HospitalInspections.org

Based on interview and record review, the facility failed to:

1. Ensure that the facility had an organized Governing Body responsible for the conduct of hospital operations in accordance with Federal regulation.

This deficient practice had the potential to result in lack of oversight for the facility's overall operations which may impact patient safety.

2. Ensure that the facility's contracted chillers service vendor furnished services per contract in order to allow the facility to comply with regulations pertaining to standards of contracted services. The rental chiller (chiller 2) was incorrectly installed on 6/15/2024 and the chiller was not functioning properly.

This deficient practice resulted in 139 patients experiencing hot temperature which was outside the acceptable range of 71 to 81 degrees Fahrenheit on 6/15/2024. This deficient practice also placed patients at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures).

Findings:

1. During an interview on 6/18/2024 at 3:55 p.m. with Chief Administrative Officer (CAO), the CAO stated that there was no organized Governing Body (GB) in the facility.

During a review of a facility letter dated 4/1/2021, the facility letter indicated that there was an absence of organized GB in the hospital. The individual identified as legally responsible for the conduct of the hospital operations is the executive board chairman (EBC).

During a review of the facility's organizational chart dated 6/2024, the organizational chart indicated the EBC was not included in the organizational chart. There was also no indication in the organizational chart that the Chief Executive Director (CEO) was reporting to GB.

During an interview on 6/18/2024 at 5:20 p.m. with the CAO, the CAO stated that she (CAO) does not participate in the meeting between the EBC (who represents the GB) and the CEO. CAO said she (CAO) does not know the GB meetings' content. CAO was not able to provide pertinent documentation such as GB minutes, meeting agenda and sign in sheet, to prove that EBC was involved in facility administrative and operational matter in the facility.

2. During an interview on 6/17/2024 at 12:56 p.m. with the facility's Chief Operation Officer (COO), the COO stated that the facility's permanent AC chiller went down due to a motor that went out on 6/14/2024 in the afternoon, no specific time. A rental chiller (chiller 2) was rented from a contracted chiller service vendor, and it was installed on 6/15/24 early morning. Facility was then using two rental portable chillers (chiller 1 installed since 2018 and chiller 2 which was just installed on 6/15/24), both chillers were rental due to existing permanent chillers were not functioning.

During an interview on 6/17/2024 at 12:56 p.m. with Chief Operation Officer (COO), the COO stated that the facility's permanent AC chiller went down, thus requiring the facility to rent a chiller from a contracted vendor. The chiller company installed a portable chiller (chiller 2) early morning on 6/15/2024. The same day in the afternoon, facility found out the new rental unit (Chiller 2) and the other rental unit since 2018 (Chiller 1) were not working correctly, and they called the chiller company to go back to the facility and check both chillers.

During an interview on 6/18/2024 at 10:30 a.m. with the facility's Administrative Director of Operation (ADO), the ADO stated that the chillers vendor was responsible for routine maintenance of all rental chillers.

During an interview on 6/18/2024 at 11:04 a.m. with the ADO, ADO stated that he (ADO) did not know when was the last time that the vendor performed the maintenance service for chiller 1 (rented since 2018).

During a review of the facility's policy and procedure titled, "HVAC (Heating, Ventilation, and Air Conditioning) system, number H.10," revised on 2/2024, the P&P did not establish a written policy to specify maintenance schedule was recommended that ensures areas/equipment have routine and preventative maintenance and testing activities in accordance with Federal and State laws, regulations, and guidelines and manufacturer's recommendations.

Based on observation, interview, and record review, the facility failed to:

1. Maintain the existing chillers for two of two chillers (Chiller 1 and Chiller 2) in working condition.

2. Develop and implement a policy to ensure all chillers have a maintenance schedule that ensures areas/equipment have routine and preventative maintenance and testing activities in accordance with Federal and State laws, regulations, and guidelines and manufacturer's recommendations.

3. Ensure and monitor its contracted chillers service vendor that provide the services per contract; the rental chillers were not working properly due to vendor installing the chillers incorrectly.

These deficient practices had caused the chillers to not function correctly and some patients in the hospital experienced hot temperature outside the acceptable normal range of 71 to 81 degrees Fahrenheit.

Findings:

During an interview on 6/17/2024 at 12:56 p.m. with the facility's Chief Operation Officer (COO), the COO stated that the facility's permanent AC chiller went down due to a motor that went out on 6/14/2024 in the afternoon, no specific time. A rental chiller (chiller 2) was rented from a contracted chiller service vendor, and it was installed on 6/15/24 early morning. Facility was then using two rental portable chillers (chiller 1 installed since 2018 and chiller 2 which was just installed on 6/15/24), both chillers were rental due to existing permanent chillers were not functioning.

During an interview on 6/18/2024 at 10:30 a.m. with the facility's Administrative Director of Operation (ADO), ADO stated that facility did not have documentation for inspection and maintenance record from facility engineer on the existing chiller which was broken on 6/14/2024. ADO confirmed that HVAC system policy did not have details of how often chillers should be inspected, maintained and serviced.

During an interview on 6/18/2024 at 10:30 a.m. with the facility's Administrative Director of Operation (ADO), the ADO stated that the chillers vendor was responsible for routine maintenance of all rental chillers.

During an interview on 6/18/2024 at 11:04 a.m. with the ADO, ADO stated that he (ADO) did not know when was the last time that the vendor performed the maintenance service for chiller 1 (rented since 2018).

During a review of the facility's policy and procedure titled, "HVAC (Heating, Ventilation, and Air Conditioning) system, number H.10," revised on 2/2024, the P&P did not establish a written policy to specify maintenance schedule was recommended that ensures areas/equipment have routine and preventative maintenance and testing activities in accordance with Federal and State laws, regulations, and guidelines and manufacturer's recommendations.

\