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12/9/2009 Survey Tag 0403 Detail for:
Tuesday, March 31, 2020 4:34 AM

Survey Date: 12/9/2009

Regulation Number:0403


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.

Surveyor Findings:

Based on observations and staff interview, the facility failed to maintain the equipment that was used by patients. Specifically, there were two chairs on the treatment floor that were in need of repair.

The findings were:

Observations were made throughout the facility during the survey on 12/8/09 and 12/9/09. The chairs located at station #4 and station #5 were noted to have breakdown in the upholstery. The patient chair at station #4 had a small crack on the left arm rest and also on the foot rest. The patient chair at station #5 had several cracks on the foot rest. The under padding could be seen through the cracks on both the chairs.

The facility was informed of the observations during the exit conference. A staff member stated that the facility was in the process of changing out the patient chairs that were defective. However, the facility did not have a schedule that specified the chairs from station #4 and #5 to be on the list for replacement or re-upholstery.

Facility Plan of Correction:

Melinda Jones, RCIT, removed and replaced the two chairs at stations #4 and #5 on December 10, 2009. Jerry’s Upholstery was hired by Loveland Dialysis on December 28, 2009, to repair and replace the upholstery on the remaining dialysis chairs and should be completed by January 10, 2010. Clinical Manager will complete a Physical Environment Audit quarterly (January, April, July and October) with a second staff member. The Director of Operations / Operations Manager will complete an AM Regulatory Review semi-annually (April and October) to ensure the integrity of the dialysis chairs on the treatment floor. Completion of the repairs and plan for monitoring will be documented in the QAI Meeting Minutes. Results of the stated audits when completed will be discussed and documented in the appropriate QAI Meeting Minutes


Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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