HospitalInspections.org

Based on observation, interview and record review the facility failed to maintain a complete inventory of all facility equipment used in the care of patients and failed to provide ongoing preventative maintenance records according to manufacturer's guidelines for 7 of 17 sampled pieces of medical equipment. These 7 items used for patient care in different departments throughout the hospital and were being utilized for patient care at time of survey. This failed practice had the potential to affect all CAH patients. Facility census at time of survey was 8 patients. Fiscal year 2023 admissions to hospital were 553 and 1371 Emergency Room visits.

Findings include:

A. Observations During tours on 2/6/24 from 9:00am - 3:37pm revealed:

Emergency Department - Two mounted MindRay Vital Monitors (to record patient blood pressure, heart rate and respirations)
were without an inventory number. DON stated the MindRay devices are newer as had been replaced recently.

Nursing Station - AccuVue Vein Finder (to assist in obtaining vein access on patients) was without an inventory number.

Respiratory Therapy - VapoTherm High Flow Oxygen Machine - (for respiratory support) was without an inventory number.
- Trilogy EV300 (Portable ventilator for respiratory support) was without an inventory number.

Physical Therapy - Two Electrotherapy Machines ( to provide muscle stimulation to increase blood flow) were without an inventory number.

B. Interview with the Director of Nursing (DON) on 2/6 /24 at 11:13am revealed that the facility currently contracts with a vendor whose technician is to apply inventory numbers and completes the safety inspections and places on the log, however the equipment lacking vendor stickers verified that no safety inspections had been completed on the above listed equipment.

-Interview with Chief Executive Officer (CEO) on 2/7/24 at 9:15am revealed that the facility process includes Maintenance Staff to send an email of new equipment to the Vendor Technician (VT) and the VT is to place a sticker on the device and conduct safety inspections and place on facility log, however, the facility process currently has holes in it (as items are not being numbered and placed on the inventory as planned).

C. Record review of document "Equipment File List" provided by facility from the Contracted Vendor dated 2/2/2024, recorded inventoried numbers and description of equipment and last date of safety inspection and next test due date, revealed 149 inventoried items of patient medical care equipment. The 7 (seven) pieces of equipment listed above without vendor numbers were not part of the 149 inventoried items.