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Based on observation, interview and record review, the facility failed to ensure timely repairs on patient care equipment on 4 of 4 units that were reviewed for equipment concerns (operating room, intensive care unit, medical-surgical unit, and radiology).

This deficient practice had the likelihood to cause harm to all patients.

Findings include:

Review of the facility's work order list revealed the following request for repairs:

Operating room/Intensive care unit

On 01/30/2025 there were 3 light switches not working in the operating room. The order was classified as a priority 2 meaning urgent.

On 01/31/2025 the anteroom sink in CV7 was not working in the intensive care unit. The order was classified as a priority 2 meaning urgent.

On 03/25/2025 a Hill rom bariatric compella bed was not inflating in the intensive care unit. The order was classified as a priority 3 meaning important.

During an interview on 05/06/2025 at 5:00 p.m., Staff #2 said they had just checked the lights in the operating room. Two lights were working and three were not working. The sink in the anteroom was not working and the whole sink needed to be replaced. They would call the manufacturer about the beds because plant operations and Biomed department did not work on them.


Radiology

According to an email and "PHILLIPS SERVICE LOG" dated 03/19/2025 there was documentation that the screen on a portable x-ray kept freezing and locking up.

During an interview on 05/06/2025 at 1:26 p.m., Staff #19 revealed that a portable x-ray machine needed fixing and that he had put the order in on 03/19/2025. Staff #19 showed the surveyor the equipment and demonstrated how the cable was loose on the equipment.


Medical-Surgical unit

According to the facility's work order list revealed there was an order written 04/14/2025 that the medication room door was not locking on the Medical-Surgical unit.

During an observation on 05/06/2025 at 2:11 p.m. the medication room door was still not locking. There was one patient medication bin in the room which had medication stored in it.

Staff #2 confirmed the observations.



Review of a facility's policy named "Equipment Repair and Problem Identification Department /Chapter:EOC/Medical Equipment" approved 07/25/2023 revealed the following:

"A. When requesting repair or maintenance of patient care equipment, staff from the user department will complete a maintenance request and send it to the Engineering/Biomedical Department.

B. The Biomedical technician will respond as follows:
Priority 1- Immediate threat to safety-immediate response.
Priority 2- Will cause delay of patient care-immediate response.
Priority 3- Not impacting the ability to provide care-as soon as possible given other tasks of higher priority..."

Based on observation, interview and record review, the facility failed to ensure the environment and patient equipment was kept sanitary in 3 of 6 departments/ units that were observed (Intensive care unit (ICU), Emergency department (ED) and Telemetry). The facility failed to:

A. ensure mattresses were kept in a condition where they could be sanitized.

B. ensure patient equipment was kept sanitary and supplies were stored in a manner, to prevent cross contamination.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:

During observations on 05/05/2025 after 2:47 p.m. the following was found:

MICU (Medical intensive care unit) Room #5

The covering on a mattress on a patient bed was ripped and the cushion inside the mattress was exposed. There was no way the mattress could be properly sanitized.

Staff #'s 1 and 2 confirmed the observation.


ICU Equipment storage room and clean utility room

There were intravenous/feeding pumps stored in a room. The bases of the pumps were soiled with dried yellow and brown stains, had peeling paint, and rusted wheel castors. A raised toilet seat was stored in the room. Underneath the toilet seat there was an area that was rusted. There was no way the seat could be properly sanitized.

Staff #2 identified the equipment in the room as being clean and confirmed the observations.


ICU Equipment storage /Multipurpose room

There was a sign on the door that read" CLEAN EQUIPMENT & FULL/PARTIAL O2 TANKS Do NOT place dirty equipment in this room. Please clean & return equipment to designated location."

There was a bair hugger in the room and the cord and hose to unit were on the floor. They were not wrapped on the unit in a manner to prevent them from getting soiled.

There were clean toilet seats and used and unused tanks of oxygen stored in the room. Other supplies found in the room were bottles of antiseptic antimicrobial skin cleanser Hibiclens, sterile test tube trays, and sterile thoracentesis trays. Trays of assorted cables and wall mount suction regulators, vital sign equipment, transport wheelchairs and sequential compression pumps were also stored in the room.

There was no separation of sterile and non-sterile supplies/equipment.

Staff #'s 1 and 2 confirmed the observation.


During observations on 05/06/2025 after 11:06 a.m. the following was found:

ED bay #12

An infusion pump was in the room and ready for use. The base of the pole the infusion pump was attached to was rusted and had peeling paint. The wheels had hair wrapped around them.
A metal linen cart in the room had wheel casters that were rusted.
A cabinet door was opened and the floor of the cabinet was soiled with light brown particles. The inside of the cabinet door had a dark brown dried smeared substance on it.


ED clean utility room

Had infusion pumps, bair huggers, wall mount suction regulators, bags of patient dressing supplies, personal protective equipment, and patient toilet seat pails stored in the room. Toilet seats were stored in the room and the frames of the seats were rusted. There were also boxes of casting/splinting supplies, some were open and some were closed. The bottom drawer of the cart which contained more splinting and casting supplies was opened. The inside perimeter of the drawer had a buildup of spills, dust and a dead fly.

A battery charger was stored on a shelf and it had an open compartment which was soiled with brown dried spills and rust. The charger was stored on an open shelf and stored up against boxes of face shields, mask and disposable stethoscopes. Underneath the battery charger was a shelf containers of sanitizing wipes.
There was a locker in the room which contained bags of patient belongings that were brought into the ED.


ED bay #7

Had fluid warmers, infusion pumps, and linen carts in the room that were ready for use. The bases of the pumps and carts had peeling paint and wheel casters that were rusted. When the mattress was lifted on the bed in the room, the bedframe was observed to be soiled with a dried brown substance and hair. The mattress covering had small holes and the inside cushion could be seen. The mattress could not be sanitized with the holes in it.

Staff #2 confirmed the observations.


Review of a facility's policy named "Storage and Handling of Medical and Surgical Supplies Chapter:Infection Control Policy Number: 1C18 with a revision date of 08/15/2023 revealed the following:

" ...D. Storage of clean and sterile medical and surgical supplies
1.General Storage Guidelines
a. Supplies will be stored in a manner that prevents package compromise and provides protection against dust, moisture, insects, and temperature and humidity extremes. This applies to storage in Materials Management Storeroom, designated bulk storage areas and inpatient care areas ....




47892

On an observation tour of the Telemetry floor on 5/6/2025 after 11:30 PM with Staff #1 and Staff #10. The following was revealed:

Inpatient room 419

The protective covering on the inpatient bed mattress was torn on the underside where the mattress rests against the bed mechanics that raise and lower the head of the bed on the right and left side. There was also chipped paint exposing wood on the sofa bed.

Clean and Sterile Supply Room
Two eight-ounce bottles of betadine preparation solution were expired. The expiration date on both bottles was 04/2024.

Clean Equipment Room
The clean equipment room had multiple IV(intravenous medication) poles. All the IV pole bases had chipped paint and rust.

An interview was conducted on 5/06/2025 after 11:30 PM with Staff #1 and #10. Staff #1 and #10 were asked if they agreed with these findings. Staff #1 and #10 confirmed these findings.