HospitalInspections.org

Based on observation, the hospital created a condition which resulted in a safety hazard to employees and the building in 1 instance.

Findings:

1. On 10-5-10 at 10:30 am in the presence of employee #A3, it was observed in Room 710, a room with the approximate dimensions of 3 feet by 5 feet, there were 2 electrical circuit breaker boxes, with several conduits going into each breaker box, and a janitorial floor sink. It was also observed there was a flexible hose, approximately 3 feet, attached to a spigot above the floor sink.

2. Due to the close proximately of the water source and the flexible hose to the electrical equipment, if any water was splashed or sprayed onto the breaker boxes or the conduits, it could cause an electrical safety hazard to any persons in the room. It could also cause an electrical safety hazard to the equipment.

17294

Based on observation, documentation and interview, the facility failed to ensure that the facility HeartStart Onsite Defibrillator be maintained to ensure an acceptable level of safety failed to ensure regular periodic preventive maintenance (PM) of 2 pieces of equipment in accordance with the manufacturer's recommendations.

Findings:

1. During the facility tour on 10-05-10 at 0915 hours, a Phillips HeartStart Onsite Defibrillator was observed in the Nurses Station located between the Mens and Womens Inpatient Units.

2. Review of the manufacturer's recommendations indicated the following on page G-1:
"Testing
The HeartStart OnSite Defibrillator automatically tests itself everyday and alerts you if it finds a problem. The OnSite's green Ready light is the signal that tells you if the OnSite is ready for use."

3. On 10-05-10 at 0915 hours, staff #43 confirmed that he/she checks the Phillips HeartStart Onsite Defibrillator weekly and does not document that the Phillips HeartStart Onsite Defibrillator was checked.

4. Review of the manufacturer's manual for the Heartstart OnSite Defibrillator (AED) indicated there should be periodic checks of:
the green Ready light
replace any used, damaged or expired supplies and accessories
the outside of the OnSite [for] cracks or other signs of damage.

5. On 10-4-10 at 9:45 am, employee #A3 was requested to provide documentation of following the manufacturer's recommendations for PM of the AED. No documentation was provided prior to exit.

6. Review of the manufacturer's manual for for the hospital's air conditioning (HVAC) units indicated the entire system be checked once a year for the following:
Filters (for cleaning or replacement)
Motors and drive system components
Economizer gaskets (for possible replacement)
Condenser coils (for cleaning)
Safety Controls (for mechanical cleaning)
Electrical components and wiring (for possible replacement or connection tightness)
Condensate drain (for cleaning)
Inspect the unit duct connections to ensure they are physically sound and sealed to the unit casing
Inspect the unit mounting support to see that it is sound
Inspect the unit to ensure there is no obvious deterioration

7. Review of a document entitled PREVENTIVE MAINTENANCE PATIENT/OFFICE HVAC UNITS indicated that at least annually the filters were cleaned, there was a check of the electrical panel, and the evaporator coil was cleaned. Thus, it did not indicate other manufacturer recommendations were followed, including but not limited to, checking:
motors and drive system components
economizer gaskets (for possible replacement)
condensate drain (for cleaning)
the unit duct connections to ensure they are physically sound and sealed to the unit casing
the unit mounting support to see that it is sound

8. On 10-6-10 at 11:40 am, employee #A3 was requested to provide any other documentation of PM of the HVAC units, per the manufacturer's recommendations, and no other documentation was provided prior to exit.

Based on document review, the facility failed to ensure inclusion of 1 directly-provided service and 2 contracted services in its quality assurance/performance improvement (QAPI) program.

Findings:

1. Review of the hospital's QAPI program indicated it did not include the directly-provided service of maintenance, including housekeeping services and patient care equipment preventive maintenance checks.

2. On 10-4-10 at 9:45 am, employee #A1 was requested to provide documentation of the directly-provided service of maintenance's inclusion in the hospital's QAPI program and no documentation was provided prior to exit.

3. Review of the hospital's QAPI program indicated it did not include the contracted services of a medical records consultant and the biohazardous waste hauler (Stericycle).

4. On 10-4-10 at 9:45 am, employee #A1 was requested to provide documentation of the contracted services of a medical records consultant and the biohazardous waste hauler's inclusion in the hospital's QAPI program and no documentation was provided prior to exit.

Based on observation and interview, the facility failed to ensure that unauthorized individuals cannot gain access to patient medical records (MR) in one instance.

Findings include:

1. During the facility tour on 10-05-10 at 0945 hours in the presence of staff #42 on the Inpatient Mens unit, room 417 was observed to be unsecured with patient #1's treatment plan sitting on the top of the printer.

2. Staff #42 confirmed that room 417 should have been locked.