Deficiency in Maintenance of Resident Lifts
Penalty
Summary
During a Life Safety Code survey, it was found that patient care related electrical equipment, specifically portable resident lifts, were not inspected and tested according to the manufacturer's recommendations. The facility's policy, titled Maintaining Resident Medical Equipment, required that all medical equipment be inspected to ensure proper operation, referencing and maintaining equipment manufacturer manuals for specific preventative maintenance. However, an observation on the first floor revealed a Hoyer-type resident lift with a sticker indicating it was inspected by an outside contractor and was due for the next inspection in the same month. The manufacturer's user manual included a Maintenance Safety Inspection Checklist, which required monthly inspections of various components of the lift. A document titled Lift Inspections indicated that eight resident lifts were inspected, but the document was undated. Interviews conducted during the survey revealed that the facility's maintenance staff had not performed preventative maintenance checks on the lifts recently. The Executive Director of Environmental Services found an undated Lift Inspections document in the former Maintenance Director's office, and the position was currently vacant. The Administrator acknowledged that the facility should follow the owner's manual for equipment maintenance and stated that an outside contractor inspected the lifts twice a year, but the maintenance staff should also perform preventative maintenance as indicated in the manual. The Executive Director of Environmental Services confirmed that most of the facility's Hoyer-type resident lifts were manufactured by Company A and that manufacturer's recommendations should be followed, expecting monthly lift inspections to be completed and documented.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Action: An audit was conducted by maintenance staff for all lifts in the house. All lifts were inspected at that time with no negative findings. At the time of the audit, maintenance ensured that all lifts were accounted for and we were following the manufacturer manuals for all lifts in use. Identify Other Residents: All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes: The Director of Facilities or Designee to in-service all maintenance staff on preventative maintenance of equipment based on the manufacturer’s manual, as well as on the updated lift inspection form. Monitor Corrective Actions: The Director of Facilities or Designee will review the monthly lift inspection and report all findings to the Administrator and the QAPI Committee at the monthly meeting. The QAPI Committee is responsible for ongoing monitoring and compliance. Person Responsible for Implementation: The Director of Facilities will be responsible for monitoring the plan.