatment for Patient 12 was ordered on 12/20/18 at 6 a.m. by him but the treatment was not provided until 1:30 p.m. on 12/21/18.

A review of clinical record record indicated Patient 12 was admitted on 12/15/18 with diagnosis of abdominal pain and was discharged on 12/26/18.

Further review of the clinical record indicated it took 31.5 hours to implement the acute HD treatment from the order as following:

12/20/18 6 a.m. - acute HD ordered
12/20/18 12:53 p.m. - consent for Permacath
12/21/18 8:24 a.m. - Placement for Permacath
12/21/18 11:26 a.m. - clear to use Permacath
12/21/18 1:30 p.m. - start acute HD

A review of the the facility's STAT (Immediate) orders summary table, from March 1 2018 through January 2019, with CSC 1 on April 2, 2019 at 11:45 a.m., indicated 98.6 % of STAT cases for hemodialysis (HD) treatments were initiated within 3 hours after the HD treatments were ordered. (73 of 74 HD treatments)

Further review of the the facility's Non-STAT (Not Immediate) orders summary table, from March 1 2018 through January 2019, indicated 83.47 % of Non-STAT cases for acute HD treatments were completed before 9 p.m. after the HD treatments were ordered. (207 of 248 HD treatments)

2. A review of the facility lists for HD patients, provided by the facility, indicated there were 128 HD patients in the year of 2018.

Further review of the the facility's QAPI program indicated the outcome of acute HD, such as hemoglobin (red protein responsible for transporting oxygen in the blood of vertebrates. Its molecule comprises four subunits, each containing an iron atom bound to a heme group), BUN (Blood urea nitrogen) (a medical test that measures the amount of urea nitrogen found in blood), and Creatinine (a waste product that comes from the normal wear and tear on muscles of the body), had not been identified as a quality indicator.

During an interview on April 2, 2019 at 12:10 p.m. , the QAPI Coordinator stated the facility had not integrated the acute HD outcome as a quality indicator into the facility's QAPI program, and collected data, measured, analyzed, and tracked the quality of acute HD treaments.