HospitalInspections.org

Based on interview and review of meeting minutes the hospital failed to ensure the contracted dialysis service was consistently monitored through the quality assessment and improvement program and the infection prevention program to improve the health and safety of patients receiving dialysis services. The active hospital census was 96 patients.

Findings include:

Staff A stated in an interview on 02/18/15 at 10:32 AM the facility is a long term acute care hospital that contracts the Dialysis Center Incorporated (DCI) to provide dialysis service to acute care patients. The dialysis unit is located in the lower level of the building. Patients with ordered dialysis treatment are transported to (DCI) in the lower level of the hospital where six dialysis stations are contracted to provide dialysis service.

Staff G stated in an interview on 02/18/15 at 3:23 PM that clinical oversight for the infection control program is the responsibility of the Medical Director.

The infection control medical director, Staff H, stated in an interview on 02/08/15 at 1:00 PM the contracted dialysis center is integrated into the facility's Quality Assurance and Performance Improvement Plan QAPI. The Performance Improvement Committee meets quarterly and infection control practices include the collected surveillance data. The contracted dialysis center collects data and reports quarterly to the performance improvement meeting.

Staff A confirmed on 02/19/15 at 3:23 PM no other data was available for review other than the performance improvement commitee DCI Dialysis report dated June 24, 2014. Staff A confirmed no one consistently has been attending and/or provididng oversight of the contracted dialysis center through QAPI.