DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11I?06f2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10l15l2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, Tx 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAO REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) A130: Continued From page 21 A 130- Any condition I b. A list of problems and needs that are to be addressed during the patient's hospitalization. c. A description of all treatment interventions including: i. Each medication prescribed along with the it targets ii. Identification of the level of monitoring the patient is assigned to A description of the short and long term goals iv. The speci?c modalities for each treatment intervention including type and frequency v. The staff member responsible for ensuring treatment vi. A description of the rationale for the treatment interventions vii. The time frames and measures to evaluate progress toward goals Documentation to justify diagnosis, treatment, and appropriate timely discharge ix. A description ofthe recommended services and supports needed by the patient after . discharge". THIS PAGE LEFT INTENTIONALLY BLANK FORM Previous Versions Obsolete Event Facility ID: 810020 if continuation Sheet Page 22 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10l15f2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 W) in SUMMARY STATEMENT OF DEFICIENCIES Io PLAN OF CORRECTION (EACH ixsi (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED To THE APPROPRIATE DATE DEFICIENCY) (Continued from Page 22) A 130. Continued From page 22 A 130i QTAG A 144 Patient Rights in a Safe Setting The DOIICY further StIpUIateS: "The treatment plan Contracted Services: Dialysis is revised when: The Plan for Correcting the Specific a. There is a change in the patient's condition or DE?Cienc Cited: diagnosis 0 The CNO issued a memorandum tints:itsMarriages ?05 A144 PATIENT RIGHTS: CARE EN SAFE A 144 SETTING The patient has the right to receive care in a safe setting. This STANDARD is not met as evidenced by: Based on Observation, interview and record review. the facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility implemented facility's policies and procedures to I provide pre-hemodialysis treatment assessment and weight evaluation to patients in 4 of 6 I sampled hemodialysis patients63. The facility failed to ensure contracted services staff who provide hemodiatysis treatment to facility's patients follows manufacturer's recommendations and the facility's policy for checking conductivity of dialysate solutions prior to initiating hemodialysis treatment on patients; I failed to ensure contracted services staff calibrated devices used for checking conductivity on dialysate solution used for patients' hemodialysis treatment. I The facility failed to ensure contracted services staff who provide hemodialysis treatmentto oversight ofthe dialysis treatment area. Oversight shall include pre/ and post dialysis weights, complete physician orders. accurate documentation of dialysis treatment/ interventions, and infection control practices. (Exhibit B). 'o A dialysis checklist (Exhibit C) was developed to capture all of the elements needed in the delivery of dialysis and to facilitate the supervisory process. 10/15/2015 The plan for improving the processes that lead to the deficiency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the deficient practice: All dialysis done in SJMC facilities is being supervised at all times by an assigned RN to ensure proper technique is used, documentation; complete, and facility patient care policies and I procedures are followed. A dialysis checklist was developed to capture all of the elements needed to ensure the practice of safe dialysis (Exhibit C) An SJMC RN is assigned each Shift to supervise dialysis and is responsible for completing the Dialysis Checklist on every patient receiving dialysis. The SJMC RN Monitors dialysis and checks the following: FORM Previous Versions Obsolete Event ID2272U11 Facility ID: 810020 If continuation sheet Page 23 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11f06f2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B-WING 10f15f2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) (9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED eY FULL CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) A144 Continued From page 23 facility's patients follow manufacturer?s recommendations for validating the composition of the concentrate of the dialysate solution with a laboratory, following installation of 3 of 4 Fresenius 2008 hemodialysis machines. Machine #3 41, 42, 43. The Facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility met the qualification outlined in theirjob description in 8 of 8 sampled contracted nurses observed and reviewed. The failure to have contracted staff complete a Color Vision Test prevents the employee from effectively monitoring the water quality used to dialyze the facility's patients therefore putting the patients at risk for harm and not practicing according to acceptable standards of practice. Citing Registered Nurses #3 KK, ll, AM, TFT, WV, WW and . The facility failed to ensure that a suicidal patient was placed on suicide precautions as outlined in the policy and procedure in one of one patient named in the complaint (Patient Findings: Review on 10/1 3/201 5, of the facility's current policy and procedure on Pre Dialysis Patient ?Assessment, direct staff as follows: "Obtain pre?dialysis weight. Compare with target weight and previous takeoff weight to determine the amount of fluid to be removed? TAG A 144 (Continued from page 23) A144a. Pre-dialysis weight done b. Post?dialysis weight done I Io. Medication Add labels done if dialysate fluid I [has additive . I I lions/2015 d. Infection control practices maintained, including Routine Dialysis Station Disinfection between patients (Exhibit 0-1) 1 Complete MD orders lf. Dialysis ?owsheet is complete All dialysis nurses currently working have been Coior Blind Tested with documentation- of this testing in their personnel ?le. New or oncoming dialysis nurses that have not (10/15/2015 been color blind tested is verified by the supervisor prior to patient care assignment or will not work. Procedures for implementing the acceptable plans of correction for each deficiency cited: in Education of the contracted dialysis company leaders and contract dialysis RNS was completed by the Director! Designee prior to the implementation of the supervision and monitoring Checklist requirement. - Designated SJMC RNS were assigned to supervise dialysis and have been trained on a 1:1 basis by the ICU Director/designee in the requirements of supervision and implementation of the dialysis Checklist (Exhibit C). A schedule was developed to I ensure supervision of the Dialysis Unit. I :0 Additional bed scales have been purchased and will be placed into use when received i Monitoring and Tracking procedures that will be implemented to ensure that the plan of correction iS effective: The Dialysis Checklist is monitored for completeness and accuracy by the ICU Director/designee. This process will take place 11/27/2015 for 100% ofthe dialysis patients for a FORM Previous Versions Obsolete Event 272U11 Facility ID: 810020 lf continuation sheet Page 24 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 8- WING 10/15/2015 NAME OF OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 W) ID I SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL i CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG I REFERENCED To THE APPROPRIATE DATE DEFICIENCY) A144 Continued From page 24 Review of the Facility's current policy and procedure on physician's order sheets, directs staff as follows: "Before a patient is to be treated, written routine dialysis standing physician's orders must be completed by the patient's attending I physician . This covers the routine procedures encountered in the course of a normal dialysis I treatment." "Non- routine orders may be written on I supplemental physician's orders sheets. The I acute nurse is responsible for ensuring that these I orders have been carried out. The acute nurse must sign and date the right hand column of the . sheet to indicate the orders have been noted." "It is understood that in emergency situations, it may be necessary for the acute nurse to take an order over the telephone. To prevent error. the - order Should be repeated back to the physician. The order should be written as follows: "Epinephrine 1:000, .5 CC 80, STAT. Telephone order per Dr Jones/Mary Smith, Transcribed as written in policy. On 10/13/2015, at 10:10 am, Patient was Observed in the facility's acute care dialysis unit receiving hemodialysis treatment using a Fresenius 2008 hemodialysis machine. Review of the Patient's treatment sheet dated 10/13/2015, located at the Chairside revealed no documented evidence that a pre-treatment dialysis weight was Obtained priorto initiation of hemodialysis treatment on the patient. Interview on 10/13/2015, at 10:15 am, with Registered Nurse KK revealed the bed that the patient was in, is capable of weighing the patient A 144 (Continued from page 24) A144gperiod of 60 days. Following successful Icompliance ofthis 60 day period, supervisory monitoring is performed randomly throughout the week utilizing the Dialysis checklist by the ICU director/designee. Exhibit C) Any new dialysis nurse will have a monitor for the first three cases. Results, recommendations and actions is aggregated and forwarded to the Quality Department to be included in the ICC, QMOC. PIC, MEC and GB. Title of person responsible: Chief Nursing Officer. Director ICU, Manager, Infection Prevention, Director, Quality Management Dialysate: Renal Dialysis Service The plan for correcting the specific deficiency cited: All new Fresenius dialysis machines were immediately taken out of service and a validation Of the composition Of concentrate ofthe dialysate solution with a laboratory was completed. Once results were validated, the machines were returned to use. 10/16/2015 The plan for improving the processes that lead to the deficiency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the deficient practice: The Technical Manual was updated to reflect the instruction: ?When new machines are put into service or the . concentrate family or concentrate manufacturer Iis changed, dialysate samples shall be taken from each machine, and shall be sent to a laboratory for verification of the dialysate electrolyte values". The machine will not be placed into service until the laboratory values have been confirmed and the machine is approved for use. FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation Sheet Page 25 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11I?06f2015 FORM APPROVED OMB NO. 0938-0391 but most Of the time the bed is not zeroed so no weight is done on the patient. Patient #61 On 10(14/2015, at 10:25 am, Patient# 61 was observed in the acute dialysis unit of the facility. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mIS/minute and dialysate ?ow rate Of 600 mIS/minute. The patient was using a Fresenius 180 non reuse dialyzer. Review on 10f14f2015. at 10:25 am, of the patient's treatment sheet dated 101141201 5, I located at the nurses's station, revealed 5 documentation which indicated that the patient's hemodialysis treatment was initiated at 7:30 am. Review the treatment sheets revealed no documented pre/hemodialysis treatment weight on the patient. I I Review of the patient's treatment sheets revealed i documentation which indicated that the patient's last recorded blood pressure was timed at 8:15 I am. The blood pressure sensor on the hemodialysis machine was inoperable SO a portable blood pressure was observed beside the patient's bed. Sections on the patient's treatment sheet for patient's prescription and pre-treatment assessmentwere blank. The sections for venous I pressure monitoring was blank, Trans membrane I pressure documentation was blank and ?uids 9 administered during hemodialysis was blank. During an interview on 10/14/2015, at 10:45 am, with Registered Nurse AM, the Surveyor notified the Registered Nurse AM that the last documented blood pressure on the patient was STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLTERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 B. WING 10115f2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE I A 144 (Continued from page 25) A 144 Continued From page 25 A144I?When new machines are put into service or the Sconcentrate family or concentrate manufacturer is changed, dialysate samples shall be taken 'from each machine, and shall be sent to a laboratory for verification of the dialysate ielectroiyte values". The machine will not be placed into service untii the laboratory values I ihave been confirmed and the machine is approved for use. he hospital?s Bio-Medical Engineering I department, working in conjunction with the I Icontracted dialysis service, is responsible for ensuring that all new equipment for the dialysis unit is speci?cally tested and Cleared per manufacturer?s recommendations. IProcedures for implementing the acceptable I iplans of correction for each deficienchited: :All dialysis nurses working at SJMC received a f10/14/2015 imemorandum (Exhibit 0-3) prohibiting the use of: the identified dialysis machines, until testing wasi Icompleted and the machines were approved andi returned to service. I All new equipment for the dialysis unit Shall be gspecificaily tested per manufacturer?s recommendations. I . IEnsuring that this is done properly is the iresponsibility of the hospital?s Bio-Medical Engineering department working in conjunction ?with the contracted service, who shall report tO ithe ICU Director that the machines are ready for ,use. Monitoring and Tracking procedures that will 'be implemented to ensure that the plan Of Correction is effective: Monitoring and tracking Of the maintenance of the dialysis equipment is checked by the: SJMC RN utilizing the monitor checklist and the Preventive Maintenance Review Form.(Exhibit and FORM Previous Versions Obsolete EvantlD:272U11 Facility ID: 810020 If continuation Sheet Page 26 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 1or15r2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 144 Continued From page 26 timed 8:15 am, and that the patient's weight, pre- treatment assessment, prescription, Trans membrane pressure, and venous pressure were not documented. The Surveyor also informed the Registered Nurse AM that the most current physician's order dated 10f12f2015, had dialysate orders for Fresenius 160 dialyzer and a dialysate flow rate of 800 minute, but the Patient was utilizing a Fresenius 180 dialyzer and the dialysate flow rate was 600imls/ minute. Registered Nurse AM said She was busy with the patient because the dialyzer clotted. She said the bed that the patient is transferred to the unit in, is I not accurate and so She did not do a weight on the patient. Registered Nurse AM said she had received a verbal order from the physician to Change the dialyzer and dialysate flow rate but . she did not write down the order. . Subsequent observation on 10/142015, at 10:50 am, revealed Registered Nurse AM took the patient's treatment sheet dated 10/14/2015 and 5 filled in all blank area on the sheet from memory. She did not obtain the information from any recorded source. The Surveyor asked the Registered Nurse AM how she was able to recall all missing information on the patients treatment sheet since she did not document the various readings for blood pressure, venous pressure, Trans membrane pressure, and blood flow rate changes over time. The Registered Nurse Stated "Because I was watching." Conductivity of dialysate solution TAG A 144 (Continued from page 26) A144 The results, recommendations, and actions taken is reported, not less than quarterly to Infection Control Committee, QMOC, PIC, MEC, I and GB. I Title of person is) responsible: Chief Nursing Officer, Director of ICU, Director ofi Bio-Medical Engineering . Renal Dialysis Services: Verify Dialysate Conductivity and pH The plan for correcting the specific deficiency cited: Solution for calibrating the Myron LD-1 Meter was located in the Dialysis department, contrary to what was stated by the contracted dialysis nurse, and the meters were immediately calibrated. Dialysis nurses were re-educated regarding: - Calibration of Myron meter I 0 Verification of conductivity and pH of the dialysate i10/16/2015 The supervisor for the contracted dialysis service: was immediately notified of this de?ciency and the hospital's expectations that the contracted service follow all applicable policies and procedures. (The contracted service was I noti?ed that immediate oversight would be . provided by SJMC to ensure that hospital policy and procedures were followed by including 1:1 Observations and monitoring by SJMC RNS.) 310/15/2015 The plan for improving the processes that lead to the deficiency cited. includinq how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the deficient practice: The hospital has assigned RNs to function in a supervisory role who are responsible for the oversight of the contracted dialysis RNS in the completion of required equipment testing. FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 2? of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/0612015 FORM APPROVED OMB NO. 0938-0391 D-1 Meter." D-1 Meter hospkal Review of manufacturer?s recommendations for Fresenius 2008 hemodialysis machines Hemodialysis machine operators manual, direct users as follows: "The operator should always check conductivity and approximate pH of the dialysate with an independent device prior to initiating treatment and whenever concentrates are changed during the operation." Review on 10/1 3/201 5, of the facility's policy and procedure on Testing Dialysate Conductivity, directs staff as follows: "Dialysate conductivity will be tested before each treatment via the Myron - On 10(13i2015, at 10:10 am, Patient #28 was observed in the facility's acute care hemodialysis unit receiving hemodialysis treatment using a Fresenius 2008 hemodialysis machine. Review of the Patient's treatment sheet dated 10!13/2015, revealed no indication that the conductivity of the dialysate solution was validated with an independent meter Myron -L Interview on 10/13t2015, at 10:12 am, with Registered Nurse (KK) revealed she did not Check the conductivity on the dialysate solution prior to initiation of hemodialysis treatment on patients because there was no solution available in house for calibrating the Myron - D-1 Meter used for checking conductivity. Further interview with Registered Nurse (KK) revealed she worked with a company that is contracted with the Review of the facility's Myron - [3-1 Meter Log revealed the last date calibration was done on the STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 SWING 10i15i'2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIEs ID PLAN OF CORRECTION (EACH (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL i CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) Tag A 144 (Continued from page 27) A 144 Continued From page 27 A 144 The conductivity and pH results are located on .the acute dialysis flowsheet. The Myron meter Calibration was added to the Preventative Maintenance Checks Review Form. (Exhibit 0-2) Procedures for implementing the acceptable plans of correction for each deficiency cited: Director/designee educated the hospital iassigned supervisory RNs including the Icontracted dialysis RNs as it relates to the ,completion ofthe acute dialysis flow sheet and 10/15/2015 'the Preventative Maintenance Checks Review Form, dialysis Pl checklist, appropriate hand jhygiene practices and the use of PPE. (Exhibits and (3-2), All new equipment for the dialysis Iunit shall be specifically tested per ,manufacturer's recommendations. All .contracted dialysis RNs were educated as to the location of the testing solution and expectation of Iconducting Myron Meter calibration, conductivity and Ph. testing as indicated. Monitoring and Tracking procedures that will be implemented to ensure that the plan of correction is effective: Monitoring and tracking of the veri?cation of conductivity and PH of the dialysate solution is 310/16/2015 included on the dialysis flowsheet and is part of . the ongoing review of treatments by the SJMC assigned supervising RN. calibration of Meters is monitored through the use of the Preventive Maintenance Review Form (Exhibit 0?2) and veri?ed by the SJMC assigned supervising RN. The results, recommendations, and actions taken is reported by the ICU Director/designee, not less than quarterly to ICC, QMOC, PIC, and GB. Title of person responsible: Chief Nursing Officer, Director of ICU, Director of Quality Management FORM Previous Versions Obsolete Event ID: 272U11 Facility 810020 if continuation sheet Page 28 of 83 PRINTED: 11i06i?201 5 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 B. WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) in SUMMARY STATEMENT OF DEFICIENCIES in PLAN OF CORRECTION (EACH (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL pREFix CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE . DEFICIENCY) i gTag A 144 (Continued from page 23) I I . . Continued From page 28 A 144 Patient Rights. Myron - D-1 Meter was dated January 11. 2015. revealed documentation which indicated the I Review of the facility's Myron - D-1 Meter Log a facility's dialysis unit has three Myron - D-1 . Meters. serial numbers 302232, 303334 and 5 302235 for checking of dialysate conductivity. Review of the log revealed documentation which i indicated that all three meters were last calibrated Ion 0111112015. Review ofthe Manufacturer's Instructions for Myron - D-1 Meter directed users as follows: "The Conductivity Standard Solutions and pH . Buffers below are used for factory calibration. Regular use of these solutions is recommended to ensure speci?ed instrument accuracy. i Frequency of conductivity recalibration depends upon use, but once every month should be suf?cient for an instrument used daily.? Review of the facility's current policy and procedure on Calibrating the Myron- D-1 Meter directs users as follows: "This procedure should be performed before once every month for an instrument that is used daily (as per manufacturer's requirement)" During an interview on at 10:41 am, with the Facility's Chief Biomedical Technician for dialysis. he said it was the responsibility of the nurses who provide dialysis to patients to calibrate the Myron - D-1 Meter. Verification of dialysate composition Interview on 10/13/2015, at 10:30 am, with the facility's Chief Biomedical Technician for dialysis revealed the facility has 4 new 2008T hemodialysis machines in use in the facility for [The plan for correcting the specific I 'deficienc cited: i CBH leadership reviewed and/or revised the following policies/procedures/Medical Staff Rules: in Special Precautions Monitoring (Revised) (Exhibit E-3), inns/2015 gI lnferdiscipfinary Assessment and Treatment Plans (Revised) (Exhibit E-1) leadership implemented the following actions: in Special Precautions sticker (Exhibit E-7) prompting the physician to review special precaution orders and their continuation or i discontinuation daily 0 Revised comprehensive behavioral health treatment planning process, which addresses medical and behavioral health I problems, is patient-centered and individualized, includes interventions. outcomes and goals, and involves the I patient in the treatment plan process. i {11/2/2015 The plan for improving the processes that led. to the deficiency cited, including how the I hospital is addressing improvements in its Systems in order to prevent the likelihood of lrecurrence of the deficient practice: new process of flagging incomplete physician forders was implemented. Night shift nurses are responsible for this process with oversight being performed by CBH leadership. 11/2/2015 The Special Precautions Policy/Procedure (Exhibit E3) was revised and delineates that all assessments and reassessments are reviewed in the process of initiating precautions. The policy now includes a self?harm risk assessment based on risk level. Nursing is responsible for contacting the physician for orders speci?c to the: risk level assigned. In addition, patients on 11/16/2015 FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 29 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 8- 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY, STATE. CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, Tx 77002 00,} ID I SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDEO BY FULL CORRECTIVEACTION SHOULD BE CRoss- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) QTag A 144 (Continued from page 29) A 144 Continued From page 29 A 144' hemodialysis treatment Of patients. Review Of manufacturer's recommendations for Fresenius 2008T hemodialysis machines direct users as follows: "The Machine must be labeled to indicate the type Of concentrate for which it is con?gured. Check the composition Na, Cl K, Ca, Mg, 1 H003 and pH) ofthe dialysate solution afterthe machine is installed or after the machine is modified for different concentrate type." "Check the conductivity and appropriate pH of the dialysate solution with an independent device before initiating dialysis." Observation on 10/13/2015, at 2:40 pm, revealed hemodialysis machine #5 41, 42 and 43 were Observed in the dialysis equipment room of the facility. Tags on the machines indicated they were ready for usage. One machine was tagged as out of service. Interview on 10/13/2015, at 2:40 pm, with the facility's Chief Biomedical Technician for dialysis revealed four Fresenius 2008 hemodialysis machines were put into service in January 2015 and were being used for hemodialysis treatment of patients. He said he did not validate the dialysate composition with a laboratory after the machines were installed. Interview with the facility's Chief Biomedical Technician for dialysis revealed he works with a company that is contracted to the facility. Registered Nurses Qualifications Registered Nurse KK special precautions are Clearly communicated on the unit?s communication whiteboard, reviewed during change of Shift report, as well as in Treatment Team meetings._ Procedures for implementing the acceptable lplan of correction for each deficiency cited: lThe clinical director has educated physicians relative to completion Of orders, including iauthentication and the new flagging process. In Iaddition, a physician newsletter (Exhibit I lIwas published for members Of the medical Staff 0/30/2015 gre~educating them on the requirements of Completing medical records/orders. The night i shift nurses were educated on the new order flagging process. I Patients on special precautions are now included ias a daily agenda item in the CBH leadership Iteam?s "daily flash meeting?. All behavioral health team members responsible 1130/2015 for the identi?cation of special precautions (nurses, social workers, activity therapists, and physicians) will receive education and training relative to the policy Change, use of sticker I{Exhibit E-7), and importance of appropriate use Iof precautions. - IClinical staff at CBH began receiving education Ion 10/22/2015 relative to the development of a patient-centered individualized comprehensive treatment plan. This education is ongoing and will be incorporated into orientation and annual education of staff. 12/1/2015 EMonitoring and Tracking procedures that willj be implemented to ensure that the plan of "correction is effective: The Executive Director and Nursing Director of CBH is providing oversight to the formal monitoring and evaluation process, which will include a review of the: 11/16/2015 FORM Previous Versions Obsolete EventlD1272U11 Facility ID: 810020 If continuation sheet Page 30 Of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ?3 SUMMARY STATEMENT OF DEFICIENCIES ID I PLAN OF CORRECTION (EACH (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE . DEFICIENCY) A 144 Continued From page 30 On 10/13/2015, at 10:10 am, Registered Nurse KK was observed in the dialysis unit of the facility providing care and services to Patient #28 who was receiving hemodialysis treatment. I Review of Registered Nurse KK's Job description I titled: "St Joseph Contract Employee Addendum - i Dialysis Revised 10/02/2015, and signed on i 10/07/2015, by Registered Nurse (KK) revealed the following "Thisjob has special vision requirementcheck all that apply. Colorvision ability to identify and distinguish colors)" The requirement to identify and distinguish colors was checked. Review on 10/14/2015, of Registered Nurse KK's personnel and health records revealed no indication that a test was performed to determine I the Registered Nurse's ability to detect and distinguish colors. Registered Nurse II On 10/13/2015, at 2:40 pm, Registered Nurse II was observed in the dialysis unit of the facility providing care and services to Patient #72 who was receiving hemodialysis treatment. Review of Registered Nurse Job description titled "St Joseph Contract Employee Addendum - Dialysis Revised 10/02/2015, and signed on 10/08/2015, by Registered Nurse (II) revealed the following "This job has special vision requirement check all that apply. Color vision ability to identify and distinguish colors.) The A 144 (Continued from page 30) A144CBH physician orders to ensure completion? including authentication; 0 Number and appropriateness of patients on special precautions, during daily flash meetings; - Completion of the fall risk assessment tool with appropriate identi?cation and treatment planning for those patients identified as high I risk for fall. Random sample of 20 cases I per month is included in this review. All patient treatment plans are being i reviewed for the next 90 days. Any identi?ed' I de?ciency is corrected with education I provided to the staff member. These real time reviews are conducted with the clinical team members that are actively engaged in the care of the patient at the time and changes made as needed. Results, recommendations and actions are reported not less than quarterly to QMOC, PIC, MEC, and GB. iTitle of person(s) responsible: Executive Director Behavioral Health, Nursing Director Behavioral Health, Behavioral Health Medical Director, Chief Nursing Of?cer FORM Previous Versions Obsolete Event ID: 272011 Facility ID: 810020 If continuation sheet Page 31 of 83 PRINTED: 11/06/2015 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 450035 10/15/2015 NAME OF OR SUPPLIER STREETADDRESS. CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 044} ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG i REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THEAPPROPRIATE DATE I DEFICIENCY) A 144 Continued From page 31 requirement to identify and distinguish colors was checked. Review of Registered Nurse personnel and I I health records revealed no indication that a test I was perform to determine the Registered Nurse's ability to detect and distinguish colors. . ITHIS PAGE LEFT INTENTIONALLY BLANK Registered Nurse AM I On 10/14/2015, at 10:25 am, Registered Nurse AM was observed in the dialysis unit of the facility 1 providing care and services to Patient #28 who was receiving hemodiaiysis treatment. I Review of Registered Nurse AM '3 Job description I titled "St Joseph Contract Employee Addendum - I Dialysis Revised 10/02/2015, and signed on i 10/07/2015, by Registered Nurse AM revealed the following: "Thisjob has special vision requirement check all that apply. Color vision (ability to identify and distinguish colors") The requirement to identify and distinguish colors was checked. Review of Registered Nurse personnel and health records revealed no indication that a test was perform to determine the Registered Nurse's ability to detect and distinguish colors. I - Interview on 10/14/2015, at 1:10 pm, with the 5 Registered Nurse in charge of the dialysis unit, the Surveyors requested documentation that tests FORM CM S?2567t02?99) Previous Versions Obsolete Event Facility ID: 810020 If continuation Sheet Page 32 0f 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES {x1} (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES i In PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL i PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG I REGULATORY OR IDENTIFYING INFORMATION) I TAG REFERENCED To THE APPROPRIATE DATE I DEFICIENCY) i . A 144 Continued From page 32 A 144 were conducted to determine the nurse's ability to to detect and distinguish colors. The Registered Nurse in charge ofthe dialysis unit said these tests were not performed on the nurses. Review of personnel ?les for Staff #s VW, WW, and revealed the staff did not have documentation that a color blind test was conducted on these staff.) Review on 10/13/2015 of St Joseph Medical Center Job Description, titled "St. Joseph Contract Employee Addendum-Dialysis states the following information: I "This job has special Vision requirements. Color I Vision (ability to identify and distinguish colors)". Patient #3 In an interview with RN Employee on the Unit, on 10/12/15, at 1100, she stated that Patient#3 was placed on suicide precautions at the time of admission. RN Employee stated She could not provide documentation of suicide precautions, adding, "Patient #3 was on automatic suicide precautions." Suicide precautions included visual checks every 15 minutes, CareView. and placement near the I nurse's station. RN Employee also stated that there was no system in place to determine if suicide precautions needed to be continued or I discontinued every 24 hours. She did not write a THIS PAGE LEFT INTENTIONALLY BLANK FORM Previous Versions Obsolete Event Facility ID: 810020 if continuation sheet Page 33 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 11/05/2015 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES Io PROVIDERS PLAN OF CORRECTION (EACH (X5) - (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) A 144 Continued From page 33 A144 nursing order for suicide precautions. She did not know that the doctor needed to co-Sign a nursing . order for suicide precautions. Record review of Physician Orders - Behavioral Medicine General/Admission by MD Employee 00 dated 10/01/15, at 01:30 pm, and 10/02/15, at 10:30 am, revealed no suicide precautions. However, suicide precautions were discontinued on 10/03/15, at 09:48 am, by MD Employee 00. Record review of the Close Observation 1 Monitoring Form of Patient #3 for 10/01/15, 10/02/15. and 10/03/15, revealed no documentation by staff that patient rooms were "Checked for hazardous items once per Shift." Record review Of ?Special Precautions Monitoring Policy," approved 06/09/15, revealed: "An order for suicide precautions is written by a physician, or by a registered nurse as an independent nursing intervention. A physician?s order must be obtained within 1 hour of the nursing order. The order must include reason The order for suicide precautions is reviewed daily, and it will be renewed, as indicated, by the physician (with input from the treatmentteam) The patient I and room are Checked once per shift for a hazardous items and this is documented on I the Close Observation Monitoring Form. A 154 482.13(e) USE OF RESTRAINT OR SECLUSION Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All TAG A 154 482.13(e) Use Of Restraint or I Seclusion . A 154 PHYSICAL HOLD vs. PHYSICAL ESCORT ,The plan for correcting the specific 'deficiency cited: Immediately during the survey, the Executive Director and Director Of Nursing for CBH met with the Clinical staff working that day, 10/14/2015 FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 34 Of 83 PRINTED: 11f06r?201 5 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10f15f2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (X4) SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TAG A 154 (Continued from Page 34) A 154 Continued From page 34 A154 as well as the subsequent shifts during the survey, to ensure the staff had a clear patlents have the right to be free from restraint or understanding between a physical hold VS- SeCIusion' 9f form' imp?sed as a means 0f physical escort. The clinical staff clearly d'SC?pI'm: convemences or reta'latlon by articulated to the Executive Director and Director staff. Restraint or seclusion may only be imposed of Nursing for CBH an understanding ofthe to ensure the immediate physical safety of the practice and knew which was considered a patient, a staff member, or others and must be restraint. An educational memo was posted to discontinued at the earliest possible time. a? Staff Venerating these prinCIpIes (EXhibit 55) To ensure the clinical staff is provided the is not met as evidenced appropriate guzdance the one sentence In the Code Green policy (Exhibit E) that caused this confusion and misunderstanding was amended. In addition, all clinical staff were re-educated on This standard is not met. The facility failed to train staff appropriately in escort technique as Staff have been trainad to Utilize a the definition of a physical hold vs. physical mOVement'restrICtIng for the purposes Of echI-tI and a return demonstration was "escort" as demonstration to the suurveyors. An completed to ensure competency on this escort does not prohibit a patient's freedom of practice. movement whereas a restraint does prohibit a The Plan for imprOVinq the processes that ?sad . to the deficiency cited, includinq how the hospital is addressing improvements in its I systems in order to prevent the likelihood of I recurrence of the deficient practice: 5 F'nd'ngs '"Cludedi All clinical CBH staff were educated on the differences between physical hold vs. physical escort. Code Green policy was revised on to 10/269015 patient?s movement. On 10/14/2015, at 3:20 pm, in the Conference remove one sentence that caused confusion with Room of the QA Department ofthe facility, a the Seclusion/Restraint Policy. The revised Code Nurse Educator (Employee was asked to Green Policy was approved by the Governing Body. The CBH Executive Director and Nursing Director met with the clinical staff working the demonstrate an appropriate method of escorting a patient to the unit's quiet room. A Quiet Room is utilized voluntarily by a patient for temporary ni ht shift to ensure the understood the . removal from the milieu and an escort is used to digrerence between a hold and a 10l15/2015 88 8? Offered handl a gentle hand 0fthe difference and understood that a physical hold is patient's shoulderto reinforce directional a restraint. The CBH Executive Director and movement. Nursing Director met with all of the Clinical staff working the day shift to ensure they understood the difference between a physical hold and a physical escort. Staff clearly articulated the difference and understood that a physical hold is a restraint. . On demonstration of the allegedly approved - escort procedure, the nurse educator immediately approached one of the surveyors, wrapping her right hand around the surveyor,s left upper arm, FORM Previous Versions Obsolete Event ID1272U11 Facility ID: 810020 If continuation sheet Page 35 0f 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. 450035 B. WING 10l1512015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED To THE APPROPRIATE DATE DEFICIENCY) surveyor's left hip. during transport". A 154 Continued From page 35 and then grabbing the surveyor's left wrist with her left hand, and pushing her right hip into the i As the surveyor Offered some resistance, the educator stated that this would be a "two person escort". Another surveyor then proceeded to do the same physical holds on the writer, mirroring the nurse educator's movements and holds on the right side of the other surveyor's body. When the surveyor being escorted asked if this was an approved escort procedure, the nurse . educator related that this was an approved CPI manner of escort. When the surveyor remarked that this was a restraint, the nurse educator again said that this was an escort and not a restraint. I Review ofthe CPI Nonviolent Crisis Intervention Training Program described this action as the Transport Position," which is meant to "assist you in safely moving an individual who is beginning to regain control", and "The cross-grain grip better secures the individual between staff The facility has a policy on restraint and seclusion, and this policy states that an escort is utilized "using appropriate CPI techniques". A review of both the CPI participant workbook and the CPI key point refresher workbook (copywrite 2005, with a reprint date of 2014) Shows no technique for an escort, there is no de?nition in the workbooks glossary of escort; ergo, there is no "approved CPI technique for escort" as TAG A 154 (Continued from Page 35) A154 The CBH Clinical Educator continues to meet with all staff to ensure a clear understanding and will integrate the principles of physical hold versus physical escort into the new hire orientation of CBH staff. The CBH new hire Orientation curriculum will include demonstration, lreturn demonstration and review of applicable policies and protocols. Procedures for implementing the acceptable of correction for each deficiency cited: 0 The Executive Director and the Director of Nursing met with each oncoming shift to provide education related to the differences between a physical hold vs. physical escort. 0 Educational memo (Exhibit E-5) included written explanation as well as physical return demonstration Of these differences. Educational sessions shall continue until all members of the CBH Staff have been adequately trained. Education will be incorporated into new hire orientation and annualeduca?on. Monitorinq and Tracking procedures that will be implemented to ensure that the plan of correction is effective: .The Executive Director of CBH and the Clinical Director will provide oversight to the formal monitoring and evaluation process, which will (include a review ofthe following: The Executive Director and the Director of I Nursing for CBH will review the in?service sign in sheets, ensuring all employees are trained. - Validation of knowledge and return demonstration ofescorts, holds, and transport for the next ninety days. Any and all identified deficiencies will result in immediate remediation. (Exhibit E-4) '10/1 5/2015 1011412015 11(30/2015 10116i2015 FORM Previous Versions Obsolete Event ID: 272U11 Facility 810020 If continuation sheet Page 36 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 1110612015 FORM APPROVED OMB NO. 0938?0391 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility implemented facility's policies and procedures to provide pre-hemodialysis treatment assessment and weight evaluation to patients in 4 of6 sampled hemodialysis patients 28, 49, 61 and 63. The facility failed to ensure contracted services staff who provide hemodialysis treatment to facility's patients followed manufacturer's recommendations and the facility's policy for checking conductivity of dialysate solutions prior to initiating hemodialysis treatment on patients; failed to ensure contracted services calibrate devices used for checking conductivity on dialysate solution used for patients' hemodialysis ETAG A 385-482.23 Nursing Services iThe SJMC Governing Board affirms its responsibility for the operations ofthe Hespital, including its compliance with all ofthe rules and standards of the CMS Conditions of Participation. Please see detailed and specific plans of correction for each deficiency at each Tag level. The Chief Executive Officer of SJMC in collaboration with the Chairman ofthe Governing Board is responsible for ensuring the implementation of this plan of correction. Refer to plan of correction A 398 Supervision of Contract - Staff STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION 013) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDWG COMPLETED 450035 1011512015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 154 (Continued from Page 36) A 154' Continued From page 36 A1543 Visual observation and random review Of stipulated in facility policy. VIdeo of staff/patent Interactlons related to use of emergency medlcatlons or to ensure appropriate use of escort vs. I transport hold (restraint) techniques. on 70/15/2015 at aPproxllmatE?Iy 8545 a-m-I "1 a ,o All episodes Of restraint is reviewed for walking With the CEO and the I proper orders and documentation per policy director of clinical services for behavioral health, . Results, recommendations and actions are as we were discussing the Citation, the surveyors reported to QMOC, PIC, MEC and GB not demonstrated the "escort" procedure, as less than quarterly. demontrated by the Nurse Educator, on the T'tIe 0f person IS) respons'ble5 remarked that this was a restraint. gmg??ngegeEEI?I? Dream Of Qual'ty A 385 482.23 NURSING SERVICES A 3855 FORM Previous Versions Obsolete Event Facility ID: 81 0020 If continuation sheet Page 37 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11f06i2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 450035 A. BUILDING B. WING (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 10I15f2015 NAME OF PROVIDER OR SUPPLIER ST JOSEPH MEDICAL CENTER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 (x4) lD PREFIX SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX I TAG I PLAN OF CORRECTION (EACH (x5) CORRECTIVE ACTION SHOULD BE CRoss- COMPLETION REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) A 385 I Continued From page 37 treatment. The facility failed to ensure contracted services staff who provide hemodialysis treatment to facility's patients followed manufacturer's recommendations for validating the composition ofthe concentrate of the dialysate solution with a laboratory, following installation of 3 of 4 Fresenius 2008 hemodialysis machines. Machine #8 41 42, 43. The facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility meet the quali?cation outlined in theirjob description in 8 of 8 sampled contracted nurses observed and reviewed.Citing Staff #8 KK, II, AM, WW, and Cross reference A 398. A 398 SUPERVISION OF CONTRACT STAFF Non?employee licensed nurses who are working in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of the clinical activities I of non-employee nursing personnel which occur within the responsibility of the nursing services. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility implemented facility's policies and procedures to provide pre-hemodialysis treatment assessment A 385 A 398 TAG A 398 Supervision of i Contract Staff: The Plan for Correcting the Specific Deficiency Cited: The CNO issued a memorandum to the ICU Director and House Supervisors instructing them to assign a SJMC RN to provide 24!? 40/14/2015 oversight of the dialysis treatment area. Oversight shall include pref and post dialysis weights, complete physician orders, accurate documentation of dialysis treatment/ interventions, and infection control practices. (Exhibit B). A dialysis checklist (Exhibit C) was deveIOped to capture all of the elements needed in the delivery of dialysis and to facilitate the supervisory process. 10/15/2015 FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 810020 If continuation sheet Page 38 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/062015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDI COMPLETED NO 450035 B. WING 10115i2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, Tx 77002 (x4) (9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) pm;th (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) A 398 Continued From page 38 and weight evaluation to patients in 4 of6 sampled hemodialysis patients. #s 28, 49, 61 and 63. The facility failed to ensure contracted services staff who provided hemodialysis treatment to facility's patients followed manufacturer's recommendations and the facility's policy for checking conductivity of dialysate solutions prior to initiating hemodialysis treatment on patients; failed to ensure contracted services calibrate devices used for checking conductivity on dialysate solution used for patients' hemodialysis treatment. . The facility failed to ensure contracted services staff who provided hemodialysis treatment to facility's patients followed manufacturer's recommendations for validating the composition of the concentrate of the dialysate solution with a laboratory, following installation of3 of 4 Fresenius 2008 hemodialysis machines. Machine #5 41, 42, 43. The facility failed to ensure contracted Registered Nurses who provided care and services to hemodialysis patients in the facility met the qualification outlined in theirjob description in 8 of 8 sampled contracted nurses observed and reviewed. Citing Registered Nurses #5 KK, ll, AM, VW, WW and The failure to have contracted staff complete a Color Vision Test prevents the employee from effectiver monitoring the water quality used to diaiyze the facility's patients therefore putting the . patients at risk for harm and not practicing according to acceptable standards of practice. TAG A 398(Continued from Page 38) A 398 The plan for improvinq the processes that lead to the deficiency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the deficient practice: All dialysis done in SJMC facilities is being supervised at all times by an assigned RN to ensure proper technique is used, documentation Ila/1512015 complete, and facility patient care policies and procedures are followed. A dialysis checklist was developed to capture all I of the elements needed to ensure the practice of: safe dialysis (Exhibit C) i1 0? 5/2015 An SJMC RN is assigned each shift to supervise diaiysis and is responsible for completing the Dialysis Checklist on every patient receiving '10l15l2015 dialysis. The SJMC RN Monitors dialySIs and checks the 1011512015 following: a. Pre-dialysis weight done b. Post-dialysis weight done c. Medication Add labels done if dialysate fluid has additive d. Infection control practices maintained, including Routine Dialysis Station Disinfection (between patients (Exhibit 0-1) Complete MD orders f. Dialysis ?owsheet is complete .o All dialysis nurses currently working have i been Color Blind Tested with documentation10116/2015 of this testing in their personnel file. New or oncoming dialysis nurses that have not been color blind tested is veri?ed by the supervisor prior to patient care assignment or will not work. Procedures for implementinq the acceptable plans of correction for each deficiency cited: FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation Sheet Page 39 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION CO) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10115f2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 pm) In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CRoss- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEDTO THEAPPROPRIATE DATE DEFICIENCY) ITAG A 398(Continued from Page 39) A 398 Continued From page 39 Education of the contracted dialysis Findings: Review of the facility's current policy and procedure on Pre Dialysis Patient Assessment, 3 direct staff as follows: ?Obtain pre-dialysis weight. Compare with target weight and previous take off weight to determine the amount of?uid to be 4 removed" Review of the Facility's current policy and procedure on physician's order sheets, directed staff as follows: "Before a patient is to be treated, written routine dialysis standing physician's orders must be completed by the patient's attending I physician. This covers the routine procedures encountered in the course of a normal dialysis treatment." "Non- routine orders may be written on supplemental physician's orders sheets. The acute nurse is responsible for ensuring that these orders have been carried out. The acute nurse I must sign and date the right hand column of the sheet to indicate the orders have been noted." "It is understood that in emergency situations, it may be necessary for the acute nurse to take an order over the telephone. To prevent error, the order should be repeated back to the physician. The order should be written as follows: "Epinephrine 1:000, .5 cc SQ, STAT. Telephone order per Dr Jones/Mary Smith, Transcribed as written in policy. On 10/13/2015, at 10:10 am, Patient #28 was observed in the facility's acute care dialysis unit receiving hemodialysis treatment using a Fresenius 2008 hemodialysis machine. A 398 company leaders and contract dialysis RNs 10/15/2015 was completed by the ICU Director/ Designee prior to the implementation of the supervision and monitoring Checklist requirement. - Designated SJMC RNs were assigned to supervise dialysis and have been trained on a 1:1 basis by the ICU Directori?designee in the requirements of supervision and implementation of the dialysis checklist (Exhibit C). A schedule was developed to ensure supervision of the Dialysis Unit. 0 Additional bed scales have been purchased and will be placed into use when received 10116f2015 11/27/2015 '.Monitorinq and Tracking procedures that will be implemented to ensure that the plan of correction is effective: The Dialysis Checklist is monitored for lcompleteness and accuracy by the ICU 10/16/2015 IDirector/designee. This process will take place for 100% ofthe dialysis patients for a period of 60 days. Following successful compliance of this 60 day period, supervisory monitoring is performed randomly throughout the week utilizing the Dialysis checklist by the ICU director/designee. Exhibit C) Any new dialysis nurse will have a monitor for the first three cases. Results, recommendations and actions is aggregated and forwarded to the Quality Department to be included in the ICC, QMOC, PIC, MEC and GB. Title of person responsible: Chief Nursing Of?cer, Director ICU. Manager, Infection Prevention, Director. Quality Management FORM CMS-2567I02A99) Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 40 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06l2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIEs ID PLAN OF CORRECTION (EACH (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL pREFix CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) '(Continued from Page 40) A 398 Continued From page 40 I A 398 LDIalysate: Renal SerVIce I . . iThe Ian for corr ctin the ecific I ReVIew of the Patients treatment sheet dated I 9 I 10113/2015 I 'd I I Idef'c'enc c'tEd: I 003 a aIrsI revea no i10/13/2015 documented evidence that a pro-treatment dialysis weight was Obtained priorto initiation of hemodialysis treatment on the patient. Interview on 101?1 3/2015, at 10:15 am, with Registered Nurse KK revealed the bed that the patient was in, is capable of weighing the patient but most of the time the bed is not zeroed so no weight is done on the patient. Patient #61 On 10/14/2015, at 10:25 am, PatientsE 61 was . Observed in the acute dialysis unit of the facility. I The patient was receiving hemodialysis treatment at a blood flow rate of 350 mIS/minute and dialysate flow rate of 600 mls/minute. The patient was using a Fresenius 180 non reuse dialyzer. Review on 10(14/2015, at 10:25 am, Of the patient?s treatment sheet dated 10f14/2015, located at the nurses's station, revealed documentation which indicated that the patient's hemodialysis treatment was initiated at 7:30 am. Review the treatment sheets reveled no documented pre- hemodialysis treatment weight on the patient. Review of the patient's treatment sheets revealed documentation which indicated that the patient's last recorded blood pressure was timed at 8:15 am. The blood pressure sensor on the hemodialysis machine was inoperable so a portable blood pressure was observed beside the patient?s bed. Sections on the patient's treatment sheet for patient's prescription and pre-treatment All new Fresenius dialysis machines were immediately taken out of service and a validation got the composition of concentrate of the idialysate solution with a laboratory was icompleted. Once results were validated, the Emachines were returned to use. :The plan for improving the processes that 'lead to the deficiency cited. including how ?the hospital is addressing improvements in its systems in order to prevent the likelihood I :of recurrence of the deficient practice: :The Technical Manual was updated to reflect the instruction: on 3/2015 -?When new machines are put into service or the concentrate family or concentrate manufacturer is changed. dialysate samples shall be taken from each machine, and shall be sent to a laboratory for verification of the dialysate electrolyte values". The machine will not be placed into service until the laboratory values have been confirmed and the machine is approved for use. The hospital's Bio-Medical Engineering department, working in conjunction with the Contracted dialysis service, is responsible for ensuring that all new equipment for the dialysis 'unit is speci?cally tested and Cleared per imanufacturer?s recommendations. IProcedures for implementing the acceptable plans of correction for each deficiency cited: All dialysis nurses working at SJMC received a memorandum (Exhibit 03) prohibiting the use ofi10r13/2015 the identified dialysis machines, until testing was completed and the machines were approved and returned to service. FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 41 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938?0391 assessment were blank. The sections for venous pressure monitoring was blank, Trans membrane pressure documentation was blank and fluids administered during hemodialysis was blank. During an interview on 10/14/2015, at 10:45 am, with Registered Nurse AM, the Surveyor noti?ed the Registered Nurse AM that the last documented blood pressure on the patient was timed 8:15 am. and that the patient's weight, pre- treatment assessment, prescription, trans membrane pressure, and venous pressure were not documented. I The Surveyor also informed her that the most current physician's order dated 10/12/2015, had dialysate orders for Fresenius 160 dialyzer and a dialysate ?ow rate of 800 mls/minute, but the Patient was utilizing a Fresenius 180 dialyzer and the dialysate ?ow rate was 600/mIS/minute. I Registered Nurse AM said she was busy with the patient because the dialyzer clotted. She said the bed that the patient is transferred to the unit in, is not accurate and so she did not do a weight on the patient. Registered Nurse AM said she had received a verbal order from the physician to change the dialyzer and dialysate flow rate but she did not write down the order. Subsequent observation on 10/14/2015, at 10:50 am. revealed Registered Nurse AM took the patient's treatment sheet dated 10/14/2015, and filled in all blank area on the sheet from memory. She did not obtain the information from any recorded source. The Surveyor asked the Registered Nurse AM - how she was able to recall all mising information STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x51 (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 398(Continued from Page 41) A 398 Continued From page 41 A 398 All new equipment for the dialysis unit shall be speci?cally tested per manufacturer's recommendations. Ensuring that this is done properly is the :responsibility of the hospital?s Bio-Medical ,Engineering department working in conjunction Qwith the contracted service, who shall report to the ICU Director that the machines are ready for use. IMonitorinq and Tracking procedures that will be implemented to ensure that the plan of correction is effective: Monitoring and tracking of the maintenance of i the dialysis equipment is checked by thaw/1512015 SJMC RN utilizing the monitor Checklist and the 1 Preventive Maintenance Review Form.(Exhibit and 0-2) iThe results, recommendations, and actions taken is reported, not less than quarterly to infection Control Committee, QMOC, PIC, MEC, and GB. Title of person is} responsible: Chief Nursing Officer, Director of ICU, Director of! Bio?Medical Engineering Renal Dialysis Services: Verify Dialysate Conductivity and pH The plan for correcting the specific deficiency cited: Solution for Calibrating the Myron LD-1 Meter was located in the Dialysis department, contrary 10/13/2015 to what was stated by the contracted dialysis nurse, and the meters were immediately calibrated. Dialysis nurses were re-educated regarding: j- Calibration of Myron meter in Verification of conductivity and pH of the dialysate FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 810020 If continuation sheet Page 42 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES {x1} (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 10I15r2015 NAME OF PROVIDER OR SUPPLIER CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) (9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- TAG REGULATORY OR IDENTIFYING INFORMATION) I TAG REFERENCED To THE APPROPRIATE DATE - DEFICIENCY) I ITAG A 398(Continued from Page 42) A 398 I Continued From page 42 A 398i on the patient's treatment Sheet, since she did not document the various readings for blood pressure, venous pressure, Trans membrane pressure, and blood ?ow rate changes over time. The Registered Nurse stated "Because I was watching." Conductivity of dialysate solution Review of manufacturer's recommendations for I Fresenius 2008 hemodialysis machines Hemodialysis machine operators manual, direct users as follows: "The operator should always check Conductivity and approximate pH of the dialysate with an independent device prior to initiating treatment and whenever concentrates are changed during the operation.? 7 Review on 10/13/2015, of the facility's policy and I procedure on Testing Dialysate Conductivity, observed in the facility's acute care hemodialysis Fresenius 2008 hemodialysis machine. directs staff as follows: "Dialysate conductivity will be tested before each treatment via the Myron - DF1 Meter." On 10/13/2015, at 10:10 am, Patient #28 was unit receiving hemodialysis treatment using a Review of the Patient's treatment sheet dated 10/13/2015, revealed no indication that the conductivity of the dialysate solution was validated with an independent meter Myron -L D-1 Meter interview on 10/13/2015, at 10:12 am, with Registered Nurse KK revealed she did not check the conductivity on the dialysate solution prior to initiation of hemodialysis treatment on patients because there was no solution available in house gThe supervisor for the contracted dialysis service" was immediately notified of this de?ciency and the hospital?s expectations that the contracted service follow all applicable policies and procedures. (The contracted service was noti?ed that immediate oversight would be provided by SJMC to ensure that hospital policy I and procedures were followed by including 1:1 observations and monitoring by SJMC RNS.) 10/13/2015 IThe plan for improving the processes that ilead to the deficiency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood 'of recurrence of the deficient practice: IThe hospital has assigned RNS to function in a supervisory role who are responsible for the loversight of the contracted dialysis RNS in the completion of required equipment testing. 10/15/2015 The conductivity and pH results are located on . the acute dialysis flowsheet. The Myron meter i10/15/2015 calibration was added to the Preventative 5 Maintenance Checks Review Form. (Exhibit Procedures for implementing the acceptable Iplans of correction for each deficiency Cited: ICU Director/designee educated the hospital assigned supervisory RNS including the contracted dialysis RNS as it relates to the completion ofthe acute dialysis flow sheet and the Preventative Maintenance Checks Review Form, dialysis Pl checklist, appropriate hand hygiene practices and the use of PPE. (Exhibits and C-2), All new equipment for the dialysis unit shall be specifically tested per manufacturer?s recommendations. All contracted dialysis RNS were educated as to the location of the testing solution and expectation of conducting Myron Meter calibration, conductivity and Ph. testing as indicated. FORM Previous Versions Obsolete Event ID: 272011 Facility ID: 810020 if continuation sheet Page 43 of 83