What is Quality Safe Care?
DCI - Redding Dialysis Center
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2567 DCI Redding recert 3-4-10.pdf Size : 86.235 Kb Type : pdf |
General Information
http://projects.propublica.org/dialysis/facilities/552537
Dialysis Facility Report (DFR) 2010
http://propublica.s3.amazonaws.com/assets/dialysis/facility-reports/CA/2010/CA_552537_2010.pdf
BRIEF OVERVIEW
"....the facility failed to ensure:
1. "Three of 6 sampled patients had a dialyzer re-use consent form in the medical record.."
2. "The facility diaalyzer re-use consent form complied with California Code of Regulations, Title 22, S75184, Informed Consent
"This failure resulted in patients not consenting to and/or being informed of potential adverse exposure/side effects to the dialyzer cleaning chemical"
COMMENT: If providers do 'reuse' then I can not understand why their consent forms are not in compliance with regulatory laws, especially when it comes to informed consent. It is imperative that patients are able to make informed decisions and choices, however, without correct and thorough information, it is impossible. If patients were aware of possible side effects from reuse, it is, more than, possible that many patients would have request single-use dialyzers. Patients need to have the advantages and disadvantages of treatment options.
"....the facility failed to ensure patients washed their dialysis access sites prior to treatment. The failure to do this increased the risk of infection at the access site for all patients on hemodialysis."
COMMENT: This is disturbing as this facility contributed to patients acquiring an infection e.g. staff wheeled patients into the treatment area and weighed them, but never wheeled them to the sink to wash their access site. Staff did not ask patients, or remind them of the necessity of same. I had to shake my head as I read the survey when the staff stated to the surveyor "It is the patient's responsibility to wash their access site:. This staff further stated "she does not ask patients very often if they ahve washed their site". Another staff said that patients were encouraged but that he 'very rarely' asked patients. I wonder if staff explained to patients the necessity of such, as mentioned above. Perhaps if staff explained to patients reasons for such, with consequences for not washing, there would be more patiens washing their access sites. Often sinks are blocked by wheelchairs or othe objects which prohibit patients from washing. At my father's unit (not this one) often the wheelchair was blocking the sink. He washed his access site all the time then just got disgusted because he kept telling staff the sink was blocked but nothing was done.. This happens in many facilities. (maybe not this one)
"...the facility failed to ensure items used or stored in the dialysis stations were cleaned and disinfected between patients. This failure had the potential to result in cross contamination and the transmission of bloodborne pathogens to other patients." " ....equipment used in the treatment stations was not being adequately disinfected. This failure had the potential toresult in cross contamination and the transmission of bloodborne pathogens to other patients."
COMMENT: When we see infection control deficiencies in the most basic of basic infection prevention practices, we must ask about the level of education and training that staff are receiving in prevention of transmission of infection. Of further concern is that of unit-level supervision. What is even more disturbing is that when staff were interviewed they were aware of correct practices, but did not implement same. So, we ask again, the question that is asked of us.....................if staff are appropriately trained and educated in correct practices but do not implement such is this an intentional act, on their part, to place patients in harm's way? Something to think about.
".....the facility failed to provide a safe environment when one opened vial of Heparin (a medication that helps prevent clotting of the blood) was not labeled according to facility policy."
COMMENT: Another example of staff not following their own facility policies and procedures.
"....the facility failed to ensure that
1. "The facility's eight fire extinguishers were being maintained in accordance with the manufacturer's recommendations."
2. "Eight expired laboratory blood tubes (tubes used when drawing blood specimens) were not available for use."
3. Drench shower logs (showers used for staff and patients should a chemical spill occur) were completed."
4. "Eye wash station logs (a faucet used to rinse the eyes if a chemical splash occurs) were completed."
5. "Maintenance of the Dialysis Machine PM (preventive maintenance) for 3 machines occurred according to manufacturer recommendation timeline."
"These failures had the potential to result in facility equipment not being maintained in functioning/operation condition."
COMMENT: The above are major patient safety issues. Again, not following manufacturer's recommendations and facility policies and procedures places patients in harm's way.
"....the facility failed to evaluate the effectiveness of their emergency and disaster plans by not conducting annual mock disaster drills. This failure would impact the facility's ability to evaluate the staff's skills and readiness needed in the event of an actual emergency, and had the potential to affect all patients and staff in the facility."
"... the facility failed to implement the initial plan of care for 1 of 6 sampled patients..." The failure to implement the initial plan of care had the potential to prevent the facility from meeting the individual needs of the patient."
COMMENT: Patients should be involved in their care and contribute by providing specific information on what their individual needs are.. however, often this does not happen. We must ask, "If this happens to one sampled patient, one must ask how many patients out of the sample experienced the same.
"..the facility failed to ensure that the treatment flowsheets for 4 of 6 samples in-centered treatment patients...... were complete when the times of pre and post assessments were not documented."
"...the facility failed to maintain a current transfer agreement with a hospital. This failure had the potential for patients not being accepted or treated by a hospital in an emergency, and had the potential to affect all patients in the facility."
