|Survey Date: 5/24/2010|
Regulation Title: PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU
Regulation Description: The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations.
Based on facility tour and review of facility documents, it was determined that the facility failed to maintain emergency equipment per facility policy. This failure created the potential for emergency patient care to be compromised.
The findings were:
On 5/20/10 at approximately 9:00 a.m. a facility tour was conducted. On the patient treatment floor, there were two emergency evacuation carts (one on the north side and one on the south side). On each cart there were inventory sheets that also contained a section for weekly checks of the locks on the carts as well as a notation of the oxygen tanks reading of fullness.
A review of the facility's inventory sheets was conducted and revealed the following:
The south cart was checked less frequently (not weekly) than the north cart in 2010 (13 times for the south cart and 21 times for the north cart). The south cart was not checked weekly from 3/15/10 until 4/12/10.
Facility Plan of Correction:
Policy #1-02-08 “Emergency Equipment Checks” has been reviewed with the teammates with emphasis on the need to complete weekly checks on both crash carts and document. A RN will be assigned to check crash carts every Thursday. FA will audit the North, South and PD crash carts utilizing the audit tool every Friday to ensure compliance with weekly checks. Audits will be conducted weekly X 1 month and then biweekly X 1 month, followed by monthly audits. Results of audits will be reported Quality Improvement Facility Management Meetings (QIFMM) and addressed as necessary. FA is responsible for ongoing compliance with POC.