The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|SUMMIT HEALTHCARE REGIONAL MEDICAL CENTER||2200 EAST SHOW LOW LAKE ROAD SHOW LOW, AZ 85901||June 27, 2014|
|VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE||Tag No: A0724|
|Based on manufacturer's recommendations, hospital policy/procedure, patient's acquisition records and staff interviews, it was determined the facility failed to ensure the Alice sleep study equipment was calibrated prior to each patient's polysomnography.
Respironics manufacturer's recommendations "Setup and User's Guide" requires: "...verify that the Alice 5 equipment is operating properly before starting an acquisition...Check Bio-Calibration...connect...and check the connections...ask the patient to lie on...back with arms along the body, eyes closed...Test the sensors by asking the patient to follow the instructions in Table...below...."
Hospital policy titled "Calibration of Sleep Study Equipment Guidelines requires: "...patient related equipment that requires calibration is calibrated prior to and after each study and pre and post calibrations are stored...."
Review of twenty-one (21) patient acquisitions (Patient's #'s 1 and 16 through 35) revealed the following patients did not receive the required calibration checks prior to their sleep studies (Patient #'s 1, 16, 17, 18, 19, 20, 21 and 22).
The Sleep Technician/Polysomnographer and the Interim Cardiopulmonary Director confirmed during an interview conducted on 06/26/14, that the Patient Acquisitions did not contain the required documentation of the calibration checks.
The Director of Quality Management confirmed during the same interview that the facility did not follow their calibration policy for the Alice sleep study equipment.