HospitalInspections.org

Based on random observations and staff interview, the facility failed to ensure completion of preventive maintenance for 6 of 12 randomly observed pieces of medical equipment: blanket warmer located on 2nd floor, Midray DS ultrasound machine (a machine using sound waves to assist with medical imaging of body parts), 2 Datascopes (blood pressure monitoring machines), arthroscopic fluid management system machine (a machine that manages fluid flow for joint surgery) and the electrocautery (a machine used to control bleeding with surgical procedures) machine. This failed practice had the potential to affect all patients of the hospital. Findings are:

A. Random observations of medical machines on 1/16/14 from 11:45 AM to 2:00 PM, revealed the following pieces of equipment with no evidence of equipment check/preventive maintenance in the last year:

2nd and 3rd Floor:
- A blanket warmer with a sticker the next preventative maintenance due 12/2013.
- Midray DS portable ultrasound with a UHS (Universal Hospital Services) sticker 196114 showing the last preventative maintenance was 11/7/12 .
- Datascope blood pressure monitor with a UHS sticker 139274 showing the last preventative maintenance was 12/1/12 .
- Datascope blood pressure monitor with a UHS sticker 139272 showing the last preventative maintenance was 12/1/12 .
- Arthroscopic Fluid Management System with an equipment number 1301CM691 showing the next preventative maintenance was due 9/23/13.
- Electrocautery with a UHS sticker 196082 showing the next preventative maintenance was due 12/21/12 .

A telephone interview with the Universal Hospital Services representative on 1/16/14 at 3:00 PM revealed, "I know there are some pieces of equipment that need the preventative maintenance. I am a little behind. I will arrange with [the Maintenance Director] to get caught up this weekend and/or Tuesday."

An interview on 1/16/14 at 2:15PM with the Maintenance Director revealed, "I don't run a report to check it, we contract with UHS to perform the Preventative Maintenance yearly or as the manufacturer suggests. I know that they come on Saturdays and Tuesdays due to the equipment is sometimes in use."

Based on staff interview and record review, the facility failed to ensure staff received education related to hospital responsibility in regards to Organ and Tissue Donation. This failed practice had the potential to affect all deceased patients of the hospital. Findings are:

Interview with the CNO (Chief Nursing Officer) on 1/16/14 at 2:15 PM revealed, "No we have not had NORS come and do education. We had the Med Center come and give us education about transplants about 6 years ago. We have not had any deaths at our hospital where we would have needed to call NORS [Nebraska Organ Recovery System] either."

Interview with Nurse Manager A on 1/15/14 at 12:30 PM revealed, "No I don't believe I had any orientation or education on the NORS [Nebraska Organ Recovery System Donor Institution Agreement] procedure here. I have had the education previously at other places I have worked. We haven't had any deaths here since I have worked here either."

Interview with Charge Nurse B on 1/15/14 at 10:00 AM revealed, "I don't remember getting education on organ donations here. I guess I am unsure of my responsibilities, but I do know we haven't had any deaths here."

Interview with Staff Nurse C on 1/15/14 at 10:40 AM revealed, "I don't know for sure what my responsibilities are here, I didn't get training here. I do know there is a protocol in the computer and I could pull that up and look at it or talk with my Charge Nurse."

Review of the Nebraska Organ Recovery System Donor Institution Agreement dated 10/1/13 revealed that NORS would provide training to hospital staff. "NORS will provide no less than annually and on an on-going basis to Hospital and critical access hospital staff training and assist Hospital to train Hospital personnel involved in the referral process. NORS shall conduct education programs for Hospital personnel regarding the referral and management of potential organ and/or tissue donors at the request of Hospital personnel."