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Based on observation, interview and record review, the facility failed to ensure contracted services which provide dialysis treatment to facility's patients received care in a safe setting by following the policies for checking conductivity of dialysate solutions prior to initiating hemodialysis treatment on patients. As a result, the contracted dialysis staff failed to ensure the daily calibration of the Myron Meter used for checking conductivity on dialysate solutions was completed prior to patient's hemodialysis treatment in accordance with the policy for the months reviewed; August, September, October and November 2020. This deficient practice could cause harm to all patients receiving dialysis services by exposing them to unsafe dialysate fluids.

Findings included:

Review of the Intake complaint TX00363771 stated that "Phoenix and other meter calibrations are almost always charted as if they were done, but are almost never actually done."

Review of the contracted services policy 910 titled, Independent Verification of Dialysate Conductivity last revised January 2020 revealed the purpose is to ensure that the delivery system provides dialysate with proper conductivity to deliver safe hemodialysis treatments. The policy states that; 1. Independent verification of dialysate conductivity and pH using an independent test method will be done daily prior to the initiation of treatment. 3. Documentation of independent verification of dialysate conductivity and pH will be done on the Equipment Log for each delivery system used each time the tests are done.

Observations on 11/6/20 at 11:20 AM in the dialysis room 311 revealed a "Myron" Meter and a bottle of conductivity standard solution used to check conductivity.

Record review on 11/6/20 of the "Myron Meter Daily Calibration" records for Meter #mm010 for August, September, October and November 2020 revealed the following:

November 1st was checked for, No patient. November 2nd, 3rd, 4th, and 5th were blank with no documentation of a daily calibration.

There was not a Myron Meter Daily Calibration record for the month of October 2020.

Review of September 2020 revealed no documentation of a daily calibration on the 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 22nd, 24th, 25th, 26th, 27th, 28th, 29th and 30th.

Review of August 2020 revealed no documentation of a daily calibration on the 18th, 26th, 27th, 28th, 29th, 30th and 31st.

Interview on 11/6/20 at 11:15 with Dialysis contracted Registered Nurse (RN) A stated that dialysis staff were to check conductivity at the start of the day and before each treatment. RN A confirmed the above records for the Myron Meter Daily Calibration records for August, September, October and November 2020 after review. RN A indicated dialysis treatments were conducted in the facility Monday through Saturday.

Interview on 11/18/20 at 11:00 AM with the Chief Executive Officer (CEO) of the contracted dialysis confirmed the records reviewed of the Myron Meter Daily Calibrations had not been completed prior to the initiation of treatment. The CEO stated some of the calibrations were conducted electronically on the "IPAD's" used, but this facility had not implemented the daily calibrations on the IPAD's; further stating, "not documented, not done."

Interview on 11/18/20 at 3:20 PM with the facility's corporate Vice President (VP) of Clinical Services confirmed the facility failed to provide the necessary oversight of the contracted dialysis services to ensure policy and procedures were followed by the contracted dialysis staff; which could affect patient safety. The VP of Clinical Services provided a monitoring plan titled, "Dialysis Oversight Plan" dated 11/9/20 to be implemented for all of their facilities in the immediate area.