HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 6 patient's (Pt. #4) clinical records reviewed, the Hospital (Location B) failed to conduct a timely nursing assessment, as required, to ensure that policies and procedure governing medical care provided in the ED (Emergency Department) was followed.

Findings include:

1. On 10/28/2021, Pt. #4's clinical record was reviewed. Pt. #4 arrived by ambulance in the ED on 10/15/2021 at 11:20 AM, due to chest pain and shortness of breath. The clinical record indicated that a triage assessment was conducted at 1:08 PM (approximately 1 hour and 39 minutes after patient's arrival). There was no other documentation prior to 1:08 PM that a nurse conducted a nursing assessment.

2. On 10/29/2021, the Hospital's policy for the ED titled, "Assessment and Reassessment of Patients" (effective 6/2021) was reviewed and required, "Policy... Initial assessments are obtained at the time of entry into the inpatient settings... Procedures... I... ii. Nursing staff completes a patient assessment upon patient arrival...a. In addition to the physical and psycho-social aspects of assessment, patients are assessed or screened for pain..."

3. On 10/29/2021, the Hospital's job description for ED Registered Nurses (Revised 2018) was reviewed and required, "... Essential Duties and Responsibilities... Documents according to standards of care... Competencies... Follows policies and procedures..."

4. On 10/29/2021 at approximately 11:00 AM, findings were discussed with E #1 (ED Manager). E #1 stated that a nursing assessment should be conducted as soon as possible.

B. Based on observation, document review, and interview, it was determined that for 2 of 2 crash carts (Cart #1 and Cart #2) in the ED at Location A, the Hospital failed to perform daily crash cart check, as required, to ensure that policies and procedure governing medical care provided in the ED was followed. This potentially affected an average daily census of 50 patients in the ED.

Findings include:

1. On 10/28/2021 at approximately 10:30 AM, an observational tour of the ED was conducted. There were two crash carts in the ED. There was no documentation that the crash carts were checked on the following dates:

- Cart 1: 10/1/2021; 10/4/2021; 10/5/2021; 10/8/2021; 10/9/2021; 10/13/2021; 10/14/2021; 10/15/2021; 10/16/2021; 10/18/2021; 10/22/2021; 10/25/2021, and 10/26/2021.
- Cart 2: 10/1/2021; 10/3/2021; 10/5/2021; 10/6/2021; 10/8/2021; 10/9/2021; 10/14/2021; 10/15/2021; 10/16/2021; 10/17/2021; 10/18/2021; 10/19/2021; 10/21/2021; 10/22/2021; 10/25/2021; and 10/26/2021.

2. On 10/29/2021 at approximately 10:30 AM, the Hospital's policy titled, "Cardiopulmonary Arrest (Code Blue) at (Name of Hospital)" (effective 4/2021) was reviewed and included, "... J. Crash Cart Checks... 2. Daily Check... b. Checklist should include at minimum: Device exterior, Cables... Paddles/Pads, Monitoring electrodes... 3. Daily Shock Test..."

3. On 10/29/2021 at approximately 11:30 AM, findings were conducted with E #1 (ED Manager). E #1 stated that the crash carts should be checked daily. E #1 agreed that based on lack of documentation, the crash carts were not checked.