HospitalInspections.org

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Based on record review and interview, the facility failed to ensure that oversight of the Preventive Maintenance Logs of the Endoscope Reprocessing System was performed by an assigned staff member to ensure that the Manufacturer's Guidelines were followed.

Findings:

A review of the Daily Checklist for the DSD Edge Endoscope Reprocessing System revealed a list of daily tasks to be performed for daily start up and daily shut down.

An interview with Staff #11 on 07/09/15 at 1:30PM revealed that she is the Manager of the Department but that she has not been trained on the system and is not familiar with what to check for. She stated that the Nurses' Aides perform the cleansing of the scopes and if they need anything, or a machine needs attention, they would tell her and she would call Bio Engineering.

Review of the Document Filter Change Log for the DSD Endoscope Reprocessing System (Serial #73980246) revealed that the air filter was changed eleven (11) days after the date that it was due to be changed.

The Manufacturer's Guidelines document that the air filters should be replaced every three (3) months.

An interview at 3:30PM with Staff #2 revealed that the filter was changed within the time-frame, but that the staff member who recorded it dated it on the day she was advised, (eleven {11} days later).

An interview with Staff #11 revealed that there are no quality review checks to ensure that the disinfectant change, the water filter, water line disinfection vapor management filters, and reusable mesh disinfectant filters are changed in accordance with the Manufacturer's Guidelines. The staff member stated that the company is under contract to perform some of the filter changes and Bio Engineering takes care of others.