HospitalInspections.org

Based on policy review and interview, the facility failed to provide a maintenance plan developed through risk assessment for piped medical gases as required. Findings include:

1. Record review on 6/21/23 at 2:30 p.m. revealed the plan to provide a medical gas outlet and system maintenance plan delegated all responsibility for risk assessment to maintenance without consideration of clinical assessment. Interview with the director of maintenance, and maintenance supervisor during the facility tour on 6/21/23 revealed no planning for maintenance or repair was available.

The deficiency could impact any patients within the hospital.

Based on observation and interview, the facility failed to provide labeling of medical gas shutoff valves as required (the emergency department trauma room 178 and the north hall of the patient care unit). Findings include:

1. Observation on 6/21/23 at 10:15 a.m. revealed trauma room 178 had no associated medical gas shutoff valve marked with room 178. There was a medical gas shutoff valve within the department, and also one within the adjacent operating room suite. However, neither included room 178. Interview with the director of maintenance and maintenance supervisor during the facility tour confirmed this finding.

2. Observation on 6/21/23 at 10:45 a.m. revealed the medical gas shutoff valve for the north hall of the patient care unit was not marked with the rooms served. Interview with the director of maintenance and maintenance supervisor during the facility tour confirmed this finding.

The deficiency could impact any patients within these two areas of the hospital.