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Based on observation during a tour of the Emergency Department, review of documents and interview with staff the facility failed to ensure that emergency equipment and supplies are inventoried and maintained. The "Monitor/Defibrillator Checklist" of the emergency equipment on the crash cart was not always completed as per hospital polices and procedure.

Findings were:

Facility Policy and Procedure entitled "Crash Carts" stated in part, "To ensure that all crash carts are up to date, fully stocked, and prepared to be used. Procedure: Every shift will perform an external check of the crash carts and document on the "Crash Cart Checklist" form. Any missing or expired supplies will be replaced. Every shift will test the defibrillator at 200joules.
Tour of the Emergency Department on the afternoon of 4/24/2017 revealed that the facility failed to maintain the accountability checklist of the Crash Cart. The checklist was not completed on the following dates on both the 7 AM shift and the 7 PM shift.
" March 2016 - 3/14, 3/15, 3/19, 3/20.
" April 2016 - 4/15 and 4/20.
" July 2016 - 7/2, 7/3, 7/16, 7/17, 7/18, 7/19.
" September 2016 - 9/1, 9/3, 9/4, 9/5, 9/14, 9/25, 9/27.
" October 2016 - 10/3, 10/4, 10/7, 10/17, 10/18, 10/22, 10/23, 10/26.
" November 2016 -11/15. 11/25, 11/26, 11/28, 11/29.

The above findings were confirmed with the Director of Nursing the afternoon of 4/24/19.

Based on documentation and interview, it was determined that the facility's Infection Control Committee failed to ensure that the kitchen was appropriately maintained.

Findings were:

Tour of the kitchen on 4/24/17 and review of 1 year of the consulting Dietician's monthly reports revealed the following:

Report dated 8/30/16 revealed the following:
" Ceiling vents are dirty and blowing lint
" Compressors on the refrigerators and freezers are dirty
" Floor needs to be scrubbed with a commercial floor scrubber and lightly sealed
Report dated 1/24/17 revealed the following:
" Ceiling vents were dirty and blowing dust
" Dirty compressors on refrigerators and freezers
" Floor, baseboards "need attention."
Report dated 3/24/17 revealed the following:
" Food items not labeled and dated as to content and when they were opened
" The area between the range and grill was not cleaned
" Muffin tins were "heavily blackened"
" Floors of walk in freezer and walk in refrigerator were dirty
" Bugs in light fixture in dining room
" Employees not "recognizing the need to check and record PPM of Sanitizer and Temps of Dishwasher."
Report dated 4/20/17 revealed the following:
" Bowls not covered or in a closed cabinet stored upright in the kitchen
" Logs not being kept on patient refrigerators
" Open items/labels and dented cans not monitored daily in the pantry

Cardboard boxes found in walk in refrigerator
In an interview on 4/25/17 with the Infection Control Nurse, it was admitted that she never went into the kitchen and had never reviewed the Consultant Dietician's Report.