Davita Union Citry Dialysis

What is Quality Safe Care?

6/24/   1/6

Here is an example of that which supports the lack
of adequate training/education and
unit-level supervision

Question: What is the underlying cause of a facility having a repeat deficiency, in the same area, that has the potential to have severe negative outcomes?

Davita - Union City Dialysis

 On 1/6/2010 the California Department of Public Health (CDPH) investigated three complaints. Two of the complaints had no deficiencies, however, there were two deficiencies written for one of the complaints. This is a serious problem.

".....the facility failed to ensure that prior to initiation of treatment the re-used dialzyer was verified as pertaining to one sampled patient (Patient 1). This failure resulted in the use of Patient 2's dialyzer to provide treatment to Patient 1, increasing the risk for infection by cross contamination, and making Patient 1 anxious and upset."

COMMENT: I find this to be totally unacceptable. Why? Recently, I can not recall, I read an article whereby a Davita spokesperson was interviewed due to this problem (not this facility). To recall, the spokesperson stated the procedure would be changed to having three staff check the dialyzer prior to using to ensure correct patient. This does not really solve this problem.
What should be done, if it was not, is the investigate as to the reasons for such -- lack of full understanding that staff have regarding dangers of not implementing correct procedures? lack of adequate unit-level supervision to ensure safe practices? lack of a more comprehensive educational training program?

Further ----- stated in the survey, of which is of greater concern...
"....unable to return the bld (blood), bld loss approximately 300 ml, pt was informed of incident......." "......the error was discovered when another staff was setting up for the next shift and could not find Patient 2's dialyzer."

Comment: Apparent that staff did NOT implement the facility policy and procedure to ensure patients receive their own dialyzer.

".....the facility failed to follow their own policy and procedure regarding patient assessment pre dialysis." "This failure may increase the risk of harm for patients and may lead to medical errors."

Comment: The facility's policy stated that pre assessments be done prior to initiation of the dialysis treatment. The facility staff conducted the patient's assessment after the dialysis treatment started.

This is yet another example of staff not adhering to their own policies ans procedures, let along the Conditions.

 The CDPH conducted a complaint investigation on 6/24/2010. This was for two complaints. 
COMMENT: This is a REPEAT deficiency. Before you read any further, keep in mind that on 1/6/2010, the survey conducted showed that a patient received the wrong dialzyer. The facility was to submit to the CDPH a Plan of Correction - how this would be corrected so that this did not happen again. WOW.. guess what...five months later, it happened again. So, we ask, what is the cause? Lack of an adequate educatonal program, training or unit-level supervision or lack of understanding, by staff, of the 'necessity' to follow procedures that the facility has set in place?

Maybe facilities should be fined when such happens within a specified time frame?

"......the facility failed to ensure the correct identification of Patient A prior to initiation of treatment. Patient A received treatment using the dialzyer of another patient."  comment: this does not necessarily mean the same patient as identified in the prior survey. Surveyors to not use patient names, just identifiers.

" ......the policy stated, "Two teammates are to check that the first and last names on reused dialyzer and any other appropriate identifying information correspond to the identifying information on the patient's permanent record.  Completion of this step is recorded on the electronic treatment record, along with signatures identifying the teammates verifying the patient's identification...""Two teammates are to confirm and document the identity of the patient and reused dialyzer prior to initiating the dialysis treatment."  COMMENT:  If this is followed no patient should ever receive the wrong dialyzer. Of great concern is that  the survey showed "...flowsheet dated 4/15/10, showed Staff 1's and Staff 2's electronic signatures of verification of the reprocessed dialzyer." It would appear to be obvious that either the staff did not check, or were quite careless when they did check. If they did not check, then they have falsified medical records by documenting something that did not happen. Further stated in the survey was "During an interview with the Clincial Nurse Specialist at approximately 2:45 p.m., she said that obviously these two staff did not check the patient's  name on the dialzyer, but went ahead and signed electronically." "The licensed Nurse who initiated Patient A's treatment on 4/15/10, failed to look at the dialzyer identification.". 

"....the facility failed to follow its own procedure when other patient's dialyzer was used to treat Patient A. This failure placed Patient A at risk for infection and emotional distress."

The Medical Director must ""Ensure that all policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;

Another area of concern is the following that makes one wonder .....
"During an interview with the Clinical Nurse Specialist (CSN) on 6/24/10, she siad that the facility did not have a policy for wrong dialzyer, because, "We don't expect taht to happen but if it does, then we immediately stop the treatment and we call the doctor, inform the patient and the family. Then whatever the doctor orders, we follow. It is physician directed."

COMMENT: This is absolutely ridiculous. I have reviewed surveys from this provider, dating back several years and believe that it has happened enough that there should be a policy in place. Further concern when reading the survey that placed a patient in harm's way as well as great emotional distress is..........

"The Clinical Nurse Specialist further said, that in the event of a wrong dialzyer, a Hepatitis Screen and HIV status of both patient were to be drawn, pending the order of a physician. Record review, showed the physician ordered lab tests for both Patient A and Patient B. The Clinical Nurse Specialist prsent for review on 6/24/10, the laboratory results of both patients. There was no result for Patient B's HBsAg screen and HBsAB quantity (tests for Hepatitis B infection) because according to the report, the samples were hemolyzed and a "Recollect request" was documented. The CNS said the facility failed to recollect or redraw another sample."

COMMENT: And, now we hope that both patients have had their blood tested and all was ok for both patients. Again, we state, if the survey was not conducted the failure to recollect specimens might not have happened. But, we are assuming that the patients had their blood redrawn for the tests.. hopefully.