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Based on record reviews and interviews, the hospital failed governing body oversite of the contracted dialysis services and infection control to ensure the provision of quality health care for 2 of 2 Hemodialysis patients (Patient #1 and #4), in that,

A. Patient #1 had five dialysis treatments with no Hemodialysis informed consent,

Cross refer to Tag A-084.

B. The 5 dialysis treatments of Patient #1 did not adhere to the physician's order, and

Cross refer to Tag A-084.

C. The Hemodialysis machine was not disinfected between 2 patients treated on the same machine. Patient #1 with an unknown antigen result was dialyzed on 9/06/14 prior to the subsequent treatment performed on Patient #4 on the same Hemodialysis machine.

This practice placed all patients at risk for infections.

Cross refer to Tag A-084 and A-749.

Based on record review and interview, the hospital failed to provide a sanitary environment to avoid sources of infections for 1 of 2 Hemodialysis patients (Patient #4), in that, the Hemodialysis machine was not disinfected between 2 patients treated on the same machine. Patient #1 with an unknown antigen result was dialyzed on 9/06/14 prior to the subsequent treatment performed on Patient #4 on the same Hemodialysis machine.

This practice placed all patients at risk for infections.

Cross refer to Tag A-749.

Based on record reviews and interviews, the hospital failed to ensure contracted dialysis services were provided in a safe manner for 2 of 2 Hemodialysis patients (Patient #1 and #4), in that,

A. Patient #1 had five dialysis treatments with no Hemodialysis informed consent,
B. The 5 dialysis treatments of Patient #1 did not adhere to the physician's order, and
C. The Hemodialysis machine was not disinfected between 2 patients treated on the same machine. Patient #1 with an unknown antigen result was dialyzed on 9/06/14 prior to the subsequent treatment performed on Patient #4 on the same Hemodialysis machine.


Findings Included

A. Patient #1's record reflected the admission date of 9/03/14 and the completion of five Hemodialysis treatments documented on 9/06/14, 9/09/14, 9/11/14, 9/13/14, and 9/16/14. The record reflected no Hemodialysis informed consents.

During an interview on 9/17/14 at 10:40 AM in the dialysis suite, Staff #13 was informed of the above findings. Staff #13 was asked to identify in the record the dialysis consent for Patient #1. Staff #3 said, "There isn't one."

B. Patient #1's record reflected a physician order for each of the five Hemodialysis treatments on 9/06/14. The physician's orders were not followed and/or documented as following the orders as evidenced below.

1) Patient #1's 9/06/14 "Hemodialysis Flow Sheet" reflected the treatment was completed from "8:40 AM to 12:40 PM" with a different dialyzer, heparin load, blood flow rate, and fluid waste removal than the physician's order required. The dialysate flow rate was not documented. The Hemodialysis and Reverse Osmosis machines used were identified on the "Hemodialysis Flow Sheet" as "DCU SN# 26612" and "WTU SN# 3083," respectively.

2) Patient #1's 9/09/14 "Hemodialysis Flow Sheet" reflected a different dialyzer and fluid waste removal than the physician's order required. The dialysate flow rate was not documented.

3) Patient #1's 9/11/14 "Hemodialysis Flow Sheet" reflected a different dialyzer, blood flow rate, and fluid waste removal than the physician's order required. The dialysate flow rate was not documented.

4) Patient #1's 9/13/14 "Hemodialysis Flow Sheet" reflected a different dialyzer, blood flow rate, and fluid waste removal than the physician's order required. The dialysate flow rate was not documented.

5) Patient #1's 9/16/14 "Hemodialysis Flow Sheet" reflected a different dialyzer, and fluid waste removal than the physician's order required.


Staff #13 was asked about the difference between what the physician ordered and how the Hemodialysis treatment was completed. Staff #13 stated, "We should have done it (the Hemodialysis treatment) per the order."


C. Patient #1's 9/06/14 "Hemodialysis Flow Sheet" reflected the dialysis treatment was completed from "8:40 AM to 12:40 PM." The Hemodialysis machine used was identified on the "Hemodialysis Flow Sheet" as "DCU SN# 26612."

Patient #4's 9/06/14 "Hemodialysis Flow Sheet" reflected the dialysis treatment was completed from "1:40 PM through 4:40 PM." The Hemodialysis machine was identified as "DCU SN# 26612."

The machine log for "DCU SN# 26612" did not reflect a disinfection between the treatments of Patient #1 and Patient #4.

Patient #1's results were unknown for the antigen at the time of Patient #4's treatment.

Staff #13 was asked to show documentation of where the dialysis machine was disinfected after Patient #1 was dialyzed on 9/06/14 prior to the subsequent dialysis treatment performed on Patient #4 with the same Hemodialysis machine. Staff #13 stated, "It (dialysis machine) was not."

During an interview on 9/17/14 at 11:00 AM in the boardroom, Staff #1 presented a contract for the Hemodialysis services. Staff #1 stated that the current contract was ending the end of September and they have a new Hemodialysis contract with another provider that will start on 10/01/14.

Based on record review and interview, the hospital failed to provide a sanitary environment to avoid sources of infections for 1 of 2 Hemodialysis patients (Patient #4), in that, the Hemodialysis machine was not disinfected between 2 patients treated on the same machine. Patient #1 with an unknown antigen result was dialyzed on 9/06/14 prior to the subsequent treatment performed on Patient #4 on the same Hemodialysis machine.

Findings Included

The "Hemodialysis Flow Sheet" for Patient #1 reflected dialysis treatment on "9/06/14" from "8:40 AM to 12:40 PM."The Hemodialysis machine used for Patient #1 was identified on the "Hemodialysis Flow Sheet" as "DCU SN# 26612."

The "Hemodialysis Flow Sheet" for Patient #4 reflected dialysis treatment on "9/06/14" from "1:40 PM to 4:40 PM." The Hemodialysis machine used was identified on the "Hemodialysis Flow Sheet" as "DCU SN# 26612."

The Hemodialysis machine log for "DCU SN# 26612" did not reflect a disinfection after Patient #1 was dialyzed on 9/06/14 prior to the subsequent use on Patient #4 on 9/06/14 at 1:40 PM.

On 9/06/14 at 8:49 PM, Patient #1's antigen was resulted as negative.

During an interview on 9/17/14 at 10:40 AM, Staff #13 was asked to show documentation of where the dialysis machine for Patient #1 was disinfected on 9/06/14 prior to subsequent use on the next patient. Staff #13 stated, "It (dialysis machine) was not."