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Based on observation, employee file review and interview, it was determined the Facility failed to ensure five (#2, #4, #6, #7 and #13) of 13 (#1-#13) radiology employees had a current CPR certification. The failed practice did not ensure employees were trained in basic CPR procedures and had the potential to affect any patient needing CPR in the Radiology Department. Findings follow:

A. Review of employee files revealed the following:
1) Radiology Employee #2 - CPR expired 10/2014
2) Radiology Employee #4 - CPR expired 07/2015
3) Radiology Employee #6 - CPR expired 05/2015
4) Radiology Employee #7 - CPR expired 07/2015
5) Radiology Employee #13-CPR expired 07/2015

B. During an interview on 11/09/15 at 1515, the Director of Radiology confirmed the employees had expired CPR certifications.

Based on policy review, Crash Cart Checklist review and interview, it was determined the Facility failed to ensure two of two crash carts in the ED (Emergency Department) were checked daily as per policy. The failed practice did not ensure the defibrillator was functional in the event of an emergency and had the potential to effect any patient needing the defibrillator. Findings follow.

A. Review of policy titled "Defibrillator Checks" stated, "...to determine correct functioning of the defibrillator on a daily basis."

B. Review of Crash Cart Checklists for 10/01/15 through 11/08/15 revealed the crash cart was not checked on the following days:
1) Trauma 1 - seven days missing (10/30/15-11/02/15, 11/04/15, 11/07/15 and 11/08/15).
2) Trauma 2 - nine days missing (10/29/15-11/04/15, 11/07/15 and 11/08/15).

C. During an interview on 11/09/15 at 1135, the ED Nurse Manager confirmed the missing crash cart checks.