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Based on observation, and interview, it was determined that the hospital failed to meet the Conditions of Participation for Patient Rights by failing to protect and promote each patient's right as evidenced by:


The hospital failed to ensure that a venous drip chamber ("dummy"drip chamber) was not stored in the treatment area where hemodialysis was being administered. This device is used to bypass the dialysis machine's air detector and can result in an undetected infusion of air which can cause an air embolism and death. Access to utilize the dummy drip chamber posed an immediate and serious threat to the patients' health and safety resulting in immediate jeopardy (IJ). Please refer to A144.

Based on observation and interviews, the hospital failed to ensure that a safe environment was maintained in the dialysis unit when a dummy drip chamber was observed to be available for use in the treatment area resulting in immediate jeopardy. The finding includes the following:

During the initial tour of the hospital conducted with the Nursing Director on 1/8/18 at 1:15 PM, two patients were observed receiving hemodialysis. Further observation identified that in a locked medication drawer located in the patient care area, a drip chamber testing device also known as a "dummy drip chamber" was found. The dummy drip chamber that was visualized had a saline syringe attached to a blood line with a chamber half filled with fluid. There was a sticker on the drip chamber that indicated "not for patient use". The "dummy drip chamber" is a manufactured device utilized to bypass the dialysis machine's air detector. The "dummy drip chamber" can be used during set-up of a dialysis machine prior to patient use to silence the alarms for staff convenience. The practice of using the dummy drip chamber to prepare the dialysis machines for patient use creates the risk to infuse undetected air into a patient's blood system creating an air embolism (presence of air in a blood vessel) which created the potential to result in death of a patient.

Subsequent to surveyor observation, the "dummy drip chamber" was immediately removed from the unit.

During an interview with the Charge Nurse on 1/8/18 at 1:20 PM she stated that the device had been in the drawer for a while but would never be used.

During an interview with the dialysis Biomedical Equipment Technician conducted on 1/8/18 at 1:30 PM stated that the machines preventive maintenance was performed through a contracted service.

Interview with the representative from the contracted service that provides preventative maintenance to the hospital on 1/8/18 at 2:45 PM indicated that his staff would utilize a "dummy drip chamber" during preventaive maintenance.

The Director Quality/Patient Experience/Regulatory Compliance and Vice President of Nursing, were notified on 1/8/18 at 3:00 PM that Immediate Jeopardy conditions existed for failure to ensure that a dummy drip chamber was secured and not present in the treatment room.

The IJ was abated on 1/8/18 at 3:30 PM in the presence of the Chief Quality & Patient Safety Officer Director when an acceptable plan of correction was presented to the survey team. Review of the plan identified that the dummy drip chamber was immediately removed from the unit, staff were educated regarding the use of a dummy drip chamber, that the dummy drip should not be in the dialysis unit, except when being used by a Biomedical Technician.