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Based on observation, record review, and interviews, the hospital failed to ensure a routine and preventative maintenance (PM) program for essential facility equipment. The facility identified mechanical problems in the air conditioning system (HVAC) through the QA process in March 2010 but failed to take action to repair the equipment. The equipment malfunctioned and the proper ambient temperature was not maintained in 3 of 3 patient care areas: Intensive Care Unit (ICU); Emergency Department (ED); and 2nd floor medical inpatient unit.

Findings:
(1) The system was not maintained in safe operating condition and it failed to function properly. Cross refer to tag C222.
Review of Quality/Safety/Care Committee and Medical Executive Committee Minutes meeting notes dated March 23, 2010 showed a discussion under the Utilities Management Section in the QA, 4th Quarter Summary Report 2009 that mechanical problems were identified with the HVAC system. It was determined the equipment was defective but the facility did not implement solutions to prevent any further failure.

(2) Proper temperature control was not achieved. Cross refer to tag C226.
During a tour of the hospital the morning and afternoon of 6/23/10, the surveyor observed that temperatures in the 2nd floor medical inpatient unit, ICU and ED were from 2-8? Fahrenheit above the required 72 degree maximum temperature range. In an interview during the tour, the Director of Plant Operations (Personnel #2) was asked if the temperatures that the surveyor recorded in the patient care areas were within the required policy range. He stated, " No."

Based on observation, record review, and interview, the hospital failed to ensure that a preventative maintenance program (PM) program for the HVAC system was maintained as required for patient safety and quality in that 1 of 2 chill water pumps (Pump #1) for the HVAC unit had been non-operational for 6 of 6 months (January 2010-June 2010) and 1 of 2 chillers (Chiller #1) for the HVAC unit had been non-operational for 7 of 7 months (December 2009- June 2010).

Findings:
During a tour of the mechanical room on the afternoon of 6/23/10, the surveyor observed Chill Water Pump #1 and Chiller #1 not working. The Director of Plant Operations (Personnel #2) verified Pump #1 and Chiller #1 was non-operational.

On the morning of 6/23/10 , the Director of Plant Operations (Personnel #2) was interviewed. He was asked if Pump #1 for the HVAC system was operational. He stated, " No. " He was asked how long Pump #1 had been non-operational. He stated, " Since January 2010. " He was asked how long Chiller #1 had been non-operational. He stated, " Since December 2009."HH He was asked if he kept preventative maintenance (PM) logs for all essential mechanical, electrical and patient-care equipment. He stated, " We have a company that performs routine and preventative maintenance on the patient equipment. They send us a report every quarter. We do not have a contract with a company that performs maintenance on the other equipment. We do those ourselves. I do not have any PM or Maintenance logs for the other mechanical and electrical equipment. I have a file that I keep receipts of repairs done but not of routine or preventive maintenance. " He was then asked if he still used the Metacheck Computerized PM Program. He stated, " No. " He was asked if the hospital still used Carrier Corporation for repairs and maintenance. He stated, " No. " He was asked to review the hospital policy " Preventative Maintenance and Operational Reliability Plan. " He was then asked if he was following this policy. He stated, " No. "

Review of Hospital Wide Policy, " Preventative Maintenance and Operational Reliability Plan," Reviewed/Revised 06/06, requires, " Purpose: To establish and maintain a Utilities Systems Management Program to promote a safe, controlled, comfortable environment of care. To assess and minimize the risks of utility failures and ensure operational reliability of utility systems and prolong the systems themselves. Procedure: 1. All components of the utility systems are included in the Utilities Management Program. These systems are monitored, inspected, maintained and tested in accordance with the procedures described in the Metacheck Computerized PM Program ...When malfunctions do occur, the staff investigates the reason for the malfunction and takes appropriate measures to repair or eliminate the cause of the malfunction thus reducing the risk of future failures ...When the cause of the malfunction is determined, the problem is corrected and action taken to correct or minimize the problem source ... "

Review of Hospital Wide Policy, " Loss of HVAC Systems ," Reviewed/Revised 06/06, requires, " I. Purpose: To define procedures for engineering personnel to follow in the event of HVAC failure. II. Policy: In the event of a failure of a component of the HVAC system, every effort shall be made towards utilizing backup equipment for the affected area. Should it become apparent that the system will be down for a prolonged period of time or if climatic conditions are such that patient and staff comfort are jeopardized, the following procedure shall be utilized ...notify Director of Engineering ...inform house supervisor ...request Director of Nursing notify affected units ...for failure of air conditioning system that are uncorrectable in house: Contractor: Carrier Corporation, Office: 972-789-3420. "

Based on observation, record review and interview, the hospital failed to ensure proper temperature control in 3 of 3 patient care areas (2nd floor medical inpatient unit, Intensive Care Unit (ICU) and the Emergency Department (ED), in that the facility temperatures were not maintained between 67? Fahrenheit (F) and 72? F as per the hospital QA process to inhibit bacterial growth, prevent infection and promote patient comfort.

Findings:
During a tour of 2nd floor medical inpatient unit on the morning of 6/23/10, the surveyor observed temperatures above 72? F in the following patient rooms:
Room 200 - The temperature of the room measured 77? F.
Room 201 - The temperature of the room measured 74? F.
Room 202 - The temperature of the room measured 74? F.
Room 203 - The temperature of the room measured 74? F.
Room 206 - The temperature of the room measured 75? F.
Room 207 - The temperature of the room measured 77? F.
Room 208 - The temperature of the room measured 76? F.
Room 209 - The temperature of the room measured 77? F.
Room 211 - The temperature of the room measured 78? F.

During a tour of the ICU on the morning of 6/23/10, the surveyor observed temperatures above 72? F in the following rooms:
Nurses Station - The temperature of the room measured 80? F.
Room 2 - The temperature of the room measured 78? F.
Room 3 - The temperature of the room measured 78? F.

During a tour of the ED on the afternoon of 6/23/10, the surveyor observed temperatures above 72? F in the following rooms:
Nurses Station - The temperature of the room measured 80? F.
Room 1 - The temperature of the room measured 76? F.
Room 2 - The temperature of the room measured 76? F.

Review of the Quality/Safety/Care Committee and Medical Executive Committee Minutes dated March 23, 2010 showed, " 4th Quarter Summary Report 2009, Utilities Management, PI Measure, HVAC (Heating, Ventilation, Air Conditioning) Variations <67 & >72 degrees, Performance Analysis, Plant Ops informed of discomfort. Followed by evaluation of cause, Actions: 1st - Thermostats found defective, 2nd - Prime HVAC unit unreliable, portable unit brought in, repair work initiated on major components, 4th - HVAC heat valves defective. Manual adjustments being made until repair. "

Review of Environment of Care Policies and Procedures did not address required or recommended temperature ranges for the facility.

On the morning of 6/23/10, the Director of Plant Operations (Personnel #2) was interviewed. He was asked during the survey to verify the temperatures that the surveyor recorded for the patient rooms. He verified the room temperatures that were documented by the surveyor. He was asked if he had a policy for required minimum and maximum environmental temperatures. He stated his policy is minimum temperature not less than 67 degrees and the maximum temperature is not greater than 72 degrees Fahrenheit. He was asked how he monitored the temperatures of the facility. He stated, " I have my guys go around and check on a daily basis. " He was asked if he kept a log of the environmental rounds. He stated, " No. " He was then asked if the temperatures that the surveyor recorded in the patient rooms were within the required policy range. He stated, " No. "