HospitalInspections.org

Based on medical record review, interview and policy review it was determined the facility dialysis unit failed to ensure blood pressures were monitored and dialysis machine alarm checks were completed as required (A392) and failed to ensure medication was administered as ordered by the physician. (A405) The cumulative effect of these systemic practices resulted in the facility's inability to ensure that the patient's nursing needs would be met. The hospital hemodialysis unit census was 3 patients.

Based on medical record review, interview and policy review it was determined the dialysis facility failed to ensure two (#2, and #10) of two patients blood pressures were being monitored every 30 minutes according to the facility's policy and procedure and three (#1, #2, and #3) of three patients dialysis machine alarm checks were completed as required. A total of 10 medical records were reviewed. The hospital hemodialysis unit census was 3 patients.


Findings include:

Review of the policy and procedure "Implementing Orders for Hemodialysis Patients", policy number I-207, effective 09/08/14, page (1 of 3) revealed vital signs including the patient's blood pressure will be routinely monitored and documented every 30 minutes during hemodialysis.

1. Review of the medical record for Patient #2 revealed the patient's blood pressure was not monitored every 30 minutes according to the policy and procedure. The blood pressure was not monitored from 10:57 AM to 11:44 AM a total of 47 minutes.
This finding was confirmed with Staff A on 06/18/15 at 11:30 AM.

2. Review of the medical record for Patient #10 revealed the patient's blood pressure was not monitored every 30 minutes according to the policy and procedure. The blood pressure was not monitored from 1:30 PM to 2:35 PM a total of one hour and five minutes. This finding was confirmed with Staff I on 06/19/15 at 10:59 AM.

Review of the Operators Manual for Testing the 2008K revealed prior to the first treatment of the day, the machine must undergo a Pressure and Alarm test to ensure proper functioning.

3. Review of the treatment flow sheets for Patient's #1, #2, and #3 from 06/01/15 through 06/18/15 lacked documented evidence the machine alarm checks were completed prior to the patient hemodialyzing.

Based on record review and interview it was determined the dialysis unit staff failed to ensure one (#2) of one patient received Epogen as ordered. A total of 10 medical records were reviewed. The hospital hemodialysis unit census was 3 patients.


Findings include:

1. Review of the medical record for Patient #2 revealed the patient had physician orders to hemodialyze the morning of 06/17/15. Patient #2 was ordered to have have 1500 units of Epogen. The medical record revealed patient #2 did not hemodialyze until 06/17/15 at 8:20 PM. The record lacked documented evidence the Epogen (medication used to treat anemia) was given as ordered.

This finding was confirmed with Staff A, clinical manager, on 06/18/15 at 11:30 AM.

Based on maintenance record review, staff interview, manufacturer recommendation review and policy review the facility failed to ensure dialysis machines were maintained per the manufacturer recommendations for three of four machines sampled out of a total of 15 total dialysis machines. This deficient practice had the potential to affect all hemodialysis patients served by the hospital. The hospital hemodialysis unit census was 3 patients.
Findings include:
1. Review of the maintenance record for dialysis machine KN102837 for the past 12 months revealed annual preventative maintenance on 06/04/14. The records failed to reveal evidence of semi-annual preventative maintenance for the machine as per manufacturer recommendation.
2. Review of the maintenance record for dialysis machine KN127204 for the past 12 months revealed the machine was purchased 07/03/14 and the six month preventative maintenance was not completed until 05/14/15 at 10 months.
3. Review of the maintenance record for dialysis machine KN127206 for the past 12 months revealed the machine was purchased 07/03/14 with no evidence of completed preventative maintenance since purchase.
An interview with Staff J on 06/18/15 at 10:30 AM confirmed the above findings and revealed the facility dialysis machine manufacturer recommendation was for semi-annual and annual preventative maintenance. The machines had been put into the computer system for an annual preventative maintenance cycle instead of six months. The work was not completed per the manufacturer recommendations as the computer did not trigger a work order due to the wrong cycle being entered into the system.
Review of the manufacturer manual for the facility dialysis machines revealed on page 57 the procedures to complete for six month preventative maintenance and on page 59 the procedure to complete for annual preventative maintenance.
Review of the facility Scheduled Maintenance of Exceptional Equipment (CE-009) last revised 08/10/10 and last reviewed 06/13/13. For Priority 2 critical equipment on page 2, all preventative maintenance will be scheduled according to clinical engineering procedures which will take into consideration manufacturer specifications and historical data. Preventative maintenance will be monitored through a continuous feedback system to determine if and when changes are needed.