HospitalInspections.org

0914 - preventive maintenance

Licensure Reference Number
9-006.14B


Based on observation, interview and record review, the facility failed to maintain a complete inventory of all facility equipment used in the care of patients and failed to provide ongoing preventative maintenance in accordance with manufacturer specifications for 1 of 11 sampled pieces of medical equipment.

Findings include:

Interview with Maintenance Director and Materials Management Manager on 4/21/21 at 1:45pm revealed no inventory list was maintained by facility staff, as the facility contracted with a vendor who was responsible for logging all equipment and any information needed would be provided by "name of service technician", who comes onsite weekly to log new equipment and provide preventive maintenance.


Tour of pulmonary care suite on 4/19/2021 at 2:38pm revealed a machine for testing blood gases with an equipment log sticker 2768 was used by Respiratory Therapy to analyze blood gas (ABG) samples of patients. Surveyor requested preventive maintenance information for 11 devices used in the facility. Asset Snapshots with safety inspection/ schedule needs, were provided by the contracted vendor for 10 of the 11 equipment devices. No Preventative Maintenance Log or Asset Snapshot was available for review for medical equipment # 2768 - the arterial blood gas (ABG) monitoring system.

An Operators Guide information sheet for the GEM Premier 400 analyzer (ABG machine) provided by the Respiratory Therapy Manager on 4/22/21 at 10:50am revealed that no maintenance is required for the first 5 years of service, (due to internal diagnostic programs that continually check unit's performance and indicates any non-performance to the operator.) A preventive maintenance during the 6th (sixth) year of operation is recommenced. The facility had completed the sixth year of use for this ABG machine without any preventive maintenance performed. The ABG machine records show purchase by facility in March 2015 and Respiratory Therapy Manager stated we are planning to purchase a new machine.

Review of facility contract with Biomedical Equipment Services Vendor revealed contract signed October 2015. The Agreement included terms for Contractor to "be responsible for Inventory of equipment... and ... maintain a history of each piece of equipment".
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Review of facility policy for "Clinical Engineering Equipment Inspection and Preventive Maintenance Program" 800.145 was last updated in May 2016. The policy included procedure for equipment inventory of "an inventory of all equipment used in the care of patients will be maintained by the Clinical Engineering vendor and the Facilities Department of MCH&HS. (Memorial Community Hospital & Health Systems).

Based on record review, staff interview and review of policies and procedures, the facility failed to ensure that staff did a complete assessment of the patient prior to discharge for 4 of 5 Emergency Room (ER) Patients (Patients 22, 23, 24 and 25). The failure to do a complete assessment prior to discharge has the potential to effect all ER patients.

Findings are:

A. A review of the Policy titled "Emergency Department-Patient Triage and Assessment" effective date of July 2018 identified under Procedures:
A. Initial Triage
B. Nursing Assessment:
-A complete, accurate and ongoing nursing assessment is an important part of the care and treatment of every emergency patient.
-All patients over the age of 5 will have complete set of vitals (temperature, blood pressure, pulse, and respiratory rate) obtain as soon as possible; these values will be documented on the medical record.
-Assessment of pediatric patient will include: actual wt of infants & children 10 years or younger; immunization status; appropriateness of age and development.
-All patients will have appropriate complete nursing assessment and any additional documentation using the ED Narrator in EPIC (the electronic medical record used in the hospital)
C. Document the patient's pain response on a 0/10 scale upon admission, discharge, and any intervention.
D. Vital signs will be obtained within 30 minutes of all discharged patients and 15 minutes of transferring patients.

B. A review of Patient 22's medical record identified that the patient came to the ER on 4/1/21 at 10:44 PM. The patient was treated for Hyperventilation Syndrome (An episode when a pattern of breathing where you breath more quickly and deeply than normal sometimes related to fear or anxiety.)

Patient 22's vital signs (VS) were:
-10:44 PM on admission to the ER- 150/89 blood pressure (Normal range 90/60-120/80); 96 pulse (Normal range 60-100 beats per minute); 36 respirations (Normal range 12-18 breaths per minute) and 100% pulse oxygenation.
-10:51 PM- 126/82 blood pressure; 96 pulse; 36 respirations; 99% oximetry.
-11:00 PM- 130/87 blood pressures; no documented pulse or respirations; 98% oximetry.
-11:06 PM- no blood pressure, pulse or respirations documented; 99 % oximetry.
-11:09 PM- Pt 22 was discharged from ER.

The medical record for Pt 22 lacked a reassessment of breathing and documentation of respirations.
An interview with the Nurse Manager (Registered Nurse-RN B) on 4/21/21 at 10:35 AM verified the chart lacked a set of VS and a reassessment just prior to discharge from the ER.

C. A review of Patient 23's medical record identified that the patient came to the ER on 6/17/18 at 10:00 PM. The patient was treated for a partial left Achilles tendon rupture (The large tendon that runs down the back of the lower leg which connects muscles in the back of your calf to your heel bone. A full or partial tear can happen when the tendon is stretched beyond its capacity.) following a fall at home.

Patient 23's vital signs (VS) were:
6/17/18
-10:08 PM on admission to the ER- 143/81 blood pressure (Normal range 90/60-120/80); 93 pulse (Normal range 60-100 beats per minute); 24 respirations (Normal range 12-18 breaths per minute) and 98% pulse oxygenation. Complains of "significant discomfort at the left Achilles."
-10:46 PM- Pt 23 received Toradol (a nonsteroidal anti inflammatory medication given for moderate to severe pain) 30 mg(milligram) IM (Intramuscular-in the muscle) for pain
-11:26 PM- Pt 23 received Morphine (a narcotic medication given severe pain) 4 mg IM for pain and Benadryl (a anti itch medication) 25 mg IM for skin itching.
6/18/18
-12:13 AM- on discharge from the ER, VS 136/69 blood pressure; 64 pulse; 18 respirations and 95% oximetry. The patient was dismissed with a prescription for oral pain pills.

The medical record for Pt 23 lacked an ongoing reassessment of the patient's pain, the tracking of the pain per the pain scale while in the ER including after the administration of medications for pain and a complete set of VS upon discharge.
An interview with the Nurse Manager (Registered Nurse-RN B) on 4/21/21 at 10:35 AM verified the chart lacked a set of VS and a reassessment just prior to discharge from the ER.

D. A review of Patient 24's medical record identified that the patient came to the ER on 2/18/21 at 9:24 PM. The patient was treated for Post Concussion Syndrome (when concussion symptoms [headache, dizzy, problems with memory & concentration] last beyond the expected recovery period.) and right foot pain following a motor vehicle accident 5 days ago.
Patient 22's vital signs (VS) were:
-9:24 PM on admission to the ER- 143/111 blood pressure (Normal range 90/60-120/80); 97 pulse (Normal range 60-100 beats per minute); 20 respirations (Normal range 12-18 breaths per minute) and rates pain at a 6 aching.
-9:45 PM- 140/96 blood pressure; 94 pulse; 100% oximetry.
-10:00 PM- 136/91 blood pressures; no documented pulse or respirations; 100% oximetry.
-10:05 PM- rated pain at 6
-10:15 PM- 133/89 blood pressure; no documented pulse, respirations or pain rating; 100% oximetry.
-10:30 PM- 124/86 blood pressure; no documented pulse, respirations or pain rating; 100% oximetry.
-10:45 PM- 130/77 blood pressure; no documented pulse, respirations, oximetry or pain rating
-11:11 PM- on discharge from the ER, there was no documented blood pressure, pulse, respirations, oximetry; rated pain at a 2

The medical record for Pt 24 lacked an ongoing reassessment of the patient's pain and vital signs while in the ER.
An interview with the Nurse Manager (Registered Nurse-RN B) on 4/21/21 at 10:35 AM verified the chart lacked a set of VS and a reassessment just prior to discharge from the ER.

E. A review of Patient 25's medical record identified that the patient came to the ER on 3/13/21 at 8:34 PM. The patient was treated for vaginal bleeding and a miscarriage.

Patient 25's vital signs (VS) were:
-8:42 PM on admission to the ER- no blood pressure documented; 95 pulse (Normal range 60-100 beats per minute); 18 respirations (Normal range 12-18 breaths per minute); 96% pulse oxygenation and 98.1 temperature; reports no pain.
-10:58 PM- on discharge from the ER, there was no documentation of blood pressure throughout the whole stay, no repeat pulse, respirations, pulse oximetry, temperature or pain assessment.

The medical record for Pt 25 lacked an ongoing reassessment of the patient's pain and vital signs while in the ER.
An interview with the Nurse Manager (Registered Nurse-RN B) on 4/21/21 at 10:35 AM verified the chart lacked a set of VS and a reassessment just prior to discharge from the ER.

Based on direct observation, staff interviews and policy and procedure review, the CAH (Critical Access Hospital) failed to ensure that the blood glucose monitoring device (Accu-Check Inform II System-a portable device that is taken to the bedside to sample a drop of the patients' blood to determine the level of sugar in the blood) was disinfected according to the facility policy to prevent cross contamination of germs/bacteria in 1 of 2 observations. The failure to correctly disinfect the Accu Check device had the potential to cause cross contamination (the inadvertent transfer of bacteria/germs from on surface/person to another). This failed practice had the potential to affect all patients having blood glucose monitoring.

Findings are:

A. A review of patient 5's medication administration record revealed that the patient is an insulin dependent diabetic that receives routine insulin every night at bedtime, and before meals as needed per a sliding scale (an amount of insulin determined by the blood sugar level).
An observation of RN A on 4/21/21 at 12:05 PM revealed, RN A completed hand hygiene, applied gloves and gathered the Accu-Check device and supplies and went to Patient 5's bedside. RN A placed the Accu-Check device directly on the bedside table (considered a dirty surface-a surface that could have germs/bacteria present) while performing the procedure of collecting the drop of blood. RN A then took the Accu-Check device and placed it on the counter near the sink. RN-A washed hands and donned gloves and carried the Accu-Check device to the nurses station. RN-A then obtained a Sani-Cloth germicidal disposable wipe (gray top tub) and wiped the device for 30 seconds then placed the device on the clean work space, where the device is stored. The device was dry within a few seconds of placing it in storage.

An interview with RN A following this process on 4/21/21 revealed when RN A was asked what the contact time needed to be to disinfect the Accu-check device wiped with this Sani Wipe cloth, RN A replied, "I am not sure". When asked if RN-A would read the directions on the Sani Wipe tub, RN A replied, "It is 3 (three) minutes" (indicating the device needs to be wiped off and have contact with the disinfecting cloth for a total of 3 minutes to disinfect the device).

A review of the facility policy titled "Accu-Check Inform II Blood Glucose System" last updated July 2019, revealed that the device should be cleaned with a hospital approved disinfectant (Sani Cloth Disposable wipes).

A review of the hospital approved disinfectant Sani-cloth germicidal disposable wipe (gray top tub) directions revealed a 3 minute wet contact time must be used to disinfect items.

An interview with Nurse Manager (RN-B) on 4/21/2021 at 12:40 PM revealed that nursing staff should have knowledge of the contact time required for any disinfectants used.

Based on staff interview and policy review, the facility lacked a swing bed policy that covered transferring or discharging a patient, a notice before transfer, timing of the notice, contents of the notice, orientation for transfer or discharge and notice in advance of facility closure. This failed practice had the potential to affect all swing bed patients.

Findings include:

A. Review of the "Discharge Planning and Summary (Recapitulation of Stay)", last reviewed 3/2/2020 by facility; revealed the policy was missing the information related to: transferring or discharging a patient, a notice before transfer, timing of the notice, contents of the notice, orientation for transfer or discharge and notice in advance of facility closure.

B. Interview with Chief Executive Officer (CEO) on 4/22/2021 at 1340 confirmed that the facility lacked a policy related to: transferring or discharging a patient, a notice before transfer, timing of the notice, contents of the notice, orientation for transfer or discharge and notice in advance of facility closure.