HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to:
*Monitor one of three blanket warmer's temperature for patient safety in the post-anesthesia care unit (PACU).
*Have a preventative maintenance program in place for one of one blanket warmer for patient safety in the PACU.
Findings include:

1. Observation on 3/21/23 at 10:10 a.m. in the PACU revealed.
*There was a blanket warmer located near the recovery rooms.
*The blanket warmer:
-Was not electronically controlled and required the temperature to have been set manually.
-The external temperature gauge was set on 130 degrees Fahrenheit (F).
-Had multiple shelves with blankets on them.
*The blankets were warm to the touch.
*There was a thermometer inside of the blanket warmer for monitoring the temperature.
-That thermometer had not been registering a temperature reading to support what the internal temperature of the blanket warmer was.
*There was a yellow sticker on the warmer that was dated 11/24/21.

Observation on 3/22/23 at 8:15 a.m. of the blanket warmer in the PACU remained unchanged from above observation.

Observation and interview on 3/22/23 at 8:20 a.m. with registered nurse (RN) E of the blanket warmer in the PACU revealed she:
*Confirmed:
-The blanket warmer temperature was set manually by the staff and had been set to 130 degrees F.
-The thermometer inside of the blanket warmer was used to verify the internal temperature had not risen above 130 degrees.
-The thermometer had not been working and could not have supported the exact internal temperature of the blanket warmer.
-The yellow sticker was a Biomedical (BioMed) sticker used to support when the blanket warmer had been checked for safety.
*Stated:
-"We don't keep logs to document the temperatures of our blanket warmers."
-"The temperatures are entered into our electronic system, Cerner."
-"The surgical techs are supposed to check this every day and enter it into our system."
-"I would also expect them to check the thermometer to make sure the temperature is okay."
-"It's clear that the thermometer is not working and I can't tell you how long it has been that way."
-"Someone should have said something because you can't take a temp [temperature] with this."-"I have to check with BioMed to see for sure when they checked it last or how often they are supposed to."
-"The temperature is set to 130 F and all the warmers are not to go over that."

Observation and interview on 3/22/23 at 8:25 a.m. with surgical technician F regarding the blanket warmer in the PACU revealed:
*She confirmed the surgical technicians had been responsible for checking the temperature of that blanket warmer daily.
*Someone else had been responsible for checking the blanket warmers that day.
*She:
-Had not been aware the internal thermometer was not registering a temperature.
-Was not sure how long the thermometer had not been working.
-Was not sure if the temperature should have been logged into their electronic system, but she thought it was.

Observation and interview on 3/22/23 at 8:33 a.m. with BioMed technician G regarding the blanket warmer in the PACU revealed he:
*Confirmed the observations above.
*Confirmed the yellow sticker was from their department and the date on it supported when it was last checked.
*Was unsure how often the blanket warmer was to have been checked and would get back to the surveyor with that information.

Interview on 3/22/23 at 11:30 a.m. with RN E revealed:
*The thermometer had been checked and it had been confirmed that it was broken.
*The BioMed department:
-Was to have been checking the blanket warmer every six months.
-Had no documentation to support the blanket warmer had been checked after 11/24/21.
-Had not put the blanket warmer on their preventative maintenance program to check it for proper functioning and safety.
*There was no documentation in the electronic system to support when the last time the staff had checked its internal temperature.
*She stated:
-"Again, I would expect them to check the thermometer and touch the blanket for warmth."
-"If it was over 130 F they should let maintenance know or flag it for them to check."
-"We have a new thermometer on order."
-"BioMed put it on their PM [preventative maintenance] log."
-"I would expect someone to say something."
*With no knowledge of the exact temperature inside of the blanket warmer that would have placed the patients at risk for possible harm.

Review of the provider's January 2023 Warmers - Blankets policy revealed:
*Blankets:
-There was no documentation to support the process for checking the temperature on the blanket warmer in the PACU.
-The policy supported the process for all the electronic blanket warmers, but not the manual setting blanket warmers.
*Calibration:
-"BioMed staff will verify the calibration for accuracy to temperature or numeric setting on all warming units,.....every six months."