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Based on observation, interview and record review, the hospital failed to ensure that the entire clinical laboratory testing equipment's received timely preventative maintenance per the manufacturer's recommendation. This failure had the potential for malfunctioning of the equipment's which could result in inaccurate results leading to medical complications for patients.

Findings:

During a tour of the Clinical Laboratory Department on February 4, 2014, at approximately 8:30 AM, with the Chief Nursing Officer (CNO) and the Clinical Laboratory Scientist (CLS) 1, observations were made of the following equipment where preventative maintenance (PM) were not current and not up to date:

1. The VITEK? 2 system (used for fast, accurate microbial identification, and antibiotic susceptibility testing) noted a PM completion date of December 5, 2012, and the next PM due date of December 2013.

2. The Carbon Dioxide (CO 2) incubator (gassed incubators used to maintain the progressive development of microbiological cultures by regulating viable growth factors such as temperature, humidity and ventilation) noted a PM completion date of December 5, 2012, and the next PM due date of December 2013.

3. The non CO 2 incubator (non- gassed or microbiological incubators used to grow and maintain cell cultures), noted a PM completion date of December 5, 2012, and the next PM due date of December 2013.

4. The stool incubator (used to identify organisms in stool) noted a PM completion date of December 5, 2012, and the next PM date of December 2013.

During an interview on February 4, 2014, at 8:50 AM, with the CNO, she verified that the PM was not up to date for the Vitek 2, the CO 2 incubator, the non CO 2 incubator and the stool incubator.

During an interview on February 4, 2014, at 9:05 AM with the Bio Med Equipment Technician, he confirmed that the PM was not up to date on the Vitek 2, the CO 2 incubator, the non CO 2 incubator and the stool Incubator. He stated that he had been busy but would work on them right away.

During a review of the hospital policy and procedure titled, "Medical Device management Plan", effective January 1, 2014, included the following:
"Clinical Engineering shall:
Repair, maintain, or manage the maintenance of diagnostic, therapeutic and monitoring equipment used to treat (Hospital) patients.
Perform and document all required safety, corrective and preventative maintenance (PM) actions for the devices specified above. ....."
"Preventative Maintenance Inspections:
In conjunction with the evaluation of equipment for inclusion in the Equipment management File, each classification of device is assigned a preventative maintenance inspection strategy and schedule ....The frequency for interval-based PM inspections is determined based upon manufacturer recommendations, risk levels, and past organizational experience ...."

Based on staff interview and record review, the facility failed to ensure that a telephone order for 1 of 22 sampled patients (Patient 1) was dated and authenticated.

This failure had the potential for inaccurate assessment and intervention necessary for Patient 1's safety and quality of care.

Findings:

During a review of the medical record conducted on February 4, 2014 at approximately 10:40 AM, revealed that Patient 1 was admitted to the hospital on February 2, 2014 at 01:34 AM with admitting diagnosis of appendicitis (inflammation and disease of the appendix).

During a review of the "Physician's Order Sheet" it showed a telephone order dated February 2, 2014 at 01:15 AM. The telephone orders included:

1. NPO (nothing by mouth) status.
2. Dilaudid (opioid analgesic medication used for moderate to severe pain) IVP (intravenous push) 0.5 - 1.5 mg (milligram) q (every) 1 hour PRN (as needed) for pain.
3. Zofran IVP (antiemetic, prevent nausea and vomiting) 4 mg q 4 hours prn for nausea and vomit.

It was noted that the telephone orders were not timed, dated and authenticated by the ordering physician.

During an immediate interview with the Licensed nurse (Registered Nurse 1), RN 1 confirmed that the telephone orders entered were not timed, dated and authenticated.

During a review of the hospital's Policy and Procedure titled, "Health Record Content" with effective date 3/29/2013, revealed under Policy Delineations:
2. General requirements: (a) "All entries must be timed, dated and authenticated." ...
8. "Order sheet including medication, treatment, and diet orders: telephone and verbal orders must be signed within 24 hours of receipt of the order scribed by the nursing staff."