Volume 2024 | No. 2
SURVEYOR
RENAL DIALYSIS
RD7-R Overview of the requirement:
RD7-J Overview of the requirement:
An emergency preparedness plan is developed and reviewed every two years to ensure the safety of patients and staff in the event of an emergency. The standard is assessed through review of policies and procedures, observation, and response to interviews. Deficiencies for in-center services noted expired and missing supplies and lack of access to emergency equipment. Deficiencies for home dialysis support focused on lack of communication with patients regarding an alternate site of care in the event of an emergency.
The facility provides a safe, functional, comfortable treatment environment.
Comment on deficiencies:
Compliance is assessed primarily through observation. Surveyor comments focused on environmental issues related to maintenance and the layout of patient care areas that compromised safety.
Comment on deficiencies:
Frequency of citation:
26%
Examples of surveyor findings:
n In one pod/bay, the laminate flooring was observed to be damaged and buckling in front of patient stations creating a significant trip or fall hazard to patients and staff. n The facility did not ensure that all equipment is monitored and maintained to ensure it is operating in accordance with the manufacturer’s guidelines. There was no evidence of temperature monitoring for the laboratory refrigerator where specific laboratory specimens are to be stored at a certain temperature range. n The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. Four patient chairs are arranged side by side with no machine between them, causing the chairside tables to be less than one inch apart making it difficult to accommodate medical emergency equipment if needed, and posing a risk for cross contamination. n Evaluate the space for function and make needed adjustments. All patients must be in direct line of sight throughout treatment but with adequate space to accommodate emergency equipment and to mitigate risk of cross contamination. n Conduct regular surveillance rounds for general environmental conditions and infection and safety risks (blood residue, rust, expired items, clutter, accessibility). n Schedule equipment maintenance per manufacturer’s instructions.
Frequency of citation:
32%
Examples of surveyor findings:
n Patients interviewed did not know what to do about missing treatments if there was an emergency and they could not make contact with the dialysis facility. They denied being notified regarding a back-up facility if the disaster/ emergency involved their clinic’s ability to provide treatment. n The emergency plan did not include a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. n Drugs and supplies earmarked for emergency use had expired. This conflicted with the organization’s emergency plan. n The emergency plan states that emergency equipment, including a defibrillator or automated external defibrillator and artificial resuscitator, are on the premises at all times and immediately available for use. There are no expired supplies. Logs show that the required AED check was not completed daily. The emergency evacuation box monthly checklist was not completed for two months and the box in was missing supplies and included expired items. The patient roster, contact information and dialysis orders in the Emergency take-out box had not been updated in the past three years. n Develop a process to confirm that emergency equipment (e.g., oxygen, airway and suction devices, defibrillator or AED, artificial resuscitator, and emergency drugs) is immediately available and includes appropriate inventory of unexpired drugs and supplies. n Advise patients of emergency precautions.
Tips for compliance:
Tips for compliance:
achc.org | (855) 937-2242 | 17
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