Deficiency in Equipment Maintenance and Inspection
Summary
During a Life Safety Code survey, it was found that patient care-related electrical equipment was not inspected and tested according to the manufacturer's recommendations. Specifically, a Brand A suction machine located on a crash cart in Unit 1 East had stickers from an outside contractor indicating upcoming preventative maintenance, but there was no record of the device in the contractor's inventory or any inspection having been performed. The Director of Plant Operations confirmed that the outside contractor was responsible for maintaining the suction machines, and in-house staff did not perform maintenance. However, the contractor admitted that their employee might have placed the stickers on the device without conducting proper inspection procedures. Additionally, nursing staff reported they did not perform maintenance tasks such as checking or replacing internal components of the suction machine. Similarly, a Brand B portable Hoyer-type resident lift in the 1 West Unit was found to have overdue preventative maintenance. The lift had stickers from the same outside contractor, but the last recorded inspection was on 11/15/23, indicating that the required twelve-month maintenance was overdue. The Director of Plant Operations stated that the outside contractor was responsible for maintaining the lifts, and the Director of Long Term Care Facilities believed that the contractor's visits were automatic and did not require scheduling by facility staff. This lack of oversight and communication led to the deficiency in ensuring that the equipment was properly maintained and inspected as per regulatory requirements.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 What corrective action will be accomplished: The suction machine on 1 East Unit and the Hoyer-type resident lift on 1 West unit have been removed from service and will not return to service until preventative maintenance is completed. All residents have the potential to be affected by the same deficient practice. Facility suction machines and Hoyer-type resident lifts will be audited by outside contractor beginning (MONTH) 3, 2025 to ensure that timely preventative maintenance has occurred. Measures to be put into place include audit of facility suction machines (monthly) and Hoyer-type resident lifts (weekly) to ensure preventative maintenance has occurred. Maintenance staff will be educated to ensure suction machine and portable resident lift are inspected, tested, and maintained per manufacturer's recommendations. Facility will maintain documentation for their inspections, testing, and maintenance. How the corrective action will be monitored: The audits will be reviewed by Administration and reported to the Quality Assurance Committee. Plant Operations Director will be responsible to ensure compliance.
Penalty
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