HospitalInspections.org

Based on Crash Cart check sheets, policy and procedure review, and interview, it was determined the Facility failed to ensure four of four (30A, 30B, 29A and 27B) crash carts examined were checked every shift by Emergency Department personnel. Failure to check the crash carts every shift did not ensure the defibrillators were functional and working in the event they were needed for patient care. The failed practice had the potential to affect any patient whose care required the use of the defibrillator. Findings follow:

A. Review of the Crash Cart check sheets showed the following:
1) 30A Crash Cart check sheet missing checks five (08/09/17, 08/10/17, 08/12/17, 08/14/17 and 08/15/17) of fifteen (08/01/17 through 08/15/17) night shifts.
2) 30B Crash Cart check sheet missing checks five (08/09/17, 08/10/17, 08/12/17, 08/14/17 and 08/15/17) of fifteen (08/01/17 through 08/15/17) night shifts.
3) 29A Crash Cart check sheet missing one (08/15/17) of fifteen (08/01/17 through 08/15/17) night shifts.
4) 27B Crash Cart check sheet missing checks nine (08/07/17 through 08/15/17) of fifteen (08/01/17 through 08/15/17) night shifts.

B. Review of the policy and procedure titled "Code Blue Process and Crash Cart Maintenance" received on 08/16/17 showed the following under "III PROCDURE ...C. Crash Cart and Defibrillator Maintenance, Standardized crash carts with emergency equipment, supplies and medications are maintained in designated locations.
1. Crash cart and defibrillator maintenance is to be performed by licensed personnel every shift during which patient care is rendered. See Crash Cart and Defibrillator Maintenance procedure.
2. Signature of person performing maintenance and the crash cart lock number are to be recorded on the Crash Cart and Defibrillator Maintenance Record located on the crash cart ...."

C. During an interview with the Nursing Director of the Emergency Department at 9:10AM on 08/16/17 he stated it was the charge nurse's responsibility to perform the crash cart checks every shift.

D. The findings in A, B and C were confirmed at 9:15AM on 08/16/17 during an interview with the Nursing Director of the Emergency Department.