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HIGHLAND-CLARKSBURG HOSPITAL, INC

3 HOSPITAL PLAZA

CLARKSBURG, WV 26301

FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE

Tag No.: A0724

Based on observation, record review and staff interviews the facility failed to ensure that equipment was maintained to ensure an acceptable level of safety and quality. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was seventy-one (71).

Findings included:

1. Observation on 06/29/20 at approximately 11:42 a.m. revealed incomplete inspection logs for the staff refrigerators on the 2 West Unit.

2. Observation on 06/29/20 at approximately 11:44 a.m. revealed incomplete inspection logs for the patient refrigerators on the 5 North Unit.

3. Observation on 06/29/20 at approximately 11:51 a.m. revealed incomplete inspection logs for the patient refrigerators on the 5 South Unit.

4. Observation on 06/29/20 at approximately 11:58 a.m. revealed incomplete inspection logs for the staff refrigerators on the 4 South Unit.

5. Observation on 06/29/20 at approximately 12:03 p.m. revealed incomplete inspection logs for the staff refrigerators on the 3 South Unit.

6. Observation on 06/29/20 at approximately 12:09 p.m. revealed the quarterly cleaning/disinfection log for the main kitchen ice machine had not been completed for the 2nd Quarter of 2019.

7. Staff interview on 06/29/20 at approximately 12:12 p.m. with the Dietary Manager revealed no documented procedures for cleaning/disinfection of the ice machine completed monthly by the dietary staff in the main kitchen.

8. Record review on 06/30/20 at approximately 9:16 a.m. revealed no documented procedures referring to manufacturer's recommendations for cleaning/disinfecting the main kitchen ice machine.

9. Record review on 06/30/20 at approximately 1:05 p.m. revealed no documented maintenance procedures referring to manufacturer's recommendations for the facility cooling system chillers.

10. Interview on 06/30/20 at approximately 1:08 p.m. with the Maintenance Director verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 06/30/20 at approximately 1:50 p.m.










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