|Survey Date: 3/23/2010|
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.
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