Failure to Maintain Essential Equipment in Safe and Clean Condition
Penalty
Summary
Surveyors observed multiple failures in the maintenance and safe operation of essential equipment within the facility. During inspections, the medication refrigerator and a specimen refrigerator were both found with significant ice buildup in their freezer compartments. In the medication refrigerator, melting ice was dripping water onto medication packages and bags stored below, and there was no documentation or recollection from staff regarding when the refrigerator was last defrosted. Similarly, the specimen refrigerator also had ice buildup, and facility leadership could not explain the cause. Additionally, a blood pressure machine in the rehabilitation area was found to be held together with clear tape, and staff could not identify the brand or provide a reason for the tape other than to keep the device intact. Further review of the facility's glucometer quality control practices revealed discrepancies in documentation and calibration. The serial number recorded on the quality control record did not match the glucometer in use, and the control ranges documented did not align with those printed on the test strip bottle. Staff interviews confirmed that calibration was supposed to be performed nightly and documented, but the records were inconsistent and did not reflect the actual equipment or correct control ranges. In the kitchen, the ice machine was found to be unclean, with brown residue observed inside the bin. The facility's policy required monthly cleaning and documentation, but the Maintenance Supervisor stated the machine was cleaned only every six months and could not provide records of the last cleaning. The Maintenance Supervisor was also unaware of the brown buildup present in the machine. These findings were verified by multiple staff members during the inspection.