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Based on record review and interview the facility failed to answer the patient's informal grievance in the time frame specified in the facility policy. Citing 7 out of 9 grievance received by the facility.

Findings:

Review of the facility's policy titled "Grievance Procedure" 2.2 "Patient grievance is a formal written or verbal grievance that is filed by a patient, when a patient issue cannot be resolved promptly by staff present. 3.6 A written response is sent to the appropriate party regarding the grievance within 7-14 days".

Review of the facility's complaint Log for 2013 revealed that seven out of nine complaints that were not handled promptly by staff present did not receive a letter with in the time frame outlined in the facility policy.

Based on record review and interview,
A. there was no evidence the water endotoxins and cultures were routinely trended and reviewed by the medical director. There was no evidence the water endotoxins and cultures were trended and reviewed as part of the Hospital Quality Improvement process in 12 out of 12 months reviewed. This deficient practice had the potential to cause harm to all patients receiving dialysis at the facility.

B. there was no evidence the facility screened for hepatitis B surface antibody (HBsAb) (antibodies to protect a patient from getting the hepatitis virus)prior to admission, citing 3 out of 3 patient records reviewed (#HD1,# HD2, and #HD3). These findings had the potential to cause harm to all non-immune patients being treated in the dialysis unit at the facility by exposing them to hepatitis B positive patients.

C. the facility failed to ensure they recorded the machine conductivity of each machine and verified it with an independent device. This procedure was indicated to verify the accuracy of the electrolyte composition of the dialysate. The independent device ensures the delivery of the solution is within safe limits. This deficient practice had the potential to cause harm to all patients receiving care at the facility by the unsafe delivery of solution that does not have the correct composition.


Findings:

A. Review of the machine and water system endotoxin and cultures reports for the period of January 2013 thru April 2013 revealed there was no evidences endotoxin and cultures were trended and analyzed over time and no evidence the Medical Director had reviewed the cultures as required.

Review of the facilities Quality Improvement from March 2012 through March 2013 revealed there was no evidence there was a Medical Director who was familiar with dialysis system who participated in the facility over site of this contract service. In addition there was no evidence the committee reviewed the water culture and endotoxin results or any other quality improvement process within the dialysis unit.

Interview with the staff # 4 on 05/22/2013 at 3:30 p.m., confirmed there was no evidence the facility had trended through its Quality Improvement processes the RO water cultures and endotoxin for the contract dialysis unit water system and dialysis machines. In addition staff # 4 confirmed the facility did not have a Medical Director who was familiar with the dialysis process involved in the oversite of the unit.

B. On review of the medical record on 05/22/2013 at the facility, patient's medical record of # HD1, #HD2, and #HD3 were admitted to the facility and treated by the contract dialysis service. All three patients tested negative for the HBsAg (hepatitis virus). There was no evidence the facility tested the patient's antibody status and provided the required immunization education and began immunization if indicated.

Interview with staff # 1 on 05/22/2013 at 2:20 p.m. confirmed the facility did not test the patients for antibodies and began immunizations if indicated. Staff # 1 stated "an acute hospital unit is not required to treat acute patients the same as patients in chronic units".
C. Review of the treatment records for patient's #HD1, #HD2 and #HD3 treatment record on 05/22/2012 revealed there was only one conductivity reading recorded. The documentation did not indicate if it was the machine conductivity reading or a reading by an independent device. There was no documented evidence both the machine reading and a reading by an independent device was recorded to determine if the results were within an acceptable range.

Interview with staff # 1 on 05/22/2013 at 09:30 a.m., confirmed the treatment record did not contain documentation of the machine reading and a conductivity reading conducted by an independent device.

Based on record review and interview, the facility failed to monitor its contracted dialysis service through the quality improvement process. This deficient practice has the potential to cause harm to all patients receiving dialysis care at the facility.

Findings:

See tag 144 for details