Volume 2025 | No. 2
SURVEYOR
RENAL DIALYSIS
RD7-R Frequency of the citation: 37%
■ The facility did not have available any preventative maintenance documentation since Oct 2023 for the 14 machines. The weight scale was due for maintenance/calibration in May 2024 and there is no evidence it has been completed. There is no documentation of the three eyewash stations being checked monthly since July 2024. ■ The home training facility was not maintained to provide a safe, functional, and comfortable environment. The staff restroom toilet would not flush. During interview it was confirmed the toilet had been broken for an extended amount of time. Both the patient and staff restroom toilets were found to contain mold, and it was evident they had not been cleaned in some time. Overall observation of cleanliness indicates that there is no routine cleaning schedule. There was no fire extinguisher located in the building, no maps to show the exit routes, and no evidence of an annual fire inspection conducted either by the local fire department, or the State Fire Marshall. ■ The side tables for all five dialysis chairs have scratches that have disrupted the integrity of the surface. There is increased risk for cross contamination as the deep scratches may not allow proper disinfection to remove all blood and/or body fluids from the spaces. ■ The facility did not ensure patients were in view of staff during the hemodialysis treatment to ensure visibility of the patient access. A staff member covering three patients in POD 2 and one patient in POD 1, left the POD area, moving to the charge nurse desk. Another staff member located in POD 3 walked out of the POD to the area where the scale and ice machine are located, leaving the POD unattended. ■ A patient’s AVG was wrapped in a chux pad preventing visibility of the access during the dialysis treatment. However, vital sign documentation by staff indicates the access is visible.
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. Comment on deficiencies: The standard is assessed through review of policies and procedures, observation, and response to interviews. Deficiencies were focused on in-center sites of service, noting expired and missing supplies and inaccessible emergency equipment. Examples of ACHC Surveyor findings: ■ Location A: The oxygen tank on the crash cart had maximum percentage of 8% which does not meet the 15% guidelines for use of an ambu bag during CPR. ■ Locations B and C: The agency did not have access to the LTC crash cart and oxygen. There was no emergency take out bag at either location to ensure emergency equipment is available to the staff inside the LTC during the dialysis treatments. ■ Location A: Emergency equipment is not immediately available, being located at a distance, down two hallways from dialysis patients. Additionally, the code cart does not include an AED. ■ The facility did not have any oxygen cylinders on the premises. A concentrator was present with no preventive maintenance noted. ■ The AED log has not been checked since August 2023. The crash cart and emergency take out box have not been checked since March 2025. Expired items observed in the emergency take out box: ٝ 4 normal saline syringes (expired Oct 2024) ٝ 4 butterfly blood collection sets (expired May 2024) ٝ 5 IV catheter sets (expired May 2023) ٝ .1 packet of Leur lock cap Set (expired Nov 2024) ٝ Heparin 10,000 units (expired Oct 2023) ٝ Inventoried as checklist items but not present in the emergency take out box: · 4 of 5 Leur lock cap sets · paper tape · hand sanitizer · Alcavis disinfectant · Gloves
Compliance tips for:
The intent of this standard is that the physical environment be organized and maintained to support safe, high quality care. Equipment is maintained in good working order. All areas are clean. Patients are in view of staff throughout treatment. ■ Conduct regular surveillance rounds for general environmental conditions and infection and safety risks (blood residue, rust, expired items, clutter, accessibility). ■ Tape down lines and tubes that create temporary tripping hazards. ■ Schedule equipment maintenance per manufacturer’s instructions. ■ 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. Train staff on the requirement to maintain visibility of patients, including vascular access sites.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 17
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