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Based on observation, interview, and record review, the facility failed to ensure that the contractor (Medi-Tek, Inc.) provides and furnishes services agreed upon to maintain the radiological machines to ensure its effectiveness and safety.

Findings:

On 12/6/11 at 11:05 a.m., an interview with the Medical Director was conducted. The Medical Director stated that he initiates the contracts. He also stated that he has responsibilities in reviewing and making sure the contracts are signed.

On 12/7/11 at 10:46 a.m., an interview with the Staff Services Analyst responsible for maintaining the contracts was conducted. The Staff Services Analyst confirmed that Medi-Tek, Inc. was the company contracted to provide the maintenance for the radiological machines. She also confirmed that the last preventive maintenance service conducted was on 6/2011. She further stated that the contracted service provider stopped providing services to the facility since 6/2011, due to the reason that the contractor felt that they are not being compensated appropriately for the services they provided.

On the same day at 10:50 a.m., a review of the contractor's (Medi-Tek, Inc.) contract was conducted. The review indicated that the contract was signed on 6/21/10, which outlined the scope of work, payment provision, and general terms and condition of the contract. The review further indicated that the term of the agreement is for July 1, 2010 through July 30, 2012.

On the same day at 11:15 a.m., an interview with the Supervising Registered Nurse (SRN) of the facility was conducted. The SRN stated that she's in-charge of the radiology department. She also stated that there are currently no contracts to provide the preventive maintenance services for the radiological machines. She further stated that radiological services were provided by a contracted mobile radiological company and the radiological machines in the Radiology Department of the facility were not currently in used.

On the same day at 11:21 a.m., an observation was conducted in the Radiological department. The observation indicated that an x-ray unit (Picker Gx550) in Room 82 and an x-ray unit (EDEC Technology) in Room 87 that controls the x-ray machines in their respective rooms were both inspected on 5/9/11. Both machines also indicated a preventive maintenance due date of 8/2011.

On 12/8/11 at 9:50 a.m., another interview with the Medical Director was conducted. The Medical Director stated that he did not know when the preventive maintenance on the radiological machines was conducted.

On the same day at 11:30 a.m., a review of the service contractor's (Medi-Tek, Inc.) preventive maintenance report was conducted. The report indicated that the preventive maintenance was conducted on 6/9/11 and 6/21/11. No other preventive maintenance records found for the service contractor after 6/2011.

Based on observation, document review, and staff interview, the facility failed to ensure patients received care in a safe setting when policy and procedure are not implemented.

Findings:

1. On 12/5/11 at 11 a.m., during the initial tour of the facility, the following was observed:

a. Medication room of Unit 55, the quality control log book of the glucometer
machine did not indicate the acceptable ranges for high and low reading.

The missing acceptable ranges for high and low reading were not documented on the log sheet from August 2011 to the present.

The administrative staff had stated that the acceptable ranges are indicated on the glucose
strip box. However, the boxes had been discarded. There were no means to identify if
readings were within the acceptable ranges, and provide accurate blood sugar levels for the
patients.

On 12/6/11 at 10 a.m., review of the facility policy on "BLOOD GLUCOSE MONITORING BY THE: BAYER ASCENCIA CONTOUR SYSTEM" dated 7/21/11 indicated, "V. QUALITY CONTROL C.2 The control result must be within the ranges stated on the bottom of the Glucose Strips Carbon Box."

Based on observation, interview, and record review, the facility failed to ensure that expired media products used for microbiological cultures were discarded after their expiration dates.

Findings:

On 12/5/11 at 12:41 p.m. while conducting an observation in the laboratory's Microbiology Room, the following products were observed in the hooded incubator and noted to be expired:

1. 12 vials/tube of BHI Broth (liquid media) for cultures with an expiration date of 11/5/11.
2. 13 Thioglycollate without indicator (liquid media) for cultures with an expiration date of 11/7/11.
3. Eight chocolate agar plates (media) for cultures with an expiration date of 10/24/11.

On the same date and time, an interview with the Senior Clinical Laboratory Technician was conducted. The Senior Clinical Laboratory Technician stated that they don't use expired products. She also stated, "Those vials/tubes should have been discarded, even though they're sterile media. No Policy and Procedure (P&P) stating that you can use expired media. All of them will be tossed and will be replaced with new ones."

On 12/8/11 at112:45 a.m., a review of the facility's Quality Assessment Policy and Procedure (P&P) was conducted. The review indicated, "6. Reagents...b. Check expiration date on all reagents before using and discard the expired reagent according to MSDS (Material Safety Data System) and laboratory standard precautions and safety rules."

Based on observation, document review, and staff interview, the facility failed to ensure that facilities, supplies, and equipment are be maintained to ensure an acceptable level of safety and quality.

Findings:

1. On 12/5/11 at 11 a.m., during initial tour of the facility, the following were observed:

a. In the medication room of Unit 55, the quality control log book of the glucometer machine did not indicate the acceptable ranges for high and low reading. The missing acceptable ranges for high and low reading were not documented on the log sheet from August 2011 to the present.

The administrative staff had stated that the acceptable ranges are indicated on the glucose strip box. However, the boxes had been discarded.

b. The medication refrigerator temperature log book on Unit 55 indicated that on 7/1 through 7/5/11, the refrigerator temperature registered at 68 degrees Fahrenheit (F) and 70 degrees (F) consecutively. There was no documentation to indicate that a corrective action was done when the reading indicated greater than 46 degrees (F). [Appropriate refrigerator temperature is between 36 (F) - 46 degrees (F)].

c. The defibrillator in the Sedation Clinic had a next due date for preventive maintenance of 11/2011. As of 12/5/11, there was no documentation to indicate that a preventive maintenance was done.

2. Ten silicone coated Foley catheters size 28 with an expired date of 10/2011
were observed in the drawer of Central Supply Department.

3. The following were observed in Occupational Treatment room:

a. One Lexa lift with a preventive maintenance with a due date of 11/2011.
b. The foot operated handwashing sink will not turn off when the pedal was activated.

The administrative staff manually turned the knob, under the sink, to turn off the hot water.

4. The following were observed in Respiratory Therapy storage room:

a. 11 of 13 air compressors were labeled "Out of Order".
b. 4 of 7 oxygen concentrators were also labeled "Out of Order".



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The respiratory staff stated that Plant Operations had been notified about the needed equipment repairs.

5. On 12/6/11 at 11:05 a.m., an interview with the Medical Director was conducted. The Medical Director stated that he initiates the contracts. He also stated that he has responsibilities in reviewing and making sure the contracts are signed.

On 12/7/11 at 10:46 a.m., an interview with the Staff Services Analyst responsible for maintaining the contracts was conducted. The Staff Services Analyst confirmed that Medi-Tek, Inc. was the company contracted to provide the maintenance for the radiological machines. She also confirmed that the last preventive maintenance service conducted was on 6/2011. She further stated that the contracted service provider stopped providing services to the facility since 6/2011, due to the reason that the contractor felt that they are not being compensated appropriately for the services they provided.

On the same day at 10:50 a.m., a review of the contractor's (Medi-Tek, Inc.) contract was conducted. The review indicated that the contract was signed on 6/21/10, which outlined the scope of work, payment provision, and general terms and condition of the contract. The review further indicated that the term of the agreement is for July 1, 2010 through July 30, 2012.

On the same day at 11:15 a.m., an interview with the Supervising Registered Nurse (SRN) of the facility was conducted. The SRN stated that she's in-charge of the radiology department. She also stated that there are currently no contracts to provide the preventive maintenance services for the radiological machines. She further stated that radiological services were provided by a contracted mobile radiological company and the radiological machines in the Radiology Department of the facility were not currently in used.

On the same day at 11:21 a.m., an observation was conducted in the Radiological department. The observation indicated that an x-ray unit (Picker Gx550) in Room 82 and an x-ray unit (EDEC Technology) in Room 87 that controls the x-ray machines in their respective rooms were both inspected on 5/9/11. Both machines also indicated a preventive maintenance due date of 8/2011.

On 12/8/11 at 9:50 a.m., another interview with the Medical Director was conducted. The Medical Director stated that he did not know when the preventive maintenance on the radiological machines was conducted.

On the same day at 11:30 a.m., a review of the service contractor's (Medi-Tek, Inc.) preventive maintenance report was conducted. The report indicated that the preventive maintenance was conducted on 6/9/11 and 6/21/11. No other preventive maintenance records found for the service contractor after 6/2011.