Colorado Denver County State Inspections
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DENVER DIALYSIS CENTER
Survey Date: 3/30/2010
Regulation Number:0113
Regulation Title: IC-WEAR GLOVES/HAND HYGIENE
Regulation Description: Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.
Surveyor Findings:
Based on observations, staff interview and review of the facility's policies and procedures, the facility personnel failed to perform adequate hand hygiene while performing patient care. This failure created the potential for contaminant transmission.
The findings were:
The facility's policy and procedure #1-05-01 entitled, "Infection Control for Dialysis Facilities," revised on September 2009, stated the following in pertinent part: "Hand hygiene is to be performed upon entering the facility, prior to gloving, after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, before touching clean areas such as supplies and before leaving the patient care area."
The following observations were made on 3/29/10 from approximately 1:00 p.m. to 1:30 p.m. A staff member was observed to be cleaning and setting up a dialysis machine for the next patient. An adjacent machine had alarms that were sounding and the staff member silenced the alarm without changing gloves. After silencing the machine, the staff member changed gloves and walked to the reuse room to get a new dialyzer. The staff member connected the new dialyzer and again changed gloves. There was no hand washing observed in between the changing of three pairs of gloves.
An observation was made on 3/30/10 at approximately 10:55 a.m. of a staff member on the treatment floor doing patient care that changed gloves without washing hands or using a hand sanitizer.
The observations made on 3/29/10 were brought to the attention of a staff educator on 3/30/10 at approximately 8:00 a.m. The educator stated that hand hygiene is stressed during training and in-house audits are periodically performed.
Facility Plan of Correction:
V 113
On 4-7-2010, the teammates were in-serviced on policy 1-05-01”Infection Control for Dialysis Facilities” with emphasis on proper handwashing, sanitizing after each glove removal, etc. Weekly infection control spot checks will be performed for 6 weeks, then bi-monthly for 8 weeks, then monthly ongoing by the Facility Administrator to ensure that all teammates are following policy and procedure
Continue monthly infection control audits by a member of the nursing staff and results reviewed with Facility Administrator. When teammates are identified not to be following policy and procedure, they will be immediately corrected and disciplinary action taken as necessary. Result of audits will be reviewed in CQI with the Medical Director and addressed as necessary. FA is responsible for ongoing compliance with POC.
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3/30/2010 Survey Tag 0729 Detail for:
DENVER DIALYSIS CENTER
Survey Date: 3/30/2010
Regulation Number:0729
Regulation Title: MR-COMPLETE RECORDS PROMPTLY
Regulation Description: (1) Current medical records and those of discharged patients must be completed promptly.
Surveyor Findings:
Based on staff interview and review of medical records, the facility failed to appropriately complete medical records in 8 of (#1 through #8) eight medical records reviewed. This failure created the potential for patient care to be compromised.
The findings were:
The medical records of eight patients were reviewed throughout the survey from 3/29/10 through 3/30/10. The "Physician Orders and Progress Notes" were reviewed for approximately the previous six months to one year. It was noted that all physician orders and progress notes were not timed. The telephone and/or verbal orders written by nurses were not timed as well. The physician orders that were noted by nurses were not timed when orders were taken off except when the nurse used a stamp which stated: "Noted and Entered into Snappy." This stamp prompted the nurse to date, time and sign the order being noted.
The above findings were brought to the attention of the facility educator on 3/30/10 at approximately 7:45 a.m. The educator stated that education regarding the necessity of timing all orders in all the associated dialysis facilities has been done several months ago.
Facility Plan of Correction:
V 729
On Tuesday April 13th, the Facility Administrator held an in-service with the dietitian, social worker and all nurses working at the dialysis center on required documentation for physician orders. This in-service covered the following items that are needed to appropriately document written/verbal orders:
1. Date and time the order was given
2. Proper notation on the type of order, whether it be a verbal order, telephone order, or following protocol.
3. Name and credentials of physician giving the order
4. First initial, last name and the title of the teammate receiving the order
5. Nurses will “note” all orders they take off going forward, new licensed teammate training will include review of the related documentation policies
a. Medical record preparation and charting 3-02-02
b. Orders for patient care 3-02-03
c. Physician’s order policy 3-02-10
d. Allied health professionals order policy 3-02-11
On an annual basis all teammates will review the above policies
FA/designee will audit 10% of records monthly x3 then do random audits quarterly to ensure compliance. Results of audits will be reviewed in CQI with Medical Director and addressed as necessary. FA is responsible for ongoing compliance with POC.
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4/11/2007 Survey Tag 0196 Detail for:
RENAL CARE GROUP-DENVER CENTRAL
Survey Date: 4/11/2007
Regulation Number:0196
Regulation Title: PATIENT CARE PLAN: FREQUENCY
Regulation Description: The care plan for patients whose medical condition has not become stabilized is reviewed at least monthly by the professional patient care team described in 405.2137(b)(2) of this section. For patients whose condition has become stabilized, the care plan is reviewed every 6 months. The care plan is revised as necessary to ensure that it provides for the patients' ongoing needs.
Surveyor Findings:
Based on medical record review, staff interview and policy manual review, the facility failed to ensure that:
1. Care plans were completed as necessary to ensure it provided for the patients ongoing needs in two (#1 and #4) of 11 sample patients and
2. A care plan for a patient whose medical condition had not become stabilized was reviewed at least monthly in one (#6) of 11 sample patients.
The failure to ensure patient care planning was conducted as necessary created the potential for inadequate and/or inappropriate provision of care. The findings were:
The facility's policy and procedure entitled "Hemodialysis Short-Term Care Plan," policy #17-PP-1.02 dated 6/7/05, was reviewed on 4/10/07. The policy reads in pertinent part; "The STCP (Short Term Care Plan) will be developed within 30 days of admission to the outpatient facility, will be updated every 6 months thereafter for stable patients, monthly for unstable patients..."
The medical record for sample #1 was reviewed on 4/10/07. The STCP dated 11/28/06 was signed by all disciplines as having been completed. However, it was only partially completed by the registered nurse. The STCP dated 1/4/07 was completed by the dietitian and the social worker but the registered nurse did not complete any portion of it.
The medical record for sample #4 was reviewed on 4/10/07. The STCP dated 1/3/06 was signed by all disciplines as having been completed. However, it was not completed by the social worker or the registered nurse.
The medical record for sample #6 was reviewed on 4/10/07. The STCPs from 11/06 through 3/07 documented the patient as being unstable and a review care plan should be done monthly. However, a STCP for 2/07 failed to be implemented.
The clinical manager was interviewed on 4/10/07 at 3:45 p.m. regarding the incomplete STCPs. The manager stated chart audits are performed on a quarterly basis, but did not know how the audit had missed the incomplete STCPs or the monthly STCP for the unstable patient.
Facility Plan of Correction:
V000
The Governing Body of this facility – whose membership includes the Medical Director, the Clinical Manager, and the Area Administrator - takes seriously its responsibilities regarding the development, implementation and monitoring of policies and procedures for the day-to-day operations and governance of the facility to ensure the health and safety of patients and staff. As such, the Governing Body initially met on 04/23/07 at 11:00 AM
to review and discuss the forthcoming Statement of Deficiencies and to develop the following Plan of Correction.
The Governing Body, at that same meeting, determined to meet at least every month, from the date of the meeting through June 30th 2007, to hear reports from staff designated as responsible for each corrective action and thus, to monitor progress, implementation and maintenance of corrective actions. Minutes of the referenced, and all subsequent GB meetings documenting this activity are available for review at the facility.
405.2137(b)
V 196
Care plans have been completed for the identified patients in the SOD.
The Clinic Manager will in-service the staff on the policies related to the care planning process. (Completed 04/19/2007 and 04/20/2007) An attendance sheet is available in the clinic as evidence of the in-service.
The Clinic Manager will review the care plan tracking process with the Facility Assistant who is responsible for tracking and scheduling of care plans by 04/19/2007.
There will a 100% chart audit conducted in the facility and will be completed by June 30, 2007:
33% of the records (40) to be reviewed by 4/30/07
33% of the records (40) to be reviewed by 5/30/07
33% of the records (40) to be reviewed by 6/30/07
The Clinic Manager will ensure any deficiencies found in the chart audit data related to the care planning process are corrected and an action plan will be put in place.
The Clinic Manager or Designee will confirm monthly times three months that the care plan tracking process in place has accurately identified all patients requiring either an initial or updated long term care plan has been completed. Findings will be documented on a monitoring tool and will be discussed in the monthly QAI meeting minutes.
Results of the monitoring will be reported to the Area Manager at least quarterly.
The Area Manager will report the status of the facility plan of correction to the Governing Board.
Short term care plans have been completed for the identified patients in the SOD.
The Facility Manager will review the care plan tracking process with the Facility Assistant who is responsible for tracking and scheduling of care plans by 04/30/2007.
The Clinic Manager or Designee will confirm monthly times three months that the care plan tracking process in place has accurately identified all patients requiring either an initial or updated short term care plan has been completed. Findings will be documented on a monitoring tool and will be discussed in the monthly CQI meeting minutes.
Results of the monitoring will be reported to the Area Manager at least quarterly.
The Area Manager will report the status of the facility plan of correction to the Governing Board
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2/16/2010 Survey Tag 0402 Detail for:
RENAL CARE GROUP-ROCKY MOUNTAIN
Friday, December 24, 2010 9:16 PM
Survey Date: 2/16/2010
Regulation Number:0402
Regulation Title: PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY
Regulation Description: The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public.
Surveyor Findings:
Based on observations, document review, patient and staff interviews, the facility failed to maintain the integrity and cleanliness of the physical environment on the treatment floor and the laboratory area.
The findings were:
The following observations were made during the survey on 2/15/10 through 2/16/10:
1. The countertop and sink in the laboratory area had lost the integrity of the surface. The countertop was flaking apart and the sink had rusty spots that appeared to have broken through the surface of the sink.
2. The computer monitor stands on the treatment floor between the patient machines were extremely soiled. The stands were an almond color and there were areas on them that had a collection of black grime and what appeared to be old blood spots. All of the 12 stands had a collection of various types of dirt, grime and dust.
3. The counter working areas in both A and B had areas where pieces of the pressed board were chipped off. The drawers in the counters were dirty with an accumulation of dust and grime.
4. The base boards around the entire treatment floor appeared to be totally rotten.
5. The partition in the center of the treatment floor had discolored areas at the base that also appeared to have rotted through.
6. The computer monitor shelf in the isolation room was dirty and dusty.
The Governing Body meeting minutes for 11/20/09 were reviewed on 2/15/10. The documentation regarding the physical plant stated: "Clinic in disrepair. Clinic has been approved for facelift. Awaiting date for remodel."
The Quality Assessment Improvement (QAI) meeting minutes were reviewed on 2/16/10. The documentation in 3/09 regarding patient complaints stated the following, in pertinent part: "Most common complaints from patients are regarding the facility and equipment (clinic is too cold, too brightly lit, cleanliness, disrepair...)"
The QAI meeting minutes documented on 6/30/09, 8/28/09, 10/23/09, regarding the physical environment, stated that it was "Urgent Priority."
The documentation in the QAI meeting minutes on 1/29/10 stated: "Project manager was in clinic evaluating current situation with leaks in bicarb/acid loop, overall condition of clinic. Project manager has been in facility with construction crews obtaining bids for repairs. Clinic to have face lift beginning in January of 2010."
An interview was conducted with a dialysis patient on 2/16/10 at approximately 7:45 a.m. The patient has been on dialysis for eight years in the facility. The patient stated that some time before Christmas in 2009 the patients were given the opportunity to pick out the new colors to be used on the treatment floor. The remodeling was promised to start before Christmas; however, they were told later that perhaps it would be better to wait until after the holidays and start at the first of the year. The patient continued to state that here it is the middle of February 2010 and still no remodeling. The disrepair of the facility bothered him/her and also the dirty computer monitor stands. (The patient appreciated the care and support of the staff, but was upset regarding the uncleanliness and disrepair of the facility.)
An interview was conducted with the clinical manager on 2/16/10 at approximately 8:15 a.m. The manager stated that approximately two years ago the facility was tested for mold and the results came back negative. At that time, the rotted baseboards had been replaced; however, the wrong materials had been used and now are rotted out again. The manager further stated that he/she was not aware that a definite date had been set to begin the remodeling project.
Information was provided to this surveyor on 2/16/10 at approximately 1:30 p.m. regarding the status of the remodeling project. The project has been let out for bids in 10/09 and again in 12/09. However, no definite date could be provided as to when this remodeling project was to actually get underway.
In summary, the uncleanliness and loss of integrity of many of the building surfaces created the potential for health risks to the patients. The promised starting date of January 2010 documented in the QAI meeting minutes has failed to materialize.
Facility Plan of Correction:
Initial Comments
The Governing Body of this facility takes seriously its responsibility to govern the everyday operations at the facility in such a manner as to ensure the quality of dialysis treatments/operations as well as the health and safety of each patient. As such, the Governing Body, which includes the Medical Director, Director of Operations and Clinical Manager met March 8 2010 to review the Statement of Deficiencies received from the Colorado Department of Public health and Environment to develop the following Plan of Correction.
V402 494.60(a) PE-Building-Construct/Maintain for Safety
A General Contractor has been hired and is to begin the following projects by March 15 20010 Due to the nature and scope of work to be completed; there is an estimated completion of the entire project on or around April 28, 2010.
1. The sink and countertop in the laboratory area will be replaced.
2. New computer stands were ordered on March 8, 2010 . The new stands are expected to arrive around April12 2010 and will be set-up and put into use upon arrival to the facility.
As an interim solution until replacement, the current carts were cleaned and disinfected on March 6, 2010. DPC staff members were educated on March 8, 2010 on policy # FMS-CS-IC-II-155-070A Dialysis Precautions, which includes guidelines for computer cleaning and disinfecting.
3. Countertops and cabinets in working areas A and B will be replaced.
4. All rotted baseboards will be replaced.
5. Treatment floor will be replaced.
6. Computer monitor shelf will be cleaned on March 6, 2010.
Effective Immediately and Ongoing:
The Clinical Manager or designee will inspect the facility at least monthly using the physical environment audit. The results of the audit will be presented at the monthly QAI committee meeting and any issues will have a plan for correction identified and implemented.
The Governing Body appointed the Clinical Manager to monitor, document and report on the implemented action plan for this Statement of Deficiencies directly to the QAI and Governing Body committees through a formalized written report. If sufficient progress to correct the identified deficiencies is not met, the Governing Body through the QAI committee will direct the revision of the action plan until resolution is achieved.
The minutes of the QAI Committee and Governing Body meetings document these actions and are available for review upon request.
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3/23/2010 Survey Tag 0187 Detail for:
UNIVERSITY OF COLORADO HOSPITAL DIALYSIS SERVICES
Friday, December 24, 2010 9:35 PM
Survey Date: 3/23/2010
Regulation Number:0187
Regulation Title: ENVIRONMENT-SCHEMATIC DIAGRAMS/LABELS
Regulation Description: 8 Environment: schematic diagrams/labels Water systems should include schematic diagrams that identify components, valves, sample ports, and flow direction. Additionally, piping should be labeled to indicate the contents of the pipe and direction of flow. If water system manufacturers have not done so, users should label major water system components in a manner that not only identifies a device but also describes its function, how performance is verified, and what actions to take in the event performance is not within an acceptable range.
Surveyor Findings:
Based on observations and staff interview, the facility failed to identify sample ports and comprehensively describe the water system components.
The findings were:
A tour of the water room system was conducted on 3/22/10 at approximately 10:45 a.m. with a patient care technician who was also trained in the disinfection of the water system. It was noted during the tour, that the ports used to take samples for chlorine/chloramine testing were not adequately identified. Also, the components of the water system were labeled and the function was described; however, the label did not describe what actions were to be taken if the component was not within an acceptable range.
An interview was conducted on 3/23/10 at approximately 1:30 p.m. with the director of the facility. The director was made aware of the water system requirements.
Facility Plan of Correction:
The University of Colorado Hospital Dialysis Services at 4311 E. Ninth Avenue, Denver, Colorado, has added information to the documents currently on the dialysis water system. Previously the information identified the water system components and function of the components. The information now includes the acceptable range for each component and actions to be taken if the component reading is out of range. This was completed April 21, 2010
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