HospitalInspections.org

Based on interview, record review, and policy review the facility failed to ensure preventative maintenance was completed in a timely manner for four of four defibrillators (an electronic device that applies an electric shock to restore the normal rhythm of the heart), one of one vital sign machine (a device that takes an automatic blood pressure and pulse) and approximately 74 other devices. This failure could potentially affect the safety and health of all patients seeking treatment. The facility census was three.

Findings included:

1. Record review of the facility's policy titled, "Equipment," dated 07/01/99, showed directive for staff that the Plant Operations Department is responsible for ensuring the safety of all equipment. Biomedical is contracted to complete annual preventative maintenance for all equipment, clinical and non-clinical, with exception of the sterilizer. Any undesired effect or equipment problems will be repaired promptly.

2. Observation on 11/15/16 at 1:00 PM showed the following equipment with orange biomedical stickers for preventative maintenance (PM):
- A vital sign machine, on the Medical Surgical (Med-Surg) Unit, date: 09/15 and PM due 09/16;
- A defibrillator in the Emergency Department date: 03/16 and PM due 4/16;
- A defibrillator in the Med-Surg Unit, date: 03/16 and PM due 4/16;
- A defibrillator in the Radiology Department date: 03/16 and PM due 09/10 (difficult to read); and
- A defibrillator in the Outpatient and Operating Room (OR) Department date: 03/16 and PM due: 09/16.

3. Record review of the facility's document titled, "Inventory/Preventative Maintenance Log," dated 08/03/16, showed the vital sign machine and all four defibrillators were due for preventative maintenance (PM) checks along with approximately 74 other devices on 09/2016.

During a concurrent interview on 11/15/16 at 1:40 PM, Staff P, Plant Operations, stated that he was not responsible for the biomedical program. A previous Chief Nursing Officer (CNO) took on that responsibility. Staff B, CNO, stated that she started in 07/2016 and was not aware she was responsible for the biomedical program.

During an interview on 11/16/16 at 10:05 AM, Staff B stated that the biomedical company staff had not been to the facility to perform PM since 08/2016.

During a telephone interview on 11/16/16 at 11:35 AM, Staff A, Chief Executive Officer (CEO), stated that he was aware that PM was past due and it was because the facility failed to have the money to pay for the PM. The facility had an increased patient volume that required more supplies resulting in not having the money for PM. He felt that defibrillator PM was critical.

Based on interview and record review the facility failed to ensure the Laboratory Medical Director was a member of the medical staff and appointed by the Governing Body. This failure potentially could lead to substandard care for all patients who required laboratory testing when seeking treatment at this facility. The facility census was three.

Findings included:

1. Record review of the facility's document titled, "Medical Staff Bylaws," dated 09/2009, showed temporary privileges were not to exceed 90 days.

2. Record review of Staff S' (Laboratory Medical Director), credentialing file showed he was granted temporary privileges on 12/07/15.

3. During an interview on 11/16/16 at 10:45 AM, Staff X, Administrative Assistant, stated that there were no Governing Body meeting minutes that showed Staff S was granted permanent privileges.

During a telephone interview on 11/16/16 at 11:45 AM, Staff S stated that he did not believe he had been granted permanent privileges. He assumed the final completion of this process was just overlooked.

During a telephone interview on 11/16/16 at 11:35 AM, Staff A, Chief Executive Officer (CEO), stated that he was aware that Staff S was granted temporary privileges, but was not aware that Staff S had not received permanent privileges. He believed this occurred due to changes in CEOs.

During an interview on 11/17/16 at 2:30 PM, Staff Y, President of the Governing Body, was not aware that the Medical Director of Laboratory's permanent privileges had not been granted. He felt this situation occurred because the change in CEOs.