Albany Medical Center Pediatric

“Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service Phase I key recall and smoke detector automatic recall, firefighter’s service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This Standard is not met as evidenced by: 33426 Based on observation and staff interview, the facility failed to ensure existing elevators conform with Firefighter’s Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. The dialysis clinic was toured during the survey between 12/5/23 and 12/7/23. The Administration Manager and Engineering and Construction Manager were interviewed on 12/6/23 at 3:15PM during the tour related to elevator service. Elevators 412P and 413P in the dialysis clinic area do not include firefighter’s service recall features. Both these elevators travel beyond 25 feet above the level that best serves the needs of emergency personnel for firefighting purposes. It was estimated these elevators were installed in 1964 and interior car modifications were made in 2005. It was noted there is an elevator adjacent to these elevators which does have firefighter’s service recall features. The findings were reviewed with staff at the time of the interviews noted.”

“LAB-CLIA LABS/MEET NEEDS OF PTS CFR(s): 494.130 The dialysis facility must provide or make available, laboratory services (other than tissue pathology and histocompatibility) to meet the needs of the ESRD patient. Any laboratory services, including tissue pathology and histocompatibility must be furnished by or obtained from, a facility that meets the requirements for laboratory services specified in part 493 of this chapter. This Standard is not met as evidenced by: 09785 Based on observation, interview, and record review, facility policy/procedure for blood specimen collection did not correlate with the actual facility practice for 1 of 1 hemodialysis patients (patient # 2) where blood specimen collection was observed during initiation of dialysis treatment. Findings: -While conducting observations on the treatment floor on 12/6/2023 at approximately 1400, Department of Health survey staff observed initiation of dialysis treatment of a patient with a central venous catheter. -A physicians’ order was in place from the Transplant Center where patient #2 is listed to collect a laboratory specimen for human leukocyte antigen (HLA) typing every month. -Staff # H drew 10 cc of blood from the venous limb of the catheter with a syringe, and the laboratory vial was filled, but there was blood remaining in the syringe. Staff reattached the syringe to the venous limb of the catheter and injected the remaining blood to the patient. -On 12/7/2023, survey staff reviewed unit policy entitled Hemodialysis/Apheresis Catheter Procedure (revised 10/20). The procedure describes steps for drawing blood from hemodialysis catheters, but does not include a directive to return the overdraw of collected blood from the sampling to the patient. -The observation was discussed with the Nurse Manager, dialysis registered nurse, and administrator on 12/7/2023 at the exit conference approximately 1415 to 1445. The observation was discussed with the Medical Director on 12/8/2023 during an interview at 1130.”