HospitalInspections.org

Based on observation and interview, it was determined the medical gas alarms located in the operating suite and at the nurse station were not functioning. The failed practice had the potential to affect all patients served by medical gases in the facility because staff was not immediately notified in the event of a malfunction of the medical gas system. The facility had no surgical patients and a census of 14 patients on 07/09/12. The findings follow:

A. On a tour of the Operating Suite on 07/09/12 at 1330 with the Maintenance Director, the medical gas alarm panel serving the area not illuminated or functioning.
B. On a tour of the facility on 07/09/12 at 1345 with the Maintenance Director, the medical gas alarm panel located at the nurse station serving the patient wing was not illuminated or functioning.
C. In an interview on 07/09/12 at 1545, the Maintenance Director verified the medical gas alarms were not functioning and had not been in operation for three to four years.

Based on Generator Log review and interview it was determined the facility failed to test the generator for at least 30 minutes for 4 of 18 months and inspect the generator for 30 of 72 weeks from January 2011 to June 2012. The failed practice had the potential to affect all patients because the reliability of the generator to provide emergency power was not tested and the ability to provide emergency power was not assured. The findings follow:

A. Review of the Generator Log on 07/10/12 at 0830 revealed the generator was exercised for a full 30 minutes on November 2011, March 2012, May 2012, and June 2012.
B. Review of the Generator Log on 07/10/12 at 0830 revealed weekly inspections of the generator were not documented as follows:
1) In January 2011, February 2011, March 2011, April 2011, May 2011, March 2012 and June 2012 weekly generator inspections were not documented for three of four weeks.
2) In June 2011, July 2011, September 2011, November 2011, December 2011, January 2012 and May 2012 weekly generator inspections were not documented for one of four weeks.
3) In April 2012, weekly generator inspections were not documented for two of four weeks.
C. In an interview on 07/10/12 at 1030, the Maintenance Director verified there was no further documentation available for review.