HospitalInspections.org

Based on a review of facility documents and staff interviews (EMP), it was determined that UPMC Altoona failed to maintain a safe setting by failing to follow their adopted policy to report an operational problem to the appropriate personnel.

Findings include:

UPMC Policy and Procedure Manual, Policy: HS-FM0209. Index Title: Facilities and Safety. Subject: Safety Management Program. Date: April 1, 2016. "... III. Resposibility/Authority ... F. Staff/Supervisors 3. Eliminate and/or report to the appropriate persons any unsafe conditions physical hazards or operational problems ... IV. Providing Activities to Reduce Risk of Injuries. A. Maintaining Grounds and Equipment Efforts to ensure the safe use of grounds and equipment by patients, visitors and staff shall include items noted as part of the Hazard Surveillance program, reported by staff or noted in Incident Reports. These items are reported to the appropriate department (for grounds and non-patient care equipment) for response ... ."

1. Altoona Regional Health System, Engineering Service Calls, Work Order WO# 407860 T - 1420 too hot ... Date Orig: 8/9/2016. Time Orig: 14:37:00 ... EMP12 ... Comments: "Looked at blue prints and checked all reheat's on T 14 all were turned off and then I looked at room 1420, what I found was the fit box was open 43 percent and the air flow was at its max, the return was sucking as much air out that was coming in, this is a pressure room but what needs to be done is OTH1 needed to come and open up the box more. I took a pressure reading and we are -0.0305 for that room. The neg pressure sheet has that room at -0.0010 we need fit to look at this room ASAP."

2. An interview was conducted with EMP12 on September 09, 2016, at approximately 9:20 AM. "... The patient was in a negative pressure room (1420). There was as much air coming into the room as going out. The temperature would remain constant. We have a contract with OTH1to maintain the computer part of the air exchange system ... The cold air was coming in and getting sucked out as fast as it was coming in. The room was staying warm. I noted that in my work order. OTH1 needed to open up the box (damper), the air flow needed to be increased ... ."

3. An interview was conducted with EMP14, on September 9, 2016 at 2:30 PM. "We have been having problems on Tower 14 with the air flows. We have a contract with OTH1 to look at the air flow. Room 1420 is a negative pressure room. We monitor the pressure. We should have contacted OTH1. they should have been called. The negative pressure effects the temperature, I cannot tell you if OTH1 got a call ... EMP15 would refer any thing that needs follow-up to EMP 16 or myself. This is actually my responsibility. In this case I should have called or e- mailed OTH1, they manage the computer system for the dampers. I do not recall receiving or reviewing this work order, they get put into the computer. We do not have a policy defining when we contact an outside vendor. We do have a contract with OTH1."