HospitalInspections.org

C 0914 - Preventive Maintenance

Based on observation, interview and record review, the facility failed to maintain a complete inventory of all facility equipment used in the care of patients and failed to provide ongoing preventive maintenance in accordance with manufacturer specifications for 2 of 19 sampled pieces of medical equipment and failed to ensure initial inspection for 1 of 19 of the sampled medical equipment.

Findings include:

A. Tour of procedure room on 8/11/2021 at 1:00pm revealed Olympus leak tester used for leak testing endoscopes and colonoscopes (for viewing upper and lower gastrointestinal tracts) and the Cygnus Medical Airtime Instrument Channel Dryer (used for drying scope channels) did not have a biomedical sticker present to indicate preventive maintenance program.

Tour of the Emergency Room on 8/9/2021 at 3:00pm revealed the Trilogy EV300 Phillips Ventilator/Bipap (used to blow air with extra oxygen into airways and lungs) did not have a biomedical sticker on the equipment.

Surveyor requested preventive maintenance information for 19 devices used in the facility. Asset Snapshots with safety inspection/schedule needs, were provided by the contracted vendor for 16 devices having current inspection reports.

B. Interview with Chief Nursing Officer (CNO) on 8/12/21 at 8:40 am revealed that she (CNO) had spoken to the Surgery Registered Nurse, who reported, "Leak tester has been in building 20 years."

Interview with Director of Maintenance and Chief Financial Officer (CFO) on 8/12/2021 at 10:15 am revealed no inventory list was maintained by facility staff, as the facility contracted with a vendor who was responsible for logging all equipment and any information needed would be provided by "name of service technician", who comes onsite to log new equipment and provide preventive maintenance. Facility did not have any department specific equipment inventory to track preventive maintenance.

Director of Maintenance stated when new equipment brought in to facility, a work order is given to Maintenance, then in a year the biomedical company will do safety checks and place biomedical sticker on equipment. Director of Maintenance reported that Olympus leak tester, had electrical inspection in 2016 and 2017 by facility maintenance, but not since then. Cygnus Medical Airtime Instrument Channel Dryer and the Trilogy EV300 Phillips Ventilator/Bipap were purchased in 2021 and hadn't been placed in the biomedical binder. Cygnus Medical Airtime Instrument Channel Dryer had electrical safety check by facility Maintenance on 4/15/2021. The Trilogy EV300 Phillips Ventilator/Bipap had not had an electrical safety inspection prior to use.