HospitalInspections.org

Based on tour observations of facility patient care areas, the clinical staff failed to ensure discharge, temperature, and glucose monitoring device logs were updated as specified by facility policy.

Findings include:
1. F1 "Crash Cart and Emergency Medication Kit" policy, Policy: 12197211, last approved 08/2022. This policy indicates that a daily check of the Automatic Emergency Defibrillator (AED), suction check, oxygen tank check, and cart lock integrity will be completed and recorded on the "Crash Cart Record."

2. F1 "Medication Refrigerator - Freezer Storage" policy, Policy: 10053946, last revised 6/2021. This policy indicates that a daily temperature check of medication refrigerators and/or applicable storage rooms will be completed by the pharmacy or nursing staff.

3. Observation conducted at 0900 - 1000 hours on 9/12/2022, and review of F1's documentation indicates that Units 1 and 3's had missing daily defibrillator check documentation since 9/3/2022. Further, Unit 1 medication refrigerator temperature checks had not been updated on 9/10-9/11/2022, and Unit 3's medication refrigerator had not been updated on 9/9/2022. Units 1, 2, and 3, did not have glucometer checks recorded.

5. At 0900 hours on 9/12/2022, per interview with S1, Interim Chief Executive Officer, confirmed that Units 1, and 3 had missing daily defibrillator check documentation since 9/3/2022. Unit 1 medication refrigerator temperature checks had not been updated on 9/10-9/11/2022, and Unit 3's medication refrigerator had not been updated on 9/9/2022. All units failed to provide any logs of glucometer checks. No additional information was provided prior to exit.