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Based on observation, review of policy and procedures, the " Acute Dialysis Services Skills Performance Checklist " , and interview with the laboratory manager (OSU Staff #1) and a nurse in the dialysis unit (FMC Staff #1), the governing body does not ensure that the services performed under a contract are provided in a safe manner. Findings:

(1) Acute dialysis services are furnished by Fresenius Medical Care (FMC) under contract.
(2) Policies and procedures relating to the transfusion of blood to dialysis patients were not readily available to the personnel responsible for transfusing blood and blood products in the acute dialysis unit. The policy faxed from the FMC corporate office referred to the general hospital policy and procedures, however, the general hospital policy and procedures were also not available to personnel in the acute dialysis unit.
(3) There was no documentation that personnel in the acute dialysis unit responsible for providing blood transfusions to dialysis patients have special training necessary to ensure transfusion services are provided in a safe and effective manner. The Acute Dialysis Services Skills Performance Checklist did not address transfusions in detail and did not include evaluation of competency for skills related to definitive identification of the recipient. Refer to Tag # A409.

Based on observation, review of policy and procedures, the " Acute Dialysis Services Skills Performance Checklist " , and interview with the nurse in the dialysis unit (FMC Staff #1), the facility does not ensure that blood transfusions are administered in accordance with approved medical staff policies and procedures and that personnel have special training. Findings:
(1) Policies and procedures relating to the transfusion of blood to dialysis patients were not readily available to the personnel responsible for transfusing blood and blood products in the acute dialysis unit. The policy faxed from the FMC corporate office referred to the general hospital policy and procedures, however, these general hospital policy and procedures were also not available to personnel in the acute dialysis unit.
(2) There was no documentation that personnel in the acute dialysis unit responsible for providing blood transfusions to dialysis patients have special training necessary to ensure transfusion services are provided in a safe and effective manner. The Acute Dialysis Services Skills Performance Checklist did not address transfusions in detail and did not include evaluation of competency for skills related to definitive identification of the recipient.