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Based on observations, interviews, and document review, the facility failed to ensure emergency patient care supplies in the crash cart were readily available and had not expired in 3 of 6 inpatient crash carts inspected.

Facility Findings:

Policy:

Supply Chain Services Inventory Ordering and Replenishment Ownership policy read, supply chain services performs distribution of expired products by gathering and delivering products to supply chain services for disposition.

References:

The Crash Cart restocking instructions read after the crash cart was used, it would be taken by the registered nurse (RN) coordinator or designee to central supply to be restocked. Pharmacy is responsible for restocking medications. Supply chain staff will update their daily log with a new lock number.

The Facility Adult Crash Cart Standardization list read, the CO2 end tidal detector PAR level was 1 for each crash cart.

1. The facility failed to ensure all emergency supplies were readily available for use and expired emergency supplied had been removed from crash carts (supply cart for medical emergencies) throughout the facility.

a. On 12/3/19 at 10:45 a.m., a tour of the medical surgical unit was conducted. An observation of the crash cart revealed in drawer #1, two statlocks (a device used to stabilize an intravenous (IV) catheter) had an expiration date of 6/19.

Manager of Medical Surgical Unit (Manager #1) stated at the time of observation the expired statlock could not be used because the adhesive would not stick. Manager #1 stated supply chain staff restocked the supplies from the crash cart after it was used and monitored expiration dates. Manager #1 stated unit staff checked the crash cart daily to ensure the expiration date on the drawer of the crash cart was current and did not contain expired supplies. Manager #1 stated the label on the drawer indicated the name and date of the earliest expiring supply. It was observed during the observation, even though the stat lock expired 6/19, the expiration date on drawer #1 was noted to be 9/20. Additionally, it was noted on the supply list located on top of the crash cart which was maintained by supply chain staff the statlock would expire 4/1/22.

b. On 12/4/19 at 10:55 a.m., an observation of the operating room (OR) crash cart was conducted. It was observed the carbon dioxide (CO2) end tidal detector (used to determine proper placement after an emergency airway was inserted) had an expiration date of 7/19/19. The supply list located on top of the crash cart noted the CO2 end tidal detector would expire 7/1/19. The label on drawer #4 (identified as the airway drawer) indicated the earliest expiring supply would expire 12/19, even though the CO2 end tidal detector was already expired.

During the observation, Manager of Perioperative Services (Manager #2) stated the CO2 end tidal detector was expired and should not be used.

c. On 12/4/19 at 2:47 p.m., an observation of the crash cart in the post anesthesia care unit (PACU) was conducted. It was noted when the airway drawer was inspected, no CO2 end tidal detector could be located. According to the Facility Adult Crash Cart Standardization list, each crash cart should have one CO2 end tidal detector. Even though there was no CO2 end tidal detector in the cart, the supply list located on top of the cart listed the expiration date was 4/21/20.

Manager #2 stated the CO2 end tidal detector was placed on the airway once inserted to verify the airway was in the proper anatomical location.

d. On 12/5/19 at 11:32 a.m., an interview was conducted with Supply Chain Technician (Tech #5). Tech #5 stated she was responsible for stocking crash cart supplies and for monitoring the supply expiration dates on a monthly basis. Tech #5 stated she maintained the labels on the crash cart drawers as well as the list of supply expiration dates which were kept on the cart.

Tech #5 stated she was not trained on restocking the crash cart and monitoring expiration dates. She stated she created her own system with a trial and error process. Tech #5 stated as part of her trial and error process, she created the labels on the crash cart drawers which displayed the name and date of the earliest expiring supply stored in each drawer. Tech #5 stated she also maintained the supply list which was stored on top of the crash cart. The supply list was an inventory of what supplies went in each drawer with the expiration date. Tech # 5 stated the expiration date on the supply was meant to match the expiration date on the supply list. She stated if the expiration dates and the supply list did not match, there could be a hindrance in response to emergency situations.

Tech #5 stated a crash cart was used in emergent situations so staff would have easy access to equipment in order to quickly save a life. Tech #5 stated missing supplies would hinder the emergency response process. She stated staff should not use expired supplies because there would be no guarantee expired supplies would function as specified by the manufacturer.

Base on the onsite investigation completed January 2, 2020, the facility failed to comply with the regulations set forth for Life Safety and therefore, the following deficiencies were cited under Life Safety Code Tags K293, K321, K353, K372, K712, K914, and K918.