HospitalInspections.org

.

Based on observation, interview and record review, the facility failed to ensure an acceptable level of safety and quality of the code cart (containing emergency equipment, supplies and medication) was maintained in the Labor and Delivery (L&D) unit. Specifically, the facility failed to ensure one code cart out of one code cart in the L&D unit was checked per facility's schedule. This failed practice had the potential to place all patients in the L&D unit at risk of not receiving emergency care.

Findings:

During an observation with concurrent interview on 10/23/24 at 10:20 AM, revealed the L&D unit had one code cart. The Assistant Nurse Manager (ANM) stated the charge nurse was responsible to check the code cart once in every 24 hours. The ANM showed the checklist with incomplete checked dates. The ANM stated the code cart should have been checked every 24 hours.

Review of the facility's "Code Cart Checklist," dated 10/2024, revealed, the items to be checked were:
"All locks Intact,"
"Check Exp[expiration] date on Outdate Card & write Date below,"
"BVM [Bag Valve Mask] back board present,"
"No expired pads, electrodes, 'transport meds,'"
"paper & cables present,"
"O2 tank full/Suction tested, (unplugged first),"
"Auto defib [defibrillator] Tests OK,"
"Weekly Manual Defib & Pacer check complete," and
"Cart cleaned weekly."

Review of the facility's "Code Cart Checklist," from April to October 2024, revealed the code cart was not checked every 24 hours on the following dates:
4/7/24, 4/13/24, and 4/25/24, with a total of three days;
5/3/24, 5/12/24, and 5/30/24, with a total of three days;
6/12/24, 6/17/24, and 6/26/24, with a total of three days;
7/19/24, 7/26/24 and 7/31/24, with a total of three days;
8/3/24, 8/10/24, 8/14/24, 8/20/24 and 8/26/24, with a total of five days;
9/1/24, with a total of one day;
10/1/24, 10/6-7/24, 10/9/24, and 10/22/24, with a total of five days.

Further review revealed the manual defibrillator was not checked and code cart was not cleaned weekly on 8/8/24, and 10/22/24.

During an interview on 10/24/24 at 11:26 AM, the Program Manager Regional Accreditation, confirmed there was only one code cart for the L&D unit.

During an interview on 10/24/24 at 12:30 PM with the Quality and Risk Director, when asked about code cart not being checked, he stated it "breaks my heart, sad to hear" and he had "nothing to say." He further stated "corrective actions" had been started, and he was not sure if it was the only code cart that was not checked.

Review of the facility's "Code Cart, Guidelines for Exchange and Checking" Policy, dated 7/2023, revealed: "This guideline specifies the areas of responsibility for maintenance of emergency equipment in the patient care units and defines the minimum emergency equipment kept in the hospital areas. . . Code Cart: cart containing emergency equipment, supplies and medications. . . Departmental responsibilities . . . at least once per day the integrity of the code cart is checked. . . The defibrillator is checked per competency, defibrillator pads are stored with the defibrillator, and integrity of the red and yellow locks are checked. . ."


.