HospitalInspections.org

Based on observation, interview and document review, the hospital failed to follow hospital policy by not keeping an appropriate record of preventive maintenance (PM) for 1 of 15 pieces of equipment.

Findings:

1. On 12-11-13 at 11:05 am, in the presence of Employees #A1 and #A2, it was observed in patient room 555 there was a patient bed with an asset tag of E05416. There was also a tag on the bed that indicated Test Date 1-13 and Due 1-14.

2. In interview on 12-11-13 at 11:05 am, Employee #A2 indicated the Test Date was when the PM was done and the Due was when the next PM would be done.

3. Review of Policy Number: 124, entitled Medical Equipment Management Plan, REVISION DATE: 01/01/13, indicated all preventive maintenance and repair work orders (regardless if equipment is maintained by Biomed, department or by vendor) will be entered into the TMS database and shall be used to manage each maintenance event.

4. In interview on 12-11-13 at 12:45 pm, Employee #A2 indicated the following:
There was no documentation of PM for the patient bed since 2009 in the TMS system. When the hospital conducted the PM, the data was loaded into a hand-hand device and a sticker, as described above, placed on the bed. The information in the hand-held device was then downloaded into the TMS database PM system. In 2009, the hospital had switched firms that were doing the bed PM. The information for that particular bed apparently had not been uploaded to the TMS system since 2009. Given this, the TMS system was supposed to indicate there was no record for this piece of equipment and the employee reading this data was supposed to follow through to correct the computer issue.

5. No further documentation was provided by exit.