HospitalInspections.org

Based on tour of facility and interview with staff it was observed that in various department in the facility the routine annual safety/performance inspections due the end of month on August 2023 was not conducted in a timely manner. This requirment was not met.

Findings:

A. Tour of the facility's Laboratory on 09/06/2023 at 11:53 am revealed the following,
1. SPBS Clinical Equipment Services (a contracted inspection company) Annual Periodic Performance/Safety Inspections were
Due 8\2023 on the following equipment:
a) Abbot Chemistry analyzers
b) GEM 5000
c) Thermoscientific refrigerator/freezers
d) Ruby cell-dyne machines
e) Instrumentation Lab machine
f) Genvert A & B covid testing machine
g) Centerfuge by Lab Corp
h) Clintek Avaus Machine by siemens

All instrumentation did not have a current safety inspection as of date of survey.

2. In further tours of other departments such as Surgical area, Operating areas, Labor and Delivery and Radiology all department had equipment who safety inspections expired the end of Aug 2023. There were no evidence of current safety inspection of machine provided during this onsite survey.

B. Interview with Staff #2 at 11:39 am on September 06, 2023 in the laboratory department stated the maintenance department checks all equipment and will notify SPBS the equipment is due for annual inspections before the end date on the sticker on instrumentation.

C. Interview with Staff #5 in laboratory at 11:53 am and on September 07, 2023 during physical environment rounds stated SPBS, the contracted performance/safety inspection company have been in the facility recently conducting safety checks. It was explained that there were only 1 or 2 people from this company who have been present in the hospital over the last two weeks conducting Performance/Safety inspections for the whole facility. They often get called away for emergencies, they leave and then come back. This maybe one of the reason it taking awhile to inspect and place safety inspection stickers on all the facility's equipment in the facility.

D. Reviewed the current contract agreement between the Performance/Safety Inspection company SPBS Clinical Equipment Services and Medina Regional hospital it is evident that a new contract agreement was made between the company and the hospital. This new agreement start date was August 21, 2023. This contract was signed by the Hospital's Chief Executive Officer on August 21, 2023 and signed by SPBS President and CEO on August 24, 2023.