Fall River Hospital - Cah

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 45683 Based on observation, interview, record review, manufacturer’s instructions for use (IFU) review, and policy review, the provider failed to ensure: *Three of three blanket warmers were operating within the manufacturer’s recommended temperatures. *One of one hydrocollators (specialized medical device used in physical therapy and sports medicine to heat and store therapeutic moist heat packs) had temperature checks documented and cleaning performed per the manufacturer’s IFU. Findings include: 1. Observation on 6/23/26 at 10:49 a.m. in the equipment room adjacent to the nurse’s station revealed an Amsco blanket warmer. Inside the blanket warmer there were four blankets and a thermometer that read 145 degrees Fahrenheit (F). The manufacturer’s IFU inside the door of the blanket warmer read, “1. Place blanket shelf in compartment. 2. Place blankets on blanket shelf. 3. Set selector to setting (noted on selector dial) Not to exceed 120 (degrees) F (Fahrenheit). 4. Turn control switch to “On”. On top of the blanket warmer was a June 2026 blanket warmer log. The blanket warmer log stated, “Normal Range Between 135-145 Degrees”. The documented temperatures on the blanket warmer for the month of June ranged from 130 to 155 degrees F. 2. Interview on 6/23/26 at 4:00 p.m. with environmental services director C regarding the blanket warmer revealed, he was unaware the blanket warmer should have been set at 120 degrees. He agreed the blanket warmers should have been set at 120 degrees according to the manufacturer’s IFU. He confirmed the blanket warmer had been running between 130-155 degrees. 3. Observation and interview on 6/23/26 at 4:20 p.m. with director of outpatient services E revealed there was a blanket warmer stored in the storage room in the radiology department. There were three blankets inside the blanket warmer. The blanket warmer was set at 135 degrees F. He was unaware of what temperature the blanket warmer was supposed to be set to. He confirmed that the blanket warmer had been running between 135 and 145 degrees F. 4. Interview on 6/24/25 at 8:05 a.m. with chief nursing officer (CNO) B regarding the blanket warmers revealed that the nursing staff was responsible for recording the blanket warmer temperatures. She was unaware of the appropriate temperature setting for the blanket warmers. The maintenance department would be notified if there was an issue with a blanket warmer. She agreed that the blanket warmers should not be set above 120 degrees according to the manufacturer’s IFU. 5. Interview on 6/25/26 at 10:30 a.m. with chief executive officer (CEO) A regarding the blanket warmers revealed, he expected staff to follow the provider’s policies and the manufacturer’s IFU. He agreed the blanket warmers had been running above the recommended temperature. 6. Review of the June 2026 ER (Emergency Room) Blanket Warmer Log revealed the recorded temperatures were between 130 and 136 degrees F. Review of the June 2026 Radiology Blanket Warmer Log revealed the recorded temperatures were between 135 and 142 degrees F. 7. Review of the provider’s undated Blanket Warmer Temperature Check policy revealed, “Daily temperature checks will ensure the warmer is operating properly. 1. Blanket warmer will be temperature checked daily by nursing staff. 2. Temperature will be recorded daily on the log sheet attached to warmer. 3. Maintenance will be notified of any out of range temperatures.” 46511 8. Observation on 6/24/26 at 12:40 p.m. in the equipment room located in the therapy department revealed a Chatanooga Hydrocollator Stationary Heating Unit stored on the countertop. There was no log to document the temperature or cleaning of the hydrocollator located in the room. 9. Interview on 6/24/26 at 12:50 p.m. with therapy manager F revealed physical therapy staff performed cleaning of the hydrocollator monthly. He confirmed staff did not document the cleaning. The temperature of the water in the hydrocollator was taken before each use. He confirmed staff did not document these temperatures. 10. Interview on 6/25/26 at 10:35 a.m. with CEO A regarding the hydrocollator revealed that he expected staff to follow the manufacturer’s IFU for temperatures and cleaning. He agreed that temperatures and cleaning of the hydrocollator should have been documented. 11. Review of the IFU for the hydrocollator revealed that regular cleaning and draining of the tank should be done every two weeks. The interior of the unit should be cleaned at least every two weeks. The recommended operating temperature is between 160 and 165 degrees F. The water temperature should be checked after every adjustment and before every use. 12. A policy for cleaning and use of the hydrocollator was requested and was not provided by the end of the survey.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 50915 Based on observation, interview, manufacturer’s instructions for use (IFU) review, Association for the Advancement of Medical Instrumentation (AAMI) review, and policy review, the provider failed to ensure that approximately 10 of 50 surgical instruments wrapped with surgical tape were free from cracks, rips, tears, and discoloration. Findings include: 1. Observation on 6/23/26 at 10:40 a.m. in the emergency department (ED) exam room 3 revealed approximately 10 of 50 sterile instruments with surgical instrument marking tape that was peeling away from the instruments. This created the potential for bacteria to remain on the surgical instruments and that could potentially infect the patient, and lead to serious complications 2. Interview on 6/23/26 at 3:40 p.m. with clinical care technician D revealed that her duties included applying identification tape to the surgical instruments and sterilizing them. She agreed that if the surgical tape was peeling away from the instrument, that would be an infection control concern, and the instrument should not be used. It was her expectation that if ED staff found instruments with peeling tape, they would remove the instruments from use and have the surgical tape replaced. 3. Interview on 6/23/26 at 4:50 p.m. with chief nursing officer (CNO) B revealed that she considered tape peeling from sterile instruments an infection control concern and the instruments should not have been used. 4. Review of online instructions for Shamrock Scientific SMT-38 Specialty Instrument Marking Tape revealed “Inspection: Routinely check the instruments during sterile processing. If the tape begins to crack, chip, or peel, remove it entirely.” 5. Review of the 2017 AAMI-ST 79 guidelines, pg. 40 revealed “Instruments should be carefully inspected for flaws, damage, debris, detergent residue, and completeness, then dried. Instrument tape and plastic dipping material, when used properly, are ways of identifying specific instruments. These types of marking products wear out over time and staff need to inspect them each time the instrument is processed, check them for wear according to the IFU of the product used, and replace them as often as needed.” 6. Review of the provider’s undated infection control policy revealed “Purpose: To reduce the risk of health care related infections among employees and patients receiving care at [provider name]. To prevent the transmission of infectious disease to patients, employees and facility visitors, and to take necessary measures to prevent the spread of communicable disease within the facility.””