HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to ensure the physical environment was maintained as evidenced by:

1. The hospital failed to ensure the storage of portable oxygen tanks was secure. Specifically, some tanks were strapped with cohesive wrap bandage instead of being secured with mounted oxygen tank holder brackets, which were broken.

2. The hospital did not have responsible leadership for identifying the elevators that were not functioning properly for patients, staff, and visitors.

3. The hospital did not develop or implement policies and procedures for safeguarding patients, employees, and visitors from improperly functioning elevators.

4. The hospital did not have contracted services for troubleshooting urgent calls for their elevators.

5. The hospital failed to ensure the cleaning of the elevators and did not clearly specify the responsibilities for elevator cleaning.

These failures had the potential for substandard patient care.

Findings:

1. Review of the hospital's P&P titled Safety Medical Gas Cylinders dated 6/15/23, showed all tanks must be secured at all times. Acceptable safety systems include floor tank holders, tank racks, portable carts, or holders attached to wheelchairs or gurneys.

On 7/17/25 at 1117 hours, an interview and concurrent observation were conducted with the Cardiac Pulmonary Services Manager and the CNO, in the Respiratory Department. The ventilators in the Respiratory Department were observed. Four ventilator carts (Ventilator 2, 4, 6, and 10) had oxygen cylinders strapped with cohesive wrap bandage. The Cardiac Pulmonary Services Manager stated the mounted secured strips to hold the oxygen cylinders were broken and that the oxygen cylinders should have been secured with mounted oxygen tank holder brackets.

On 7/17/25 at 1335 hours, an interview was conducted with the Cardiac Pulmonary Services Manager. The Cardiac Pulmonary Services Manager stated the oxygen tank holder brackets had been broken since July last year, and the problem had not been reported yet, and he was in the process of finding new replacements. The Cardiac Pulmonary Services Manager stated there were five out of 19 ventilators with broken oxygen tank holder brackets.


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2. On 7/17/25 at 1047 hours, during a tour of the Telemetry unit, an interview and concurrent observation were conducted with RN 2. RN 2 stated she was aware of an incident on a weekday where the elevator alarm sounded loudly for 30 minutes, with a staff member trapped inside for the same duration. RN 2 stated the incident was not reported to the facility's incident system.

On 7/17/25 at 1517 hours, an interview with the PI Director was conducted. The PI Director stated if the elevators were not functioning properly, it was considered unsafe and should have been reported to the hospital. The PI Director stated it was every employee responsibility to report incidents when they occurred.

On 7/17/25 at 1536 hours, an interview was conducted with RT 8. RT 8 stated on 7/12/25, RT 8, RN 3, and Patient 2 were trapped in an unidentified elevator for approximately one hour, on the 2nd floor, as the door would not open. RT 8 stated he reported the incident to the House Supervisor expecting the House Supervisor to file a report in the incident system. RT 8 stated if someone on the 1st floor needed the elevator, they would either have to run up the stairs to the 3rd floor to make it come down or call someone on the 3rd floor to push the button. The elevator frequently stopped on the 2nd floor.

On 7/17/25 at 1601 hours, an interview with the House Supervisor was conducted. The House Supervisor stated she did not file an incident report about the elevator event on 7/12/25, because the patient was safe. The House Supervisor stated there was another episode where a family member, a patient, and a staff member were trapped in an elevator.

On 7/18/25 at 1026 hours, an interview was conducted with RN 3. RN 3 confirmed the elevator incident on 7/12/25. RN 3 stated Patient 2 and RT 8 were in the elevator when it stopped for more than 20 minutes and released with assistance from engineers. RN 3 stated the House Supervisor was involved and it was House Supervisor's responsibility to report the incident.

On 7/18/25 at 1109 hours, a review of Patient 2's medical record was conducted with the CNO. The medical records showed Patient 2 left the ED on 7/12/25 at 1247 hours and arrived at the med/surg unit at 1338 hours, indicating a 35-minute duration to travel from the 1st floor ED to the 2nd floor Med/Surg.

On 7/18/25 at 1314 hours, an interview was conducted with the CNO. The CNO stated that documented events of employees being trapped in elevators were not found in the hospital system, but leadership was aware of these incidents. These events were reportedly discussed during daily huddles but were not formally documented. The hospital was not tracking or trending these occurrences.

3. On 7/18/25 at 1216 hours, when questioned about P&P for safeguarding the safety of patients, employees, and visitors for elevators rides, the Director of Plant Operations stated there was no existing policies or procedure specifically addressing scenarios where an elevator was not functioning properly.

4. On 7/18/25 at 0928 hours, the Director of Plant Operations stated that the hospital currently had a contracted services company on-site working on a new elevator. The PI Director also mentioned that this contractor assisted with troubleshooting urgency calls for their elevators. Review of the "Facility Services Agreement" did not include provisions for responding to urgency calls. Both the CNO and the Director of Plant Operations confirmed the findings.

5. On 7/17/25 at 1039 hours, the CNO accompanied riding hospital elevators. One elevator site was covered with a plastic seal, and the two other service elevators were in use. During the elevator ride, the CNO stated one of two service elevators had not been cleaned, noting visible matter on the ceiling's clear panels. A note inside the elevator instructed passengers to "push the bottom to let the elevator to go to the first floor." The CNO understood the instruction but was unsure of its purpose or each elevator's identification number.

On 7/18/25 at 0928 hours, during an interview with the Director of Plant Operations. The Director of Plant Operations stated that both Environmental Services and engineers were responsible for elevator cleaning. The Director of Plant Operations clarified that it would ultimately be the responsibility of the engineers. The Director of Plant Operations was unable to provide a cleaning schedule for the elevators.