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Based on observation, interview and record review, the facility's contracted dialysis service failed to apply proper identification label on a water system component for hemodialysis treatment. Contract Staff (C), (D).

Findings:

Contract Staff # C

On 07/07/2014 at 02:30 p.m., inside the dialysis stock room supply, 2 Fresenius Machine 2008H labeled TKC8 and TKC1 has no label on a pre-filter cartridge located at the back of each machine. The Surveyor notified the Director of Quality Management, and saw each machine has missing identification labels.

During an interview on 07/07/2014 at 03:30 p.m., with Contract Staff #C, the Surveyor asked for her role, and notified her that filter cartridge has no identification labels at the back of the dialysis machines. Contract Staff #C said she is a Registered Nurse for Total Kidney Care Acute Dialysis and stated " I do not think we should change those filters and label them. "

Review on 07/07/2014 of the Hemodialysis contract with the hospital, Total Kidney Care Acute Dialysis is referred as a " Provider " . It stated on page 3 item # 1.7 that " Compliance with Applicable Law: Provider agrees that all covered Services provided by or through Provider pursuant to this Agreement, and documentation thereof, will be in compliance with applicable law and certification or licensure requirement through the Texas Department of Health. "


Contract Staff # D & E

On 07/07/2014 at 01:45 p.m., inside the ICU #2, patient #2 completed hemodialysis treatment. The Surveyor asked Contract Staff # D to identify which machine was used for treatment, and which company he worked for. He said " I am of the Acute Nurses sent by DaVita here; this machine is what I used for this patient ' s treatment (pointing to Machine # 392KOS-176545) " . The Surveyor verified if he is aware of a pre-filter cartridge that requires replacement as labeled on the date at the back of the machine, he said " Oh, I am not aware " .

On 07/07/2014 at 01:45 p.m., Contract Staff # E came-in at 03:50 p.m. and the Surveyor asked him for the total number of machines in the hospital that their company has, and asked him for the frequency of changing the pre-cartridge filter, he replied " For our company, we only have 1 machine and the frequency of changing the filter is per manufacturer ' s recommendation as our policy. "

Review on 07/07/2014 of the Hemodialysis contract with the hospital, DaVita Facility # 1143 is known as the " Company " . It stated on page 2 item #3.1 that "Performance of Services. Company will perform Services in accordance with generally recognized standards of care as outlined by The Joint Commission, federal, state, and local applicable laws and regulations, as such may be amended from time to time " .

Review on 07/07/2014 of the contracted service ' s policy # 7-09-07 titled " REVERSE OSMOSIS (RO) WATER TREATMENT SYSTEM MAINTENANCE AND REPAIR " stated on item # 1 page 1 " RO systems will be maintained in accordance with manufacturer ' s recommendations, including intervals and procedures for maintenance of water treatment system and chemical cleaning and descaling of RO membranes. " Contract Staff # E provided copy of the maintenance procedure of the Reverse Osmosis item # 3.2 stated Changing the prefilter cartridge frequency is monthly or according to local recommendation.