HospitalInspections.org

Based on review of policies and procedures, observations, and interviews with staff, the hospital failed to ensure radiology services be free from hazards for patients by not ensuring necessary equipment be provided and maintained to immediately respond to potential adverse events.

Findings:

Review of hospital policy "Emergency Code Cart Monitoring & Maintenance" (PolicyStat ID 11415224 approved on 04/24/2022) read, "All Code Carts shall be checked by the individual departments in which they are located . . . the Code Cart shall be inspected by trained personnel every day . . . ."

A tour of the hospital to include the Computed Tomography (CT) procedure room located just off the Emergency Department, the actual Radiology Department, and the Labor and Delivery area in Women's Services was conducted on 10/12/2022 between 4:10 p.m. and 5:06 p.m. Review of hospital's documents entitled Code Cart Checklist located with the Code Carts were not being signed to indicate Code Carts were being properly maintained per hospital policy as evidenced by the following. Observation of the Code Cart Checklist located in the CT procedure room reflected it had been signed as checked for only one day, 08/27/2022, and not since that day.
Observation of the Code Cart Checklist located in the Radiology Department reflected missing signatures and/or initials indicating the Code Cart had been inspected on multiple dates: July 2, 3, 4, 10, June 11, 12, 18, 19, 20, 26, 27, 30, and May 18 and 22, 2022.

Interviews on 10/12/2022 at 4:30 p.m. with the Manager of Radiology Services, Director of Radiology Services, and the Vice President of Quality and Patient Safety confirmed missing signatures on these Code Cart checklists in the areas of Radiology Services, therefore not complying with the hospital's policy.