|Survey Date: 5/25/2010|
Regulation Title: RO-MONITOR/ALARM/PREVENT UNSAFE H20 USE
Regulation Description: 5.2.7 Reverse osmosis: alarm/prevent use of unsafe water
Refer to RD62:2001, 4.3.7 Reverse osmosis: Reverse osmosis devices shall be equipped with on-line monitors that allow determination of rejection rates and product water conductivity. The product water conductivity monitor should activate audible and visual alarms when the product water conductivity exceeds the preset alarm limit. The audible alarm must be audible in the patient care area when reverse osmosis is the last chemical purification process in the water treatment system. Monitors that measure resistivity or TDS may be used in place of conductivity monitors.
6.2.7 Reverse osmosis:
Reverse osmosis systems should be monitored daily using continuous-reading monitors that measure product water conductivity (or total dissolved solids (TDS)).
5.2.7 Reverse osmosis:
Refer to RD62:2001, 4.3.7 Reverse osmosis: When a reverse osmosis system is the last chemical purification process in the water treatment system, it [should] include a means to prevent patient exposure to unsafe product water, such as diversion of the product water to drain, in the event of a product water conductivity or rejection alarm.
Based on observation and staff interview it was determined the facility failed to have an audible alarm that was audible in the patient care area. The failure of not having an audible alarm created the potential for negative patient outcome.
On 5/18/10 at approximately 1:30 p.m., during a tour and observation of the patient care area it was noted the water alarm was not audible when the visual alarm light was flashing.
Interview with the Water Treatment Technician on 5/18/10 revealed the alarm had been turned down in the patient care area due to the nocturnal dialysis patients. H/she stated that the patients like to sleep and the alarm was annoying to them, and that the alarm had been turned down for at least a year. The alarm was then turned up to a volume which was audible in the patient care area.
Facility Plan of Correction:
The audible alarm was fixed on May 19th,
2009 and is fully functional. The Biomed
tech will check monthly during facility
audit to ensure the alarm is still audible
and document results. FA is responsible
for ongoing compliance with POC.