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Based on observation, interview, and record review; the hospital failed to ensure patient safety by not maintaining one (#17) of four crash carts.

This failed practice has the likelihood to place patients at risk of not having access to emergency supplies.

Findings:

Review of a policy titled, "Emergency Response and Resuscitation," read in part, "Nursing clinical staff is responsible for determining the integrity of the break-away locks." The policy also stated upon finding a broken locking device, the crash cart should be replaced.

On 11/13/19 at 10:35 AM, it was observed that crash cart #17 in the 9 East Nurses Station had a broken break-away safety lock.

On 11/13/19 at 10:40 AM, Staff J stated locks on the crash cart should not be broken.

Based on record review and interview, the hospital failed to ensure completion of a doctor's order for one (Patient #14) of 16 patients.

This failed practice has the likelihood to result in a delay of healing and a delay in being discharged from the facility.

Review of a patient order dated 11/12/19 at 2:39 PM, read, "OK to give 9pm meds at 8pm 11/12/19. Please clamp PEG after giving meds for ~30 minutes. Then please UNCLAMP! Please leave unclamped overnight."

Review of nursing shift assessment of the gastrointestinal system dated 11/12/19 at 8:05 PM showed no documentation of the percutaneous endoscopic gastrostomy (PEG) tube being clamped for 30 minutes after medication administration and unclamped afterward.

On 11/14/19 at 1:15 PM, Staff R reviewed the medical record for Patient #14 and stated there was no documentation of clamping or unclamping the PEG tube.

Based on observation, record review, and interview, the hospital failed to ensure:
1. medication refrigerator temperatures were documented for one (10 East Medication Refrigerator) of three refrigerators.
2. patients and medications were scanned prior to medication administration for one (Patient #16) of 16 patients.

These failed practices have the likelihood to place patients at risk of receiving medications that could cause physical harm.

Finding #1:

Review of a policy titled, "Medication Management," read in part, "temperatures in medication refrigerators will be monitored and documented daily."

Review of Medication Refrigerator Log, located in 10 East Medication Room, showed no entries documented for: Temp, Signature, or Time for 11/02/19 and 11/09/19; and no Temp or Signature for 11/06/19.

On 11/13/19 at 10:52 AM, Staff J stated data was missing from the Medication Refrigerator Log.

Finding #2:

Review of a facility policy titled, "Medication Management," read in part, "Immediately prior to administration, the dose of medication to be administered to the patient is scanned by the individual administering the dose to confirm a medication order for that medication is on the medication profile...Immediately prior to administration of the medication, the patient's armband will be scanned to ensure the correct medication is being administered to the correct patient."

Review of the medication administration record (MAR) for Patient #16 showed acetaminophen was administered on 10/03/19 at 8:49 AM and 3:29 PM and showed no documentation of patient scanning or medication scanning prior to the medication administration.

On 11/15/19 at 10:52 AM, Staff R reviewed the MAR for Patient #16 and stated the patient and medication were not scanned prior to the medication being given.