HospitalInspections.org

Based on tour of facility, review of facility policy, and interview with staff, it was determined the facility failed to ensure compounding maintenance was consistent with the manufacturers instructions for use and maintenance.

Findings include:

Review of Pharmagard Positive Pressure Recirulating Sterile Isolator Operation and maintenance manual revealed, "... Depending upon isolator usage, NuAire typically recommends sleeve/glove replacement on the following schedule: Sleeves - Once every six months ... ."

During a tour of the pharmacy on October 2, 2019 at 10:00 AM revealed documentation the sleeves were last changed on March 4, 2019.

Interview with EMP7 confirmed the sleeves had not been changed every 6 months.

Based on a review of facility documentation and staff interview (EMP), it was determined the facility failed to employ a full-time Director of Nutrition/Food Services.

Findings include:

A review of the facility's contracted service for the dietary department revealed the title: "General Manager...JOB SUMMARY, Plans, organizes and oversees all activities and systems in the Dining Service and Nutrition Departments. Functions as the liasion in all administrative roles within the facility and may participate in multidisciplinary capacities...Performs related duties as assigned by supervisor..."

A list of the facilities supervisors revealed EMP2 as the "Director" (of dietary).

A review of the facility's organizational chart provided upon request lists EMP2 as the "assistant director."

During an interview on October 1, 2019, at 12:45 PM, with EMP2 stated he was "assistant director" of dietary and was not full time at this facility but worked both here and at the other sister hospital.

An interview was conducted on October 3, 2019 with EMP11 to clarify the discrepancy of EMP2's employment status. EMP11 confirmed that EMP2 is the dietary director at this facility; however, this employee is not employed at this facility in the full time capacity.

Based on review of facility documentation and staff interview (EMP), it was determined the facility failed to ensure equipment was maintained at an acceptable level of safety and quality.

Findings included:

A review of facility policy "Medical Equipment Management Plan" revised date of February 24, 2019, revealed "II OBJECTIVES..7. Maintain preventive maintenance standards/goals by an equipment inspection process."

A review of facility document "Equipment Inventory w/Frequency & Fixed Information" revealed the facility had two ventilators. The Respironics Trilogy 202 ventilator was listed to have maintenance due on June 5, 2019, and was listed as "Late."

During an interview on October 3, 2019, at 11:00 AM, EMP9 confirmed that the preventative maintenance (PM) was late on the Trilogy ventilator.

During an interview on October 3, 2019, EMP10 confirmed the Trilogy ventilator was out of compliance with the PM maintenance"