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Based on observations, staff interviews and review of policies the facility staff failed to ensure the contracted hemodialysis provider in the facility followed the policies of the dialysis provider for bleach treating the dialysis machines every 7 days, heat treated every 24 hours and the chlorine levels did not exceed 0.1% prior to use.

The Findings Include:

The dialysis unit of the facility was inspected during the initial tour of the facility on 10/27/10 and again on 10/28 and 29/10. The contracted registered nurse who was in charge of ensuring the unit has the supplies and equipment necessary stated on 10/29/10, "We have 4 machines that are regularly here and 2 that can travel to other facilities.

Each machine was observed to have an information booklet (3 ring binder that contained the Dialysis Delivery System Log and the RO Machine information) attached to the machines. was reviewed. The information obtained from the booklets is as follows:

The contracted registered nurse who was in charge of the dialysis unit stated, "The machines should be cleaned with bleach every 7 days even if they are not used." "It is not necessary to heat treat them after each use." "But if they are used they should be heat treated every 24 hours." She also stated, "The machines should be checked for the presence of bleach prior to every use." "The form should have a + in the present column and a - in the residual column. There should not be just initials. Without the + or - you don't know if it was present or not."
The registered nurse stated, "The chlorine should always be less than 0.1%."

The contracted registered nurse who was in charge of the dialysis unit also stated, "The presence of chlorine in the RO water should be checked prior to every use."

Machine #9: Dialysis Delivery System Log dated 7/15/10 through 10/26/10.
There were 82 entries over 14 weeks.
There were 3 entries with + and - entries and 2 entries that had written "neg" in the residual column and a line drawn through the present column.
The machine was used 41 different dates. The machine should have been heat treated 41 times and was initialed as heat treated 6 times.
There were entries on 8/23/10, 8/30/10 and 9/6/10 indicating the machine was bleached cleaned.
The RO on this machine was labeled as #27 with the dates of 7/5-10/26/10. There were 32 entries during this time. There were 25 entries that did not indicate a less than 0.1% chlorine prior to use of the machine. Three (3) of the entries does not document the check for chlorine prior to use of the machine.

Machine #F-18: Dialysis Delivery System Log dated 7/14/10 through 10/25/10.
There were 28 entries over 14 weeks.
There were no entries indicating the machine was ever bleached.
There was 1 entry indicating the machine was checked for the presence of bleach with a + and -.
The machine was used on 18 different dates.
The RO on this machine was labeled as #51 with only the dates of 7/28/10 and 9/29/10 and does not document the check for chlorine prior to use of the machine.

Machine #32: Dialysis Delivery System Log dated 9/27/10 through 10/28/10.
There were 30 entries over 4 weeks.
There was one entries indicating the machine was ever bleached.
There was 2 entries indicating the machine was checked for the presence of bleach with a + and -.
The machine was used on 21 different dates.
There were 5 entries indicating the machine had been heat treated.
The RO on this machine was labeled as #23. There were 40 entries from 9/1-10/28/10 There were 25 entries that did not indicate a less than 0.1% chlorine prior to use of the machine.

Machine #52: Dialysis Delivery System Log dated 8/1/10 through 10/28/10.
There were 87 entries over 12 weeks.
There were no entries indicating the machine was ever bleached.
There was 5 entries indicating the machine was checked for the presence of bleach with a + and -.
The machine was used on 39 different dates.
There were 29 entries indicating the machine had been heat treated.
The RO on this machine was labeled as #24. There were 51 entries from 4/10-10/26/10. There were 5 entries that did not indicate a less than 0.1% chlorine prior to use of the machine.

Machine #14: Dialysis Delivery System Log dated 9/1/10 through 10/28/10.
There were 85 entries over 7 weeks.
There were no entries indicating the machine was ever bleached.
There was 3 entries indicating the machine was checked for the presence of bleach with a + and -.
The machine was used on 38 different dates.
There were 31 entries indicating the machine had been heat treated.
The RO on this machine was labeled as #39. There were 24 entries from 4/10-10/26/10. There were no entries indicating that the presence of chlorine was less than 0.1% prior to use of the machine.

Machine #24: Dialysis Delivery System Log dated 9/1/10 through 10/28/10.
There were 85 entries over 7 weeks.
There were no entries indicating the machine was ever bleached.
There was 3 entries indicating the machine was checked for the presence of bleach with a + and -.
The machine was used on 38 different dates.
There were 31 entries indicating the machine had been heat treated.
The RO on this machine was labeled as #55. There were 21 entries from 6/14-10/26/10.
There were 2 entries that indicated a less than 0.5% chlorine level prior to use of the machine. This check was done on 10/8/10 and 10/11/10 by two different staff.
There was one (1) entry with no indication the chlorine level was checked prior to use.

The Director of Nursing Administration who was responsible for coordinating the hospital with the contracted staff stated, "Obviously we need to improve the overseeing of this unit a little better."

The contracted registered nurse who was in charge of the dialysis unit stated, "All the machines in here were just moved in last week because we had trouble with the other machines. There is no way to immediately identify what patients were on each machine and in which facility."

Based on observations, staff interviews and review of policies the facility staff failed to ensure that expired medications and undated, opened and accessed medications used in respiratory therapy were not available for use.

The Findings Include:

On 10/27/10 during the initial tour of the Emergency Department (ED) with the ED Nursing Director and the Associate Administrator for the Levinson Heart Hospital, two Respiratory Carts were inspected. The two locked carts were opened by the Respiratory Technician (RT). Cart #1 was located by the trauma area and Cart #2 was located by the intermediate area. Cart #1 contained 1 package of 5 ampules of Pulmicort Respules (budesonide inhalation suspension) 0.25 mg (milligrams)/2 ml (milliliters) with an expiration date of 07/10. Cart #1 also contained 8 ampules of Sodium Chloride 3% with the expiration date of 09/09.

Cart #2 contained a 5 ampules package of budesonide inhalation suspension 0.25 mg/2 ml which had 4 ampules missing. Cart #2 also contained a 5 ampules package of Pulmicort Respules which had 4 missing ampules. Both packages have written instructions on the packages that indicate once the package is opened the ampules should be used within 2 weeks. Both packages had a label with "Expiration Date:______". Both labels had no dates in the blank area indicating when the packages would expire.

Cart #2 also contained 9 ampules of Sodium Chloride 3% with the expiration date of 09/09.

The RT stated, "The expired medications and Sodium Chloride should not be in the cart. The Pulmicort Respules is the same as the budesonide inhalation suspension and they should both have a date on them indicating when they expire."

During the tour of the PICU (Pediatric Intensive Care Unit) on 10/27/10 with the Nursing Manager of the PICU and the Associate Administrator for the Levinson Heart Hospital the Respiratory Cart was inspected with the assistance of the RT.

The Respiratory Cart in the PICU contained a sterile flexi Slip Stylus used during the intubation (opening the airway) of a child. The stylus was labeled with an expiration date of 08/10. The Nursing Manager stated, "I don't know how we missed that, it must have gotten caught by the drawer."

The Director of Respiratory Therapy was interviewed on 10/29/10 regarding a policy for the medications in the Respiratory Carts in the ED. He stated, "We do not have a policy related to checking the carts and the medications on the carts. The Respiratory Cart in the PICU is maintained by the nursing department."