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Based on observations made during a tour of the facility, a review of the facility's inventory list, a review of policies and procedures, and an interview with a staff, it was determined that the facility failed to maintain equipment to ensure an acceptable level of safety and quality.


Cross-reference A0724 Facilities, Supplies, Equipment Maintenance, as it relates to the facility failure to maintain equipment to ensure an acceptable level of safety and quality.

Based on observations made during a tour of the facility, a review of the facility's inventory list, a review of policies and procedures, and an interview with a staff, it was determined that the facility failed to maintain equipment to ensure an acceptable level of safety and quality.

A tour of the ICU, 2nd and 3rd-floor nursing units was conducted with the Director of Quality (DQ) GG on 4/26/22 at 12:42 p.m., with the following observations:

2nd Floor:

* Three Blood Pressure monitors. One monitor had a Preventive Maintenance (PM) sticker with a due date of 2/2022.
* One Hoyer lift. PM sticker with a due date of 2/2022.
* Two feeding pumps. No PM sticker on either pump.

ICU:

* Four feeding pumps. One pump had a PM sticker with a due date of 8/2019. Three other pumps did not have PM stickers.
* Three IV pumps. Two PM stickers with due dates 3/20, 2/21, and one pump with no PM sticker.
* Three ventilators. One ventilator had a PM sticker with a due date of 4/22. The other two ventilators hadcurrent PM stickers.

3rd Floor:

* One ventilator: PM sticker with due date 4/21/22

A review of an Equipment Summary printed on 4/26/22 revealed the following equipment at the facility with expired or no Preventive Maintenance (PM):

" Ventilators, Intensive Care - 14 current, 14 expired PM- In Use: 16
" Electrocardiogram (EKG) Machines - no EKG machines were listed on the Equipment Summary
" Infusion Pumps (enteral feeding)- 6 current, 10 with no PM, and 60 expired PM- In Use: 27
" Infusion Pumps (multi-therapy)- 78 current, 2 expired PM- In Use: 15
" Vital Signs Monitors - 9 current, 2 with no PM
" Monitoring Systems, Physiologic, Bedside - 10 current, 4 expired PM (use included in telemetric)
" Monitors, Physiologic Multipurpose, Telemetric - 31 current, 1 expired- In Use: 25
" Pulse Oximeters - 22 current, 14 expired PM

A review of the facility's policy titled "Medical Equipment Management Activities," policy #252, reviewed 2/2/22, revealed the hospital would provide equipment that was safe for use through inspection, testing, and maintenance. All equipment would be approved for safe patient use and maintained by an external contractor. Maintenance history would be recorded and maintained on each piece of equipment. If a piece of equipment failed or were defective, it would be immediately removed from use and reported to Materials Management.

A review of the Medical Device Program revised 4/7/22 revealed that a medical device fleet would be maintained at the corporate warehouse to be available upon procurement approved request. Corporate fleet inventory would be conducted and entered on a spreadsheet twice per year. Preventive Maintenance would be performed on all devices in the corporate fleet in cycles per a designated schedule three times per year and as needed to ensure that all equipment was cleaned and prepared to be sent to requesting hospitals. The facility needing equipment would complete a request form. Upon procurement approval, the request would be sent to the warehouse team for packaging and shipment. The warehouse team would track the equipment to ensure accurate recording of inventory.

An interview was conducted with the Regional Chief Nursing Officer (CNO) HH on 4/27/22 at 10:32 a.m. in the classroom. CNO HH stated that during the survey, on 4/26/22, the facility went into every patient room and storage area to remove all equipment without a Preventive Maintenance sticker, or an expired sticker, until the PM could be validated. CNO HH further said that if there were a feeding pump without preventive maintenance, the equipment would be switched with a current preventive maintenance pump. Two feeding pumps were pulled out of the Intensive Care Unit (ICU), and the broken blood pressure (BP) machine on the 3rd floor was removed on 4/27/22. CNO HH stated the preference was for manual BP cuffs instead of machines for infection control, and most System facilities did not use BP machines. CNO HH said the Biomed company recently converted to a new tracking system. Beginning on 4/27/22, the Biomed company would service and inventory all equipment at the facility and start with a new tracking system to ensure preventive maintenance was completed on schedule.