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On the days of Validation Survey based on record review, interviews, review of hospital policies and procedures, and review of the hospital's infection control data and quality data, the hospital's governing body failed to ensure that its high risk dialysis unit had functional oversight through its Quality and Patient Safety Council and its Infection Control entity.


The findings are:


Cross Reference to A 0263: The hospital failed to ensure that data was collected in its high risk hemodialysis unit, failed to ensure that clear expectations for safety were established in the hemodialysis unit by the hospital's governing body, medical staff and administrative officials, and failed to ensure that its program reflected the complexity of the hospital's organization and services by way of failing to evaluate care and services in its high risk hemodialysis unit.

Cross Reference to A 0747: The hospital failed to ensure an environment to track, monitor, and reduce sources and transmission of potential infections and communicable diseases in that the hospital's Infection Control entity had no system in place to monitor and evaluate the safety risks in the hospital's high risk dialysis center.

On the days of the Validation Survey based on observations and interview, the hospital failed to provide the necessary information for patients who wish to file a grievance in the emergency department and the outpatient services department with the telephone number and address of the state agency.

The findings are:

On 06/03/13 at 1253, random observations of the hospital's emergency department waiting room revealed the signage listed no telephone number or address for State Agency for those patients who wish to file a grievance.
On 06/03/13 at 1254, Administrative Assistant #1 revealed all posters are the same throughout the hospital system.


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During an interview with the Admission/Registration Supervisor on 6/4/13 at 1000, he/she revealed that patients and/or representatives receiving outpatient services do not receive information with the state agency's address and telephone number necessary to file a complaint and/or grievance with the state agency.

On the days of the Validation Survey based on interviews and administrative record review, the hospital failed to ensure that patients are notified of the results of their grievance complaint for 1 of 4 patient grievances reviewed. (Patient Grievance #3)


The findings include:


On 6/4/13 at 1315, a review of the complaints/grievances log revealed patient grievance #3 had no documentation of the grievance resolution and/or of patient notification of the resolution of the grievance. The findings were verified by the Director of Patient Relations on 6/4/13 at 1500.

Hospital policy # 01-0000-UP000970, titled, "Complaint Management System for Patients, Family Members and Guests", revised 4/13, states, "...Procedure...Grievances...5. Once the investigation is completed, the findings are communicated to the patient or HPOA (Health Care Power, if appropriate) to ensure that the resolution is satisfactory. All findings and resolutions are communicated by certified letter within 28 days whenever possible. Occasionally some investigations are prolonged due to the number of persons needed for discussion of the case or the nature of the complaint...".

On the days of the Validation Survey based on record review, interview, and review of hospital policy and procedures, the hospital failed to obtain consent for patient treatment for 1 of 40 open patient charts reviewed. (Patient #24).


The findings are:


On 6/4/13 at 1352, review of patient chart #24 revealed the patient was admitted to the hospital on 6/1/13 for "Urinary Tract Infection, Sepsis....". Review of Emergency Department notes on 6/1/13 at 1706 showed a past medical history of "Parkinson's Disease, Dementia....". Review of the patient's chart revealed a general admissions consent form dated 6/1/13 at 1804 that had a notation that the patient "unable to sign" and the consent form was witnessed by a staff member. Review of the patient's History and Physical dictated 6/02/13 at 0456 by the admitting physician revealed the patient had a past medical history of Parkinson Disease, Dementia, Senile Psychosis, and other underlying illnesses. Review of the patient's chart revealed a Case Management Progress Note dated 6/4/13 at 1352 that read, "LMSW (Licensed Masters Social Worker) visited pt (patient) yesterday afternoon. No family present at time of visit. Reviewed chart....Will follow up with family and facilitate pt transition back to SNF (skilled nursing facility) as appropriate....". During an interview on 6/4/13 at 1355 with Administrative Assistant #2, he/she revealed that if a patient is unable to provide consent for treatment and a family member is unreachable then two doctors must provide consent for treatment and document it. Review of the patient's chart showed no consent for treatment between two physicians for the patient or documentation of conferring with another physician for the consent to treat requirements.


Facility Policy, reads, "Policy Number: 01-6017-RM000025, Consents, 9. Incompetent: Spouse or next of kin can, if reasonably available, sign authorization/consent when the physician has noted statement of incompetence in the medical record....11. All authorization/consent forms are part of the patient's legal record and must be completed in its entirety prior to performance of any procedure. 12. In case of a life-threatening situation, a physician may proceed with treatment without signed authorization/consent after conferring with another physician if one is available. NOTE: The chart should reflect the physician's and hospital's efforts in trying to reach the appropriate next of kin....".

On the days of the Validation Survey based on observations, interview, and hospital policy and procedures, hospital staff failed to promote 3 of 10 patient's personal privacy and dignity in hallway beds (Random A, B, and C), 1 of 1 patient receiving care and services in hallway bed E (Random Patient D), and 1 of 1 random patients partially clothed in room #7 (Random Patient E) in the hospital's emergency department.


The findings are:


On 06/03/13 at 1305, random observations in the hospital's emergency department revealed 3 of 10 hallway beds were occupied by patients without the use of privacy protection devices and/or equipment. On 06/03/13 at 1305, Administrative Assistant #1 revealed that to accommodate the volume and provide timely evaluations and treatments, the department will place a patient in a hallway bed, but staff try as much as possible not to disclose too much personal information.

On 06/03/13 at 1307, random observations in the hospital's emergency department revealed Respiratory Therapist #1 performed Tracheostomy replacement and Tracheostomy care for the patient located in hallway bed E with no privacy curtains or devices to prevent observation by others.

On 06/03/13 at 1330, random observations in the emergency department revealed the patient located in room #7 lying on the stretcher bare chested with an opened curtain and door.

Hospital policy "01-0000-UP000470, Patient Rights and Responsibilities", reads, "....The right to considerate, respectful care at all times under all circumstances, with recognition of their personal dignity....The right to security and personal privacy and confidentiality of information....".
Hospital Patient Rights and Responsibilities handout, reads, "....Undergo examinations in reasonably private visual and auditory surroundings....".

On the days of the Validation Survey based on interview and record review, the hospital failed to ensure that data was collected in its high risk hemodialysis unit, failed to ensure that clear expectations for safety were established in the hemodialysis unit by the hospital's governing body, medical staff and administrative officials, and failed to ensure that its program reflected the complexity of the hospital's organization and services by way of failing to evaluate care and services in its high risk hemodialysis unit.


The findings include:


Cross Reference to A0283: The hospital failed to ensure a system in which data was collected and evaluated for safety in its high risk hemodialysis unit.

Cross Reference to A0286: The hospital failed to ensure that clear expectations for safety are established in its high risk hemodialysis unit by the hospital's governing body, medical staff, and administrative officials.

Cross Reference to A0308: The hospital failed to ensure that its Quality and Patient Safety Council program reflects the complexity of the hospital's organization and services and involves all hospital departments and services by way of failing to evaluate care and services in its high risk hemodialysis unit.

On the days of the Validation Survey based on interview and record review, the hospital failed to ensure that data related directly to the safety of its high risk hemodialysis unit was monitored through the hospital's Quality and Patient Safety Council.


The findings include:


On 6/05/2013 at 1500, review of the hospital's Quality and Patient Safety Council meeting minutes for the months of February 2013, March 2013, and April 2013 revealed no reporting of any quality data items such as water quality monitoring, staff competencies, or water and dialysis machine cultures from the hospital's hemodialysis unit. On 6/06/2013 at 1030, the Administrative Director of Quality revealed, "We have no means and/or system in place for reporting of water cultures or any information from the Dialysis unit. They haven't had any problems, so they have been okay and no data has been reported or trended...".

On the days of the Validation Survey based on record reviews, interviews, and review of the hospital's infection control and quality and patient safety data, the hospital failed to ensure that a system for monitoring and tracking indicators in the hospital's high risk dialysis unit to identify and reduce the potential for adverse patient events in its high risk dialysis unit.


The findings are:


On 6/5/13 at 1205, interview with Nursing Director #2 revealed when asked what quality information is maintained for dialysis responded, "No Quality information is maintained for dialysis. Things are discussed at the staff meeting and reviewed with the Medical Director if there are any issues but no information is reported anywhere". On 6/5/13 at 1437-1442, interview with Medical Director #1 revealed when asked are any quality indicators reported to the hospital wide Quality Committee for dialysis, responded "No formal report sent to Quality Committee as such....".

On the days of the Validation Survey based on interview and record review, the hospital's governing body failed to ensure that its Quality and Patient Safety Council program involved all hospital departments and services by way of failing to evaluate care and services in its contracted high risk hemodialysis unit.


The findings include:


On 6/05/2013 at 1500, review of the Quality and Patient Safety Council meeting minutes for the months of February 2013, March 2013, and April 2013 revealed there was no data reported from the hospital's contracted high risk hemodialysis unit. On 6/06/2013 at 1030, the Administrative Director of Quality revealed, "We have no means and system in place for reporting of water cultures or any information from the Dialysis unit. They haven't had any problems, so they have been okay and no data has been reported...".

On 6/5/13 at 1205, Nursing Director #2, when asked what quality indicators are reviewed for the hospital's high risk dialysis unit, responded, "No Quality information is maintained for dialysis. Things are discussed at the staff meeting and reviewed with the Medical Director if there are any issues but no information is reported anywhere".

On 6/5/13 from 1437-1442, Medical Director #1, when asked what quality indicators are reported to the hospital wide Quality Committee for dialysis, "No formal report sent to Quality Committee as such....".

On 6/5/13 at 1505, Infection Control Officer #1 reported, "the dialysis unit reports to me on a basis of exception. They only send me information if there is an issue. I'm not worried about them....". When asked if infection control audits are performed of the dialysis unit, the Infection Control Officer responded, "No. I follow the recommendations that are sent from CMS (Centers for Medicare and Medicaid) and Joint Commission". When asked who audits the dialysis unit for infection control practices, the officer responded, "we don't require that of them. We don't do any audits for hand hygiene, personal protective equipment, or blood spills".

On 6/5/13 at 1600, review of infection control surveillance logs and audits revealed the hospital's infection control officer had no system in place for the monitoring of and surveillance of the water quality and machine cultures in the dialysis area. On 6/5/13 at 1600, the hospital's infection control officer revealed that he/she did not monitor the dialysis area unless a problem presented.

On the days of the Validation Survey based on patient chart review and interview, the hospital failed ensure the nurse initiated all of the primary diagnoses on the care plan for 2 of 40 patient care plans reviewed. )Patient # 4 and Patient #26)

The findings are:

On 6/4/13 at 1330, review of Patient #4's nursing care plan revealed the patient's primary problem of Acute Renal Failure (ARF) was not initiated by the admitting RN. On 6/4/13 at 1345, RN #34 confirmed the finding.






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On 6/4/13 at 0930, review of Patient #26's nursing care plan showed no documentation that the care plan was reviewed by the nursing staff on 6/3/13 and 6/4/13. The findings were verified on 6/4/13 at 0930 by Director #10.

On the days of the Validation Survey based on observations, interview, and review of hospital policy and procedure, the hospital failed to obtain physician orders for 2 of 41 patient (Pt) records reviewed for care and services. (Patient #9 and #23)


The findings are:


On 06/03/13 at 1413, observations of Patient #9 in the hospital's emergency department exam room #2 revealed that Patient #9 was receiving 3 liters per minute of oxygen through a nasal cannula. On 06/03/13 at 1413, review of Patient #9's chart revealed the patient presented to the Emergency Department on 06/03/13 at 0957 with the complaint of facial droop. Further review of the patient's chart revealed there was no physician order for administration of oxygen therapy. On 06/03/13 at 1421, the findings were verified by Administrative Assistant #1.

Hospital policy "01-7300-RC000203, titled, "Oxygen Protocol", reads, "The Oxygen Protocol will be initiated for all patients upon written order from the physician for administration of oxygen therapy....".

On the days of the Validation Survey based on observations and interview, the hospital failed to ensure safe storage of drugs and biologicals in its emergency department.


The findings are:


On 06/03/13 at 1337, random observation of the Emergency Department revealed a IV (intravenous) tray sitting on a hallway bed with five (5) prefilled 3ml (milliliters) normal saline syringes. On 06/03/13 at 1340, the findings were verified with Administrative Assistant #1.

On the days of the Validation Survey based on observations and interview, the hospital failed to remove unusable biologicals from the patient care areas.


The findings are:


On 6/3/13 at 1345, random observations of the Cardiovascular Intensive Care Unit revealed (1) central line kit expired 4/2013 and (1) impervious surgical gown expired on 1/2013. The findings were verified by Director #9 on 6/3/13 at 1345.

On 6/3/13 at 1530, random observations of the Intensive Care Unit revealed (2) size 7 Esteem Powder free Surgical gloves expired 11/2012, (2) size 7 1/2 Esteem Powder free Surgical gloves expired 5/2012, (4) size 6 Triflex custom sterile latex powdered surgical gloves expired 11/2012 and (1) packet of 450 Foam ECG (electrocardiograph) adhesive electrodes expired 08/2012. On 6/3/13 at 1530, Director #10 stated the crash cart had just been used over the weekend and restocked.

On the days of the Validation Survey based on observations and interviews, the hospital failed to ensure a sanitary environment for food preparation in the hospital's kitchen and failed to label food in the kitchen's refrigerator.


The findings are:


On 6/03/2013 from 1300-1330, random observations of the kitchen area revealed the grill had embedded food and grease covering the grill rack, brown debris on floor and under a cabinet located at the stove area, dirty ovens, and water on the floor in the preparation area. On 6/03/2013 at 1330, the Executive Chef verified the findings.

On 6/03/2013 at 1345, random observations of the refrigerator in the dietary area revealed 3 large containers of chicken, sitting in a watery substance, uncovered, without any date, time, or identifying information on the containers. On 6/03/2013 at 1345, the Lead dietician revealed, "...That is the chicken for the staff. We are having a cookout for lunch today and we prepared this chicken this morning. We should have put a label on it and covered it...".

On the days of the Validation Survey based on interview, record review, and review of hospital policy and procedures, the hospital failed to ensure staff monitored the crash cart and medication refrigeration logs in the Intensive Care Unit and linen storage in the emergency department per the hospital's own policy and procedure.

The findings are:

On 6/4/13 at 1615, random observations in the Intensive Care Unit (ICU) at Hospital B revealed the Emergency Crash Cart and the Medication Room refrigerator logs had no documentation on 5/8/13, 5/23/13, and 5/30/13. On 6/4/13 at 1635, RN #41 confirmed the findings.







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On 06/03/13 at 1255, random observations of the emergency department revealed exposed linen stacked on top of a 3 drawer clear plastic container behind the door in Triage room #2. On 06/03/13 at 1259, Emergency Department Technician #1 revealed that linens are kept on the linen carts. If the linen is stored elsewhere, it is covered with a sheet.

Hospital policy "32: Storage, Collection and Transportation of Linen", reads, "All linens will be stored, handled, transported and processed in a manner that prevents the transmission of microorganisms to other patients and areas....".

Hospital policy Number: 01-0000-UP000310, titled, Emergency Response System : Cart Readiness, reads "....4. Emergency cart requires at minimum a daily (q(every) 24 hr) check to insure cart readiness....".

Hospital policy Number: 01-0000-UP000900, titled, Medication Refrigerator Temperature Monitoring, reads "....All medication refrigerator temperatures are checked and logged daily in areas where medications are refrigerated....".

On the days of the Validation Survey based on observations, record reviews, interviews, and review of hospital policies and procedures, the hospital failed to ensure an environment to avoid sources and transmission of potential infections and communicable diseases in that the Infection Control entity has no system in place to monitor and evaluate the hospital's high risk dialysis center.


The findings are:


Cross Reference to A 0749: The hospital's Infection Control Officer failed to develop a system failed to ensure staff prevented potential cross contamination by failing to clean/disinfect equipment before or after patient use (stethoscope), failed to perform hand hygiene prior to or after glove use, failed to change soiled gloves during procedures, opened sterile package of suction tubing, tape strips placed on the patient's bed railing prior to use, failed to don personal protective equipment (PPE) in the dialysis unit, and the hospital's Infection Control Officer failed to ensure a system for monitoring the water quality and machine disinfection in the dialysis area, and failed to develop specific infection control policies for the high risk dialysis area.

Cross Reference to A 0756: The chief executive officer, the medical staff, and the director of nursing failed to ensure that hospital's infection control entity developed and implemented infection control policies and procedures for monitoring the hospital's high risk dialysis unit.

On the days of the Validation Survey based on observations, interviews, and administrative record reviews, the hospital's Infection Control Officer failed to develop a system failed to ensure staff prevented potential cross contamination by failing to clean/disinfect equipment before or after patient use (stethoscope), failed to perform hand hygiene prior to or after glove use, failed to change soiled gloves during procedures, opened sterile package of suction tubing, tape strips placed on the patient's bed railing prior to use, failed to don personal protective equipment (PPE) in the dialysis unit, and the hospital's Infection Control Officer failed to ensure a system for monitoring the water quality and machine disinfection in the dialysis area, and failed to develop specific infection control policies for the high risk dialysis area.

The findings include:

On 6/5/13 at 1505, Infection Control Officer #1 reported, "the dialysis unit reports to me on a basis of exception. They only send me information if there is an issue. I'm not worried about them....". When asked if infection control audits are performed of the dialysis unit, the Infection Control Officer responded, "No. I follow the recommendations that are sent from CMS (Centers for Medicare and Medicaid) and Joint Commission". When asked who audits the dialysis unit for infection control practices, the officer responded, "we don't require that of them. We don't do any audits for hand hygiene, personal protective equipment, or blood spills".

On 6/5/13 at 1600, review of infection control surveillance logs and audits revealed the hospital's infection control officer had no system in place for the monitoring of and surveillance of the water quality and machine cultures in the dialysis area. On 6/5/13 at 1600, the hospital's infection control officer revealed that he/she did not monitor the dialysis area unless a problem presented.




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On 6/04/2013 at 1000, observations of the crash cart located in the hospital's out patient infusion center revealed opened suction tubing connected to the portable suction machine sitting on top of the crash cart. On 6/04/2013 at 1000, the Director confirmed the suction tubing was not in its sterile packaging, and the Director reported that he/she did not know when the suction tubing was changed last.

On 6/04/2013 at 1010, observations of Registered Nurse (RN) #6, in the hospital's infusion area, initiating an intravenous infusion in the patient's left arm showed RN #6 failed to perform hand hygiene prior to donning gloves. After donning gloves, RN #6 touched the computer to input information regarding the patient, assisted the patient to the bathroom, and then, started the IV infusion without performing hand hygiene or donning clean gloves.






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On 6/6/13 from 0825-0835, random observations on the dialysis unit revealed Registered Nurse (RN) #39 disinfected the patient's left arm access site at Machine F8. Then , RN #39 removed his/her soiled gloves and placed the soiled gloves on top of the patient's dialysis machine. Without performing hand hygiene, RN #39 donned clean gloves. Torn strips of tape without an anchor were observed hanging from the patient's bedside rail. After accessing the patient's left arm access site, RN #39 removed the tape strips from the bedside rail and applied the tape strips to patient's left access site.

On 6/5/13 at 1145, random observations on the dialysis unit revealed RN #33 and RN #39 discontinuing the patient's dialysis treatment for patients located at Dialysis Machine F8 and Dialysis Machine F6 without protective gowns (PPE). On 6/5/13 at 1148, Charge Nurse #1 reported that when discontinuing patients from dialysis treatment that "only gloves and a face shield are required".





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On 06/03/13 from 1305-1310, random observations of Respiratory Therapist #1 performing a Tracheostomy replacement/change in the emergency department at hallway bed "E" revealed Respiratory Therapist #1 failed to disinfect the stethoscope he/she used to asses the patient. With gloved hands, Respiratory Therapist #1 replaced the stethoscope around his/her neck and walked into nursing station to chart.

On 06/03/13 from 1340-1355, random observations RN #14 initiating a peripheral Intravenous catheter (IV) in Triage room #2 revealed RN #14 failed to perform hand hygiene prior to and after completing initiation of the peripheral IV. Also, RN #14 failed to disinfect the Dynamap machine used to obtain the patient's vital signs.

On 06/03/13 from 1425-1430, random observations RN #15 discharging the patient in Hallway bed E in the emergency department revealed RN #15 applied the blood pressure cuff to patient's right arm, charted on computer, removed blood pressure cuff, rolled the dynamap machine to the side of the hallway and completed the discharge process without performing hand hygiene and disinfection of the equipment used on the patient.




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On 6/6/13 at 0900, random observations in the dialysis unit revealed Physician #1 failed to wear PPE (personal protective equipment) while making rounds on patients located at station F-9 and F-6, and failed to disinfect the stethoscope between each patient use.


Hospital policy # 00-8405-IC002100, titled, "Infection Prevention Program Overview and Plan of Service", revised 3/13, states, "...A. Administrative Controls 1. Policies, Procedures and Practice Monitoring: As part of the ongoing Infection Prevention Plan, members of the Infection Prevention Team shall participate in the development of new policies and procedures that have infection prevention implications toward patient care. The Infection Prevention Team as agents of the Infection Prevention Council, shall also work with departments and services to review existing policies and procedures annually and as needed. The Infection Prevention Team shall also participate in the monitoring of patient care practices. Policies and procedures will follow evidenced-based practices and regulatory guidelines... 5-6. Reduce a patient's risk for a hospital acquired infection associated with procedures, medical equipment, devices or supplies through prioritized, targeted surveillance activities and data analysis. As previously stated, follows all IHI, CDC, WHO, CMS, DHEC, SCIP and other applicable professional organizations, governmental agencies and best practice guidelines...Reduce the risk for infection in Dialysis Patient. * Monitor dialysate reports for organisms * Filter all dialysis water through a reverse osmosis machine * Use clean technique when placing patients on dialysis * Follow all American Nephrology Nurses Association guidelines *Follow contact precautions when indicated...".

Hospital policy # 00-8405-IC002130, titled, "Methods for Surveillance Calculation and determining HAI status", revised 3/13, states, "...1. Targeted surveillance methods include but are not limited to: Hand Hygiene and Artificial Nail Compliance... Method: Unknown to nursing staff monitor for hand hygiene and artificial nail compliance during their daily activities. Compliance is documented on the hand hygiene surveillance tool, which was created by Infection Prevention. The hand hygiene surveyors are to complete 10 audits per shift, for a total of 20 audits per unit monthly (with the exception of outpatient areas which complete 10 audits a month)...".

Hospital policy 01-0000-UP000310, titled, "Emergency Response System: Cart Readiness", Effective Date: 12/2002, states, "...All unit personnel are responsible for awareness related to cart contents...".

Hospital policy 00-8405-IC002120, titled, "Objectives, Goals and Strategies, Reduce the risk for infection in Dialysis Patients," reads, " ....Use clean technique when placing patients on dialysis, Follow all American Nephrology Nurses Association guidelines, Follow contact precautions when indicated....".

Hospital policy "00-8405-IC005100, titled, "Standard Precautions", reads, "....B. Standard precautions are indicated for ALL patients and are to be used routinely in the healthcare environment....".

Hospital policy "00-8405-IC005600, titled, "Patient Equipment Cleaning Policy", reads, "....F. Each user of an item, with the exception noted above, is responsible for cleaning any non-dedicated non-critical items, he/she just used....".

Hospital policy "01-0000-UP000520, titled, "Hand Hygiene", reads, "....A. Indications for Hand Hygiene....1. Before patient contact....4. After patient contact. 5. After contact with the patient's surroundings....".

On the days of the Validation Survey based on observations, record reviews, and interviews, the chief executive officer, the medical staff, and the director of nursing failed to ensure that hospital's infection control entity developed and implemented infection control policies and procedures for monitoring the hospital's high risk dialysis unit.

The findings are:

On 6/5/13 at 1505, Infection Control Officer #1 reported, "the dialysis unit reports to me on a basis of exception. They only send me information if there is an issue. I'm not worried about them....". When asked if infection control audits are performed of the dialysis unit, the Infection Control Officer responded, "No. I follow the recommendations that are sent from CMS (Centers for Medicare and Medicaid) and Joint Commission". When asked who audits the dialysis unit for infection control practices, the officer responded, "we don't require that of them. We don't do any audits for hand hygiene, personal protective equipment, or blood spills".

On 6/5/13 at 1600, review of infection control surveillance logs and audits revealed the hospital's infection control officer had no system in place for the monitoring of and surveillance of the water quality and machine cultures in the dialysis area. On 6/5/13 at 1600, the hospital's infection control officer revealed that he/she did not monitor the dialysis area unless a problem presented.

On the days of the Validation Survey based on record review, interview, and review of hospital policy and procedures, the hospital failed to ensure that all patient care staff were educated on the hospital's organ procurement requirements for two (2) of four (4) Registered Nurses and 1 of 1 Directors interviewed (Registered Nurse (RN) #28 and #30 and Director #1), and failed to ensure that color blindness testing competency was completed for 8 of 8 Registered Nurses using reagents in the performance of chlorine and chloramine testing in the hospital's dialysis unit. (Registered Nurses #33, #35, #36, #37, #38, #39, #40, and Charge Nurse #1)


The findings are:


On 06/05/13 at 1400, Registered Nurse (RN) #28 reported that he/she had not received in-service training or education provided by the hospital for the hospital's requirements for organ donation. On 06/05/13 at 1407, Director #1 reported that he/she had not received in-service training or education provided by the hospital for the hospital's requirements for organ donation. On 06/05/13 at 1415, RN #30 reported that he/she had not received in-service training or education provided by the hospital for the hospital's requirements for organ donation. On 06/05/13 at 1500, Administrative Assistant #1 reported that only the intensive care unit staff received Organ Procurement education.

Hospital policies, "01-0000-UP000580: Organ, Eye, & Tissue Procurement" and "01-0000-000850: Donation Following Cardiac Death", revealed there was no hospital policy for the training of all patient care staff on organ procurement policies and procedures.

On 6/5/13 from 1035 to 1115, review of the dialysis clinic personnel files revealed that Registered Nurse #33, #35, #36, #37, #38, #39, #40, and Charge Nurse #18 had no documentation that they had been tested for color blindness to read the testing strip color resulted from reagents. On 6/5/13 at 1335, Charge Nurse #1 reported that all of the nurses in dialysis are required to perform the chlorine/chloramine testing, but staff have never been required to be tested for color blindness.

Review of the Manufacturer guidelines from Watercheck RC, reads, "....Directions For Use-Two test procedures can be used depending ;on the convenience and sensitivity requirement of individual facility operation....Since reading of strip color may vary depending on the lighting condition and an individual's visual perception of color, correlation of the results with a standardized DPD procedure can only be considered semiquantitative....".

On the days of the Validation Survey based on record review and review of hospital policy and procedures, the hospital failed to ensure the physician completed an updated patient history and physical no more than 30 days before or 24 hours after admission prior to surgery for 1 of 40 open patient charts reviewed. (Patient #11)

The findings are:

On 06/04/13 at 1405, review of Patient #11's chart revealed the patient was admitted on 05/07/13 with the diagnosis of Acute Renal Failure for surgery. Review of the patient's history and physical on the chart revealed the history and physical was not completed until 05/31/13. There was no updated history and physical in the patient's chart for day of surgery.

Hospital policy, "General Rules and Regulations of the Medical Staff", failed to include the information regarding requirements for the completion of updated patient history and physicals related to surgery or other procedures after the patient's admission.

On the days of the Validation Survey based on record review and interview, the hospital failed to ensure anesthesia documented a post anesthesia assessment for 2 of 40 open patient records reviewed for surgical services. (Patient #5 and #37)

The findings are:

On 6/4/13 at 1115, review of Patient #5's chart revealed the patient was admitted on 5/29/13 at 0530 with a diagnosis of Coronary Artery Disease (CAD), and had a Coronary Artery Bypass Graft (CABG) with Mitral Valve Replacement (MVR) on 6/4/13. Review of the patient's chart revealed there was no post anesthesia assessment recorded by the anesthesiologist. On 6/4/13 at 1130, Certified Registered Nurse Anesthetist (CRNA) #2 verified the chart had no post-anesthesia assessment documented by the anesthesiologist.

On 6/6/13 at 1445, review of Patient #37's chart revealed the patient was admitted on 2/19/13 at 0247 with a diagnosis of shortness of breath. On 4/6/13, the patient had a toe amputation. On 6/6/13 at 1445, review of the patient's chart showed there was no documentation of a post anesthesia assessment. On 6/6/13 at 1445, Director # 2 verified there was no post-anesthesia assessment report in the patient's chart.