HospitalInspections.org

Based on a review of facility documents, tour of sample nursing units and staff interviews (EMP), it was determined that the facilty failed to maintain equipment to minimize health hazards to patients and employees.

Findings include:

"DLP Conemaugh Health System DLP Memorial Medical Center Facility Operations Policy Manual Title: Ice Machines Statement of policy: It is the responsibility of Facility Operations to establish guidelines to prevent infection transmission from contaminated ice and ice machines. Responsibility: The refrigeration section of the department of heating, ventilation and air conditioning will be responsible for routine cleaning and preventative maintenance of ice machines in patient care areas per manufacturer's recommendations. ... Original Policy Dated: 6/2015 Next Review Date: 6/2017."

1) Manufacturer's recommendations for cleaning ice machines, Dated August 1993. "NDE550 Cleaning and Sanitizing ... In order to receive the best return for that investment, it Must receive periodic maintenance. It is the USER'S RESPONSIBILITY to see that the unit is properly maintained. It is always preferable, and less costly in the long run, to avoid possible down time by keeping it clean; adjusting it as needed; and by replacing worn parts before they can cause failure. The following is a list of recommended maintenance that will help keep the machine running with a minimum of problems. Maintenance and Cleaning should be scheduled at a minimum of twice per year. Sanitizing of the ice storage bin should be scheduled for a minimum of 4 times a year. ... ."

2) A review of an "Asset" list, document revealed 62 assets (ice machines) were on the list, with preventative maintenance descriptions and their location. The asses list provided the date preventive maintenance was completed and the next date preventative maintenance was due. The dates preventive maintenance was completed on ice machines ranged from March 13, 2017 to November 30, 2017. It was also noted that 41 ice machines were to be completed semi-annually and 21 ice machines were to be completed quarterly, according to the asset list. A review of dates the ice machines were last serviced revealed that 41 ice machines had preventative maintenance completed in August and September 2018. It was revealed that prior to the August and September preventative maintenance, all 62 ice machines failed to have preventative maintenance quarterly and 42 ice machines were not cleaned for greater than one (1) year.

An interview was conducted with EMP7, Manager Facilities Operations, on September 26, 2018, at approximately 12:15 PM "late in 2017, we switched the computerized preventative maintenance (pm) program tracking system. We had TMS and we went with Sight FM preventative maintenance system ... We had lost the history for our preventative maintenance ... we discovered that we only had 4 ice machines on the asset list. We did not perform preventative maintenance on the ice machines."

3) A tour of the staff pantry areas in the Emergency Department (ED) (two areas), 7 Rose, 6 Ashman (ICU) and 6 Rose (CCU) was conducted on September 26, 2018, at approximately 10:00 AM with EMP4 and EMP19 to ascertain the cleanliness of the ice machines. Upon inspection of the ice machines on 7 Rose and 6 Rose, there was noted to be a scant to small amount of black substance that was easily removed with a paper towel from the top of the interior, non-removable ice spout on the left side of each unit respectively.

EMP4 and EMP19 confirmed the findings.

4) EMP8 had taken a picture of the bug on personal cell phone and photo was viewed by the surveyor. The bug was clear to white in color, appeared flat, oval in shape with many legs on either side.

Interview with EMP8 was conducted on September 26, 2018, at approximately 10:25 AM and revealed, "... On August 8th, an employee came to me and showed me the bug. It was described as though the water drop was going up into the ice machine. We put it in a cup and called EMP4 and environmental. Ehrlich came in to ID'd. ... Environmental said that the ice machine was moldy inside and we were not to use it ... "

Interview with EMP4 was conducted on September 26, 2018, at approximately 10:15 AM and revealed, "7 Rose called me and said they captured a bug. We kept it so Ehrlich could see, we inspected the ice machine and there was mold inside, facilities removed it. ... ."