HospitalInspections.org

Based on review of documentation it was determined that the hospital failed to ensure that there were sufficient quantities of emergency equipment (internal defibrillator paddles) immediately available during cardiac (open chest) surgery.

Findings were:
There were not sufficient quantities of emergency equipment (internal defibrillator paddles) immediately available during cardiac (open chest) surgery. Patient #1 had cardiac surgery on January 2, 2018. During the surgery the surgeon utilized a defibrillator and internal defibrillator paddles. Problems with the defibrillator resulted in staff members replacing the defibrillator with a second defibrillator. Staff later went to the cardio vascular operating room sterile core area to obtain a replacement set of internal defibrillator paddles and none were immediately available.

Review of facility documents provided to the survey team for review revealed that on January 2, 2018 revealed the comments:
"Pt begin to fibrillate, multiple attempts made to defibrillate but defibrillator failed to discharge. Paddles disassembled and reassembled by OR staff resulting in successful charge and defibrillation of pt. Pt begin to fibrillate later during the case; original paddles failed to discharge again and original paddles did not discharge; second set of paddles were then opened to sterile field. Plugged in, and used to successfully defibrillate the patient. During instance of no discharge, it was discovered that there were no sterile internal paddles on the shelf in the CV0R core; sterile paddles were obtained from SPD."