University of Iowa Hospital & Clinics - Grinnell

“CARBON ADSORPTION-TWO TANKS/SAMPLE PORTS CFR(s): 494.40(a) 5.2.5 Carbon adsorption: two tanks/sample ports Refer to RD62:2001, 4.3.9 Carbon adsorption media: Carbon adsorption systems shall be adapted specifically to the maximum anticipated water flow rate of the system. Two carbon adsorption beds shall be installed in a series configuration. 5.2.5 Carbon adsorption Two carbon beds shall be installed in series with a sample port following the first bed. A sample port shall also be installed following the second bed for use in the event of free chlorine or chloramine breaking through the first bed. This Standard is not met as evidenced by: 36083 Based on documents review, interviews, and observations, the facility did not follow manufacturer’s instructions for use related to the procedure for total chlorine testing using the test strips provided during 1 of 2 observations (Patient Care Technician [PCT] B). In addition, the facility failed to ensure staff members’ knowledge regarding procedure to follow in the event of a total chlorine breakthrough during observations of 2 of 2 staff members (PCT B and PCT C) performing total chlorine tests. The facility reported a census of 10 hemodialysis patients during the survey. Findings include: 1. The manufacturer’s document titled, RPC K100-0118 and K100-0118F Ultra-Low Total Chlorine Test Strips Instructions for Use, undated, provides the procedure for testing dialysis water sample for total chlorine that included step #3, which directs to remove the test strip from the water after swish time, and shake the test strip “once, briskly, to remove excess water.” 2. The policy titled, Ultra-Low-Level Total Chlorine Test Procedure, revised on 10/21, directs staff members to remove the test strip from the water sample, and shake once, briskly to remove the excess water. The policy indicates that if the total chlorine test result is equal to or above 0.1 ppm (parts per million), from the port after the primary carbon tanks, repeat the test from the same ports (post primary carbon tanks), however, if the tests remained high, the next step would be to test from the port after the secondary carbon tank. 3. On 3/13/24 at 8:35 AM, observation showed PCT B in the process of performing total chlorine test in the facility’s water room. PCT B collected 100 ml (milliliters) water sample from “Port A” post-1st primary carbon tanks, performed the required swish time, PCT B removed the test strip from the water sample and shook the strip multiple times, as opposed to “once” as directed by the manufacturer. PCT B then waited for the color to develop in order to compare with the color code. Thereafter, PCT B collected another 100 ml of water sample from “Port B” post-2nd primary carbon tanks, dipped and swished a test strip. PCT B removed the test strip from the water sample and shook it multiple times again while waiting for the color to develop for comparison with the color code. PCT B stated that in the event of a high result from “Port A” (post-1st primary carbon tanks), which would be at 0.1 ppm or higher (based on the color code), PCT B would retest from the same port. PCT B also stated if the test result from “Port A” remained at high level, PCT B would then test water sample from “Port B” (post-2nd primary carbon tanks), and if the result was still at 0.1 ppm or higher, the facility would have to stop dialysis treatments. 4. On 3/13/24 at 11:45 AM, PCT C was observed for the process of total chlorine testing. PCT C stated in the event of chlorine breakthrough or when the test result of the water sample obtained from the port post-1st primary carbon tank would be at 0.1 ppm, PCT C would do another test from the port post-2nd primary carbon tank, and if the result remained at 0.1 ppm, PCT C would alert other staff members and would then stop or not proceed with the patients’ dialysis treatments. PCT C identified “Port A” (post-1st primary carbon tanks) as where to obtain water sample for the 1st test. PCT C also identified “Port B” (post-2nd primary carbon tanks) would be where to obtain water sample to check for chlorine “breakthrough” and be directed from there. PCT C failed to identify the location of the secondary carbon tank sample port. 5. On 3/13/24 at approximately 11:55 AM, the Water Specialist (WS) reported that staff members were trained regarding the procedure for testing water for total chlorine including the chlorine breakthrough process and had no concerns identified during staff practice audits. The WS also identified the presence of the sample port after the secondary carbon tanks and stated that is the final port where to validate chlorine breakthrough. 6. On 3/13/24 at 1:45 PM, PCT B indicated lack of knowledge about the secondary carbon tank and the presence and function of the sample port after the secondary carbon tank. PCT B also indicated being the main person responsible for opening the dialysis clinic and testing water samples before and during patients’ dialysis treatments. PCT B further stated that however, she was unaware “Port A” and “Port B” were both post primary carbon tanks. 7. On 3/13/24 at 3:50 PM, the Administrator acknowledged the potential adverse effects to patients when dialysis treatments were unnecessarily stopped or continued. The Assistant Nurse Manager (ANM) and the Administrator also indicated expectations that staff members follow the facility’s policy and procedure pertaining to ensure safe water and dialysate for patients.”