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CUBA MEMORIAL HOSPITAL, INC
No Description Available
Tag No.: C0222
Based on observation, document review and staff interview, the facility does not ensure that 2 of 2 roof top units (RTU) have maintenance performed on the heating, ventilation and air-conditioning system (HVAC). Failure to perform maintenance on the system may result in failure of the system.
Findings include:
Review of the provided documentation on 10/18/18 at 11:30 AM did not provide evidence that routine maintenance was performed on the 2 RTU.
During the facility tour on 10/18-19/2018 it was observed that exhaust vents were not operational/inadequate in the regulated medical waste room, clean utility room and soiled utility room on the medical care unit (MCU). It was also observed that mechanical exhaust was not present in the janitor's closet on the MCU and that dust and debris had accumulated on the vents and required cleaning.
Interview with Staff (B), Maintenance on 10/18/18 at 11:30 AM and on 10/19/18 between 11:00 AM and 1:30 PM verified this finding.
PATIENT CARE POLICIES
Tag No.: C0278
Based on document review and interview the facility has not conducted a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system, as well as the development and implementation of a water management program that considers the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) industry standards and the Centers for Disease Control toolkit.
Findings include:
Review of facility policy "Legionella: Strategies and Surveillance", last reviewed 02/2011 revealed no evidence that the policy had been updated or that a facility-wide risk assessment of the water system, along with the development and implementation of a water management program, including testing protocols and acceptable ranges for control measures based on the risk assessment had been conducted.
Interview with Staff (A), Administration and Staff (C), Infection Control confirmed that a risk assessment of the facility water system, along with the development and implementation of a water management program has not been conducted.