HospitalInspections.org

Based on observation and staff interview, it was determined the hospital failed to ensure the condition of the physical environment is maintained in a manner that assures the safety and well-being of the patients it serves.

Findings include:

1. A review of the Maintenance Work Order book revealed the air handler filters for the Behavioral Health Unit were last changed on 5/14/15.

2. During a brief interview with the Engineering Manager on 4/19/16 at approximately 8:30 a.m. he stated the scheduled preventive maintenance for air handler filter changes are expected to occur quarterly (every three (3) months). He agreed that the filters were not changed as required on 11/4/15 and 2/4/16.

3. During a facility tour on 4/19/16 between 9:00 a.m. and 11:30 a.m. an inspection of the air handler supplying the Behavioral Health Unit revealed the filters for the air handler were last changed on 8/4/15. Documentation of this filter change was not recorded in the Maintenance Work Order book.

4. The above findings were discussed during the tour with the facility Administrator and the Engineering Manger and they agreed with the findings. Both stated this issue would be corrected to ensure compliance with the federal regulations.