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Based on observation, interview, policy and document review, the facility failed to protect and promote each patient's rights by failing to ensure the facility provided safe administration of dialysis treatments (A0144). The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of dialysis patients. The facility's contracted staff administered approximately 410 dialysis treatments during July, 2019.

Based on medical record review, review of Routine Total Chlorine Testing Logs, policy review and interview, the facility failed to ensure safe administration of dialysis treatments for two patients (Patient #15 and #16) of 47 dialysis treatment flowsheets reviewed. This had the potential to affect every patient who receives dialysis treatments. The facility has 28 patients who are receiving dialysis treatments.

Findings include:

The Facility's Hospital Services Policy & Procedure, # 1(Policy: 7-10-04, Review Date: April 2017) "Total Chlorine Monitoring for Multi-Station (Non-Portable) Water Treatment Systems" stated: 2. Total Chlorine testing is done on a daily basis prior to the first patient treatment and every four (4) hours until all activities that require use of dialysis quality water are completed. All samples are to be drawn only after the water system has been operating for at least 15 minutes.
NOTE: If patient treatments are not occurring continuously during the treatment day, total chlorine testing will be performed prior to any subsequent treatments or until all activities that require use of dialysis quality water are completed.
10. Results are recorded in the "Water Treatment Log - Routine Total Chlorine Testing" log which contains entries for day, date, test time, test results, signature of person performing the test and signature of licensed nurse verifying that daily log is complete and results appropriate. If the licensed nurse performs the Total Chlorine test, they may also sign results as verified. may also sign results as verified.


1. On 07/01/19 at 4:20 PM, the contracted dialysis staff began Patient #16's dialysis treatment. The dialysis treatment sheets contained a documented Chlorine check on 07/01/19 at 6:40 PM; greater than two hours after the patient's treatment was started and approximately 12 hours after the last documented chlorine check at 6:35 AM.

The findings were shared with Staff Y on 08/29/19 at 8:21 AM and confirmed.

2. On 06/18/19, the contracted dialysis staff began Patient #15's dialysis treatment at 10:31 AM. According to the documented Chlorine Checks the Chlorine was checked at 7:15 AM and not again until 12:50 PM, almost six hours after the first check. The Chlorine check should have been done no later than 11:15 AM.

The findings were shared with Staff Z on 08/29/19 at 1:53 PM and confirmed.