DIALYSIS SPECIFIC EOC OBSERVATION Data Definition Tool This audit is to be completed by the manager or designee on a monthly basis. "Dialysis Specific EOC Observation" audits are due by the last day of the month. Instructions: Indicate Yes, No, NA (Not Applicable) for each question below. Submit 1 "Dialysis Specific EOC Observation" audit per month using the "Dialysis Specific EOC Observation" audit tool. Updated: 3/01/2015 QUESTION STANDARD LOCATION YES DIALYSIS - BUILDING INTERIOR PHYSICAL ENVIRONMENT INSPECTION 1 Date of Observation 2 Name of Observer 3 Are floors clean, intact, and free from damage? observed in clinic Floors are clean, intact, and free from damage 4 Are ceiling tiles free of stains, cracks, or missing tiles? observed in clinic Ceiling tiles are free of stains, cracks, or missing tiles 5 Grids are secure and free from rust? observed in clinic Grids are secure and free from rust Is the interior lighting clean, illuminated, intact, and free 6 from damage? observed in clinic The interior lighting is clean, illuminated, intact, and free from damage 7 Is door clearance adequate? observed in clinic The door clearance is adequate 8 Do Fire Doors remain closed? observed in clinic Fire doors are closed 9 Are walls and baseboards intact and free from damage? observed in clinic Walls and baseboards are intact and free from damage. 10 Are windows and window blinds clean? observed in clinic Windows and window blinds are clean. Are the lobby/waiting room chairs clean and in good 11 repair? Lobby The lobby/waiting room chairs are clean and in good repair. 12 Are Emergency Call Systems fully operational? Lobby restroom Emergency Call System is fully operational 13 Are countertops intact and free from damage allowing cleaning and disinfection? observed in clinic Countertops are intact and free from damage to allow cleaning and disinfection.
DIALYSIS - CLEANING AND DISINFECTION OF THE DIALYSIS STATION 14 Date of Observation 15 Staff Observed Were gloves, gown, protective eyewear and mask or faceshield worn during the cleaning and disinfection 16 procedure? Were all blood lines and disposables discarded in the 17 biohazardous waste? 18 Was the prime waste receptacle emptied and disinfected? Were gloves removed following the disposal and 19 disinfection part of the procedure? Was hand hygiene performed before putting on new 20 gloves? Were clean gloves put on before beginning the next 21 cleaning step? 22 Were the internal and external surfaces of the prime waste receptacle wiped and allowed to dry? Was a disinfectant-soaked cloth used to wipe the top, 23 front, and side surfaces of the machine? Was a disinfectant-soaked cloth used to wipe the dialysate 24 hoses of the machine? Was a disinfectant-soaked cloth used to wipe the Hansen connectors of the machine? 25 Was a disinfectant-soaked cloth used to wipe the BP cuff 26 and tubing? 27 Was a disinfectant-soaked cloth used to wipe the outside surfaces of the dialysate concentrate containers? Gloves, gown, protective eyewear and mask or faceshield were worn during the cleaning and disinfection procedure All blood lines and disposables were discarded in the biohazardous waste The prime waste receptacle was emptied and disinfected Gloves were removed following the disposal and disinfection part of the procedure Hand hygiene was performed before putting on new gloves Clean gloves were put on before beginning the next cleaning step The internal and external surfaces of the prime waste receptacle were wiped and allowed to dry the top, front, and side surfaces of the machine the dialysate hoses of the machine the Hansen connectors of the machine the BP cuff and tubing the outside surfaces of the dialysate concentrate containers
Was a disinfectant-soaked cloth used to wipe the data 28 entry station? 29 30 31 Were any unused disposable supplies removed from the dialysis chair and disposed? Was a disinfectant-soaked cloth used to wipe all external front-facing and side surfaces of the fully reclined chair? Was a disinfectant-soaked cloth used to wipe the sides of the seat cushion of the fully reclined chair? Was a disinfectant-soaked cloth used to wipe the tops of 32 the side tables beside the fully-reclined chair? Was a disinfectant-soaked cloth used to wipe the TV 33 controls? Was a disinfectant-soaked cloth used to wipe the call 34 button? 35 Was a disinfectant-soaked cloth used to wipe the IV poles? Was a disinfectant-soaked cloth used to wipe the O2 36 concentrators? 37 Was a disinfectant-soaked cloth used to wipe the counters around the dialysis station? 38 Were all clamps cleaned? 39 Were all cloths and wipes discarded properly? 40 Was hand hygiene performed immediately after cleaning and disinfecting the Dialysis Station? the data entry station Any unused disposable supplies were removed from the dialysis chair and disposed all external front-facing and side surfaces of the fully reclined chair the sides of the seat cushion of the fully reclined chair? the tops of the side tables beside the fullyreclined chair the TV controls the call button? the IV poles the O2 concentrators the counters around the dialysis station All clamps were cleaned Aall cloths and wipes were discarded properly Hand hygiene was performed immediately after cleaning and disinfecting the Dialysis Station
DIALYSIS - HOME TRAINING TREATMENT AREA AUDIT Is there a documented method in place to summon 41 immediate assistance for a patient or solitary staff? Is emergency resuscitation equipment immediately 42 available? 43 Did staff respond to a TEST emergency call for assistance in < 4 minutes? Is the treatment space adequate to prevent crosscontamination when multiple patients are training? 44 Does the treatment space provide adequate patient 45 privacy? There is no visible evidence of dry or wet blood on the 46 equipment or surfaces? 47 48 There is no visible evidence of dry or wet PD effluent on the equipment or surfaces? Is the patient treatment area (including floors, countertops, and ceiling tiles) in good repair? 49 Are treatment chairs in good repair and functional? There is a documented method in place to summon immediate assistance for a patient or solitary staff The emergency resuscitation equipment is immediately available The staff responded to a TEST emergency call for assistance in < 4 minutes The treatment space is adequate to prevent cross-contamination when multiple patients are training The treatment space provide adequate patient privacy There is visible evidence of dry or wet blood on the equipment or surfaces There is visible evidence of dry or wet PD effluent on the equipment or surfaces The patient treatment area (including floors, countertops, and ceiling tiles) is in good repair Treatment chairs are in good repair and functional
DIALYSIS - ISOLATION PRACTICES Is the Isolation room or area equipped with dedicated equipment and supplies for use by only HBsAG+ positive 50 patients? 51 52 53 54 55 56 57 58 Is the door to the Isolation room closed during initiation and discontinuation of dialysis treatment? Do staff caring for HBVsAG positive ANTIGEN+ patients only provide care for HBsAG positive V ANTIBODY+ patients in close proximity during the same shift maintaining a proper buffer zone? Do all patients seated in the "Buffer Zone" have a documented HBsABy titer of > 10 in the past 12 months? Are staff providing medications to isolation patients prohibited from caring for susceptible patients during the same shift? Is Isolation equipment labeled and dedicated for use for HBsAG positive V+ patients only? Is the Isolation room used for HBsAg positive V+ patients when the census includes any HBsAg positive V+ patients? Does staff wear gloves, gown, protective eyewear and mask or faceshield when entering the isolation room during treatment? Does staff remove gloves, gown, protective eyewear and mask or faceshield when entering the isolation room during treatment? The Isolation room or area equipped with dedicated equipment and supplies for use by only HBsAG+ positive patients The door to the Isolation room is closed during initiation and discontinuation of dialysis treatment Staff caring for HBVsAG positive ANTIGEN+ patients only provide care for HBsAG positive V ANTIBODY+ patients in close proximity during the same shift maintaining a proper buffer zone. All patients seated in the "Buffer Zone" have a documented HBsABy titer of > 10 in the past 12 months Staff providing medications to isolation patients are prohibited from caring for susceptible patients during the same shift The Isolation equipment is labeled and dedicated for use for HBsAG positive V+ patients only The Isolation room is used for HBsAg positive V+ patients when the census includes any HBsAg positive V+ patient The staff wears gloves, gown, protective eyewear and mask or faceshield when entering the isolation room during treatment The staff removes gloves, gown, protective eyewear and mask or faceshield when leaving the isolation room during treatment
Does staff perform hand hygiene immediately after leaving 59 the isolation room? 60 Does the isolation room or area have equipment, instruments, and supplies desginated to be used only for patients with MRSA? The staff performs hand hygiene immediately after leaving the isolation room The isolation room or area has equipment, instruments, and supplies desginated to be used only for patients with MRSA Does the isolation room or area have equipment, instruments, and supplies desginated to be used only for 61 patients with VRE? DIALYSIS - PATIENT TREATMENT AREA AUDIT 62 Are there dummy drip chambers in the patient care area? 63 Is the patient care area in good repair? 64 Are the patient chairs in good repair? 65 Emergency supplies include: AED? 66 Emergency supplies include: O2? 67 Emergency supplies include: Suction? 68 Emergency supplies include: Ambu bag with face mask? 69 Emergency supplies include: IV solutions? 70 Emergency supplies include: Back board? 71 Emergency supplies include: Oral airway? 72 Emergency supplies include: Emergency medications? The isolation room or area has equipment, instruments, and supplies desginated to be used only for patients with VRE No Dummy drip chambers are present in the patient care area The patient care area is in good repair The patient chairs are in good repair Observed on emergency cart Emergency supplies include: AED Observed on emergency cart Emergency supplies include: O2 Observed on emergency cart Emergency supplies include: Suction Emergency supplies include: Ambu bag with emergency cart face mask emergency cart Emergency supplies include: IV solutions emergency cart Emergency supplies include: Back board emergency cart Emergency supplies include: Oral airway Emergency supplies include: Emergency medication room medications
73 Are AED checks performed daily? Are emergency supplies checked monthly or after use for 74 expiration dates, cleanliness, and proper function? DIALYSIS - SUPPLY CONTAMINATION PREVENTION 75 Date of Observation 76 Staff Observed 77 78 Were all supplies stored in designated clean areas at a safe distance from the dialysis stations? Was the staff member compliant with never keeping patient care supplies in pockets or on their person? documented in AED log AED checks were performed daily. medication room The emergency supplies are checked monthly or after use for expiration dates, cleanliness, and proper function All supplies were stored in designated clean areas at a safe distance from the dialysis stations. The staff member was compliant with never keeping patient care supplies in pockets or on their person. 79 80 81 Was all non-disposable equipment (thermometers, IV poles, ph/conductivity meters, O2 concentrators, glucometers, stethoscopes) disinfected when removed from the used dialysis station BEFORE is was returned to a common area or another dialysis station? Was all non-disposable equipment disinfected by wiping all surfaces with EPA-registered hospital disinfectant and allowed to dry? Were all unused disposable supplies discarded or dedicated to the patient and not returned to the common supplies? All non-disposable equipment (thermometers, IV poles, ph/conductivity meters, O2 concentrators, glucometers, stethoscopes) were disinfected when removed from the used dialysis station BEFORE is was returned to a common area or another dialysis station. All non-disposable equipment was disinfected by wiping all surfaces with EPA-registered hospital disinfectant and allowed to dry. All unused disposable supplies were discarded or dedicated to the patient and not returned to the common supplies.