Deficiency in Maintenance of Patient Care Related Electrical Equipment
Penalty
Summary
During a Life Safety Code survey, it was found that patient care related electrical equipment (PCREE) in the facility was not properly maintained according to the manufacturer's recommendations. Specifically, four portable resident lifts, identified as Brand A, Brand B, Brand C, and Brand D, were not inspected and tested as required. The facility's policy stated that such equipment should be maintained in accordance with state, federal, and National Fire Protection Association (NFPA) regulations, and that testing and maintenance should follow the manufacturer's service manual recommendations. However, observations revealed that the lifts had either outdated inspection stickers or no inspection stickers at all, indicating lapses in the required maintenance schedule. The facility's preventative maintenance documents showed that maintenance checklists from each manufacturer's owner's manual were used, but these were only completed up to August 2024. Interviews with the Assistant Maintenance Director revealed that monthly inspections were not consistently performed after a maintenance assistant left the facility in mid-2024. The Assistant Maintenance Director admitted to inspecting the lifts only when complaints were made or when lifts were returned to their designated units, rather than following a regular preventative maintenance schedule. Additionally, the Maintenance Director, who had been in the position for less than two weeks, was unaware of the specific inspection schedules for the lifts as indicated by the stickers. The Administrator confirmed that preventative maintenance should be conducted according to the manufacturer's recommendations and expected maintenance staff to document all equipment testing. However, the departure of key maintenance personnel in mid-2024 led to a gap in the regular inspection and maintenance of the lifts. This lack of consistent maintenance and documentation resulted in the facility's non-compliance with the required standards for maintaining patient care related electrical equipment.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 The Maintenance Director thoroughly inspected all 4 facility lifts per manufacturer specifications found in the Manufacture User Manual and those found in the Maintenance Safety Inspection Checklist of each to ensure safe proper working order. A certified technician was scheduled to inspect Brand A lift. All lifts had the potential to be affected. An audit of other PECREE items was conducted to ensure safe proper working order and compliance with Manufacture User Manuals inspection requirements. The Administrator, Maintenance Director, and maintenance staff were educated on the requirement to establish, maintain and document Portable Patient-Care Related Electrical Equipment (PCREE) inspection and testing per each equipment’s specific Manufacturer User Manual and any Maintenance Safety Inspection Checklists found in those manuals, including utilizing certified technicians when required. The Maintenance Director will begin to utilize PECREE stickers to note inspections on each lift. A PECREE audit tool that mirrors the Manufacturer’s Maintenance Safety Inspection Checklist will be utilized by the Administrator to audit PECREE documentation to ensure compliance. The Administrator will scan and email the PECREE audit to the Corporate Regional Administrator every month for review. The Corporate Regional Administrator will review the PECREE audit and the maintenance PECREE documentation in-person each quarter. The Administrator will audit the PCREE documentation weekly x 4 and then monthly x 3. The Corporate Regional Administrator will review the PECREE audit monthly x 3. The Corporate Regional Administrator will review the PECREE audits and documentation in person quarterly x 2. The results of the audit will be reported at the monthly QAPI meeting. The Corporate Regional Administrator is responsible to ensure compliance.