HospitalInspections.org

Based on observations, record review and staff interview the Critical Access Hospital (CAH) failed to maintain a complete inventory of all facility equipment used in the care of patients and failed to provide ongoing preventative maintenance in accordance with manufacturer specifications for 12 of 52 sampled pieces of medical equipment. This failed practice had the potential to affect all patients of the CAH. The CAH had 379 inpatient admissions, 207 observation admissions, 145 swing bed admissions, 4,105 emergency department visits and 7,176 outpatient specialty clinic visits for fiscal year 2023.

Findings include:

A. Tour of inpatient area (3/19/2024 at 9:00 AM) revealed the following equipment not listed on the Bio-Electronics equipment file listing or testing was documented:

-IV pump with an equipment log sticker 1069. Equipment number 1069 on Bio-Electronics equipment file list revealed the columns "last test" and "test due" were blank.
-Suction unit on the crash cart with an equipment log sticker 1108. Equipment number 1108 was not listed on Bio-Electronics equipment file list.
-Baby warmer in the labor and delivery area with an equipment log sticker 1138. Equipment number 1138 was not listed on Bio-electronics equipment file list.
-Kangaroo pump with an equipment log sticker 1144. Equipment number 1144 was not listed on Bio-Electronics equipment file list.
-Kangaroo pump with an equipment log sticker 1145. Equipment number 1145 was not listed on Bio-Electronics equipment file list.

B. Tour of radiology department (3/19/2024 at 3:30 PM) revealed vital sign machine in CT room with an equipment log sticker 861. Equipment number 861 was not listed on Bio-Electronics equipment file list.

C. Tour of emergency department (3/20/2024 at 7:59 AM) revealed the following equipment not listed on the Bio-Electronics equipment file listing or testing was documented:

- Cardiac monitor in exam room A with an equipment log sticker 1118. Equipment number 1118 on Bio-Electronics equipment file list revealed the columns "last test" and "test due" were blank.
-Cardiac monitor in exam room A with an equipment log sticker 1119. Equipment number 1119 on Bio-Electronics equipment file list revealed the columns "last test" and "test due" were blank.

D. Tour of outpatient specialty clinic (3/20/2024 at 3:00 PM) revealed the following equipment not listed on the Bio-Electronics equipment file listing or testing was documented:

-Suction unit with an equipment log sticker 852. Equipment number 852 was not listed on Bio-Electronics equipment file list.
- Electrocardiogram (EKG) machine (records heart's electrical activity) with an equipment log sticker 942. Equipment number 942 was not listed on Bio-Electronics equipment file list.
-Vital sign machine with an equipment log sticker 1103. Equipment number 1103 on Bio-Electronics equipment file list revealed the columns "last test" and "test due" were blank.

E. Tour of respiratory therapy (3/21/2024 at 8:00 AM) revealed a bipap machine (machine used to help you breathe) with an equipment log sticker 930. Equipment number 930 was not listed on Bio-Electronics equipment file list.

F. Review of facility policy titled Equipment & Electrical Safety Management (Reviewed August 2023) stated that "Department heads are responsible for identifying, evaluating and keeping an inventory list of all patient equipment in use in their departments" and, "The department heads keep a record of all inspections, maintenance or repair on file according to the record retention policy." The policy also stated "Any new, under contract, leased or borrowed equipment should be tested prior to use by the operator to be sure it is operating within the parameters it is to be used."

-Review of facility policy titled Preventive Maintenance Program (Revised March 2024) stated "Each piece of equipment, responsible to the engineering department, is listed on a preventive maintenance form. Each unit is assigned an equipment number, along with the location and frequency of the duties to be performed. Each a month a printout is made of the equipment to be serviced that month. When the equipment is serviced, the date the work was completed, as well as the work performed, will be put on the printout. The printout will be used as the documentation of the work completed."

G. Interview with Director of Plant Operations (3/21/2024 at 9:20 AM) revealed new pieces of equipment goes to materials management and either Bio-electronics or facility puts equipment log sticker on equipment. Bio-Electronics are contacted by the facility when new equipment is received.

-Interview with Director of Materials Management (3/21/24 at 9:22 AM) confirmed vital machines, IV pumps and kangaroo pumps are no longer under warranty. Facility acknowledged the need to contact Bio-Electronics to add patient care equipment to their list to do preventive maintenance on.

Based on medical record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed for 1 of 6 surgical medical records (Patient 30) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. The CAH performs an average of 55 procedures a month.

Findings are:

A. Review of Patient 30's surgical medical record (3/20/24 at 2:35 PM) revealed the patient had Electrocal cardioversion (procedure used to return an abnormal heartbeat to a normal rhythm) under MAC (Monitored Anesthesia Care- medications that help you relax during a minor procedure) on 12/20/23. Review of the entire medical record revealed the "Preprocedural Evaluation" signed, dated 12/20 (lacked year completed) and lacked documentation of time ensuring that the examination was completed before surgery.

B. Interview (3/21/24 at 12:50 PM) with the Director of Nursing (DON) confirmed the pre-procedural evaluation lacked documentation of the year and time the assessment was completed. The DON also stated there was no policy and procedure in place for the pre-procedural examination.