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Based on a facility tour, interviews with staff, medical record review, a review of facility policies and procedures, and review of other related documentation, it was determined that the facility failed to protect and promote the rights of the patients.

Findings include:

1. The facility failed to ensure that patients receive care in a safe setting (Cross refer to Tag A 144).


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2. The facility failed to ensure that the use of restraint was in accordance with a written modification to the patient's plan of care within a timeframe specified by hospital policy (Cross refer to Tag A 166).

3. The facility failed to ensure that the use of restraint was in accordance with the order of a physician or other licensed practitioner in accordance with hospital policy (Cross refer to Tag A 168).

Based on observation, staff interview and review of facility documents, it was determined that the facility failed to ensure a safe patient environment by implementing visitation and security policies and procedures.

Findings include:

Reference #1: Facility policy titled, "Visitor and Facility Access" states: "Policy: [facility name] provides for 24 hour a day, seven day a week visitation for family, friends and caregivers (visitors) of inpatients while maintaining a safe, secure and healing environment. The use of and access to [facility name] facilities is limited to patients, their visitors ... Proper identification must be provided at all points of entry. Unauthorized individuals will not be permitted on hospital property. ... [facility name] will respect and promote patient's rights to designate visitors of their choosing ... Purpose: To provide guidelines for facility access ... as well as outline a process for recording and identifying all individuals accessing [facility name]. ... The purpose of this policy is to provide guidance to: ... b. Provide restful, non-disruptive nursing care ... d. Promote safety and control appropriate access to the [facility] Procedure: The Safety and Security department will be responsible for the enforcement of this policy and will partner with the nurse managers and hospital leadership. Upon facility entry, all individuals must present proper identification to the ... security officer and if necessary, sign in and obtain a pass. ..."

Reference #2: Facility document titled, "Safety & Security Post Orders" states: "... Location: Emergency Department Main Entrance Coverage: 24/7 General Duties: Security personnel will be responsible for visitor control at the Emergency Department Main Entrance. Specific Duties: Request identification upon entrance to the facility of ALL visitors entering the Emergency Department, Maintain an accurate visitor log book. ..."

Reference #3: Facility document titled, "Visitor Pass" states: "... Please keep this pass visible while visiting us ..."

Reference #4: Facility document titled, "Lieutenant Check List" states: "... Keep an eye on your guards ...Leaving post without proper relief ..."

1. On 1/16/20 at 1:14 PM, review of facility video recorded surveillance and staff interview conducted with Staff #1 and Staff #2, revealed the following:

a. On 1/12/20 at 9:34 PM, two individuals were observed to enter the facility through the entrance lobby in the Emergency Department (ED).

(i) Staff #1 and Staff #2 confirmed that the individuals were not provided visitor passes and were not entered into the visitor log book because a security officer was not present in the lobby at the entrance to the ED upon their arrival. This was not in accordance with Reference #1 and #2 listed above.

(ii) Staff #2 explained that a security officer is present 24 hours a day, seven days a week at the ED entrance lobby, however, at the time of the individuals arrival, the security officer was attending to an incident that had occurred in another area of the facility at the time of the individuals arrival at the ED and was not relieved by another officer. This was not in accordance with Reference #2 and #4 listed above.

b. At 9:37 PM, the two individuals were observed at the desk located in the ED waiting area. One (1) of the individuals was observed to communicate with Staff #36, a patient care technician.

(i) Staff #2 confirmed that he/she provided Staff #36 with his/her name and chief complaint (later identified as Patient #10) and was told to be seated in the ED waiting area. Staff #2 explained that the individual (Patient #10) did not receive a patient identification band because he/she was not registered at this point in the encounter.

c. At 9:39 PM, Patient #10 and the accompanying individual were observed to re-enter the ED entrance lobby from the ED waiting room. A second accompanying individual was now observed with the patient in the lobby. Staff #2 confirmed that the security officer was still attending to another incident that had occurred in another area of the facility, therefore the second accompanying individual did not receive a visitor pass and was not entered into the visitor log book.

(i) Staff #2 confirmed that Staff #37, the ED security officer, was not present in the ED entrance lobby from 9:32 PM until 9:43 PM.

(ii) On 1/22/20 at 1:15 PM, Staff #1 explained that the "Lieutenant Check List" contained the duties to be carried out by the security departments shift supervisor. Staff #1 indicated that the shift supervisor was aware that Staff #37 was not at his/her post during the above referenced time frame and that he/she was not provided relief. This was not in accordance with Reference #4 listed above.

d. At 9:45 PM, Patient #10 was observed to enter the "G-Wing" elevators and exit onto the 5th floor, which contains the Intensive Care Unit (ICU), an Adult Medical Unit (AMU/5D) and the Cardiac Progressive Care unit (CPCU/5B).

(i) On 1/16/20 at 12:02 PM, Staff #6 explained that upon interview with Staff #39 and Staff #40, the patient was observed on the CPCU/5B unit at the nurse's station during the evening shift on 1/12/20.

(ii) Staff #6 stated that Staff #39 and Staff #40 asked the patient upon arrival to the unit, "Do you need help?" Staff #6 explained that Patient #10 stated "I figured it out."

(iii) Staff #6 explained that Staff #40 indicated that Patient #10 then proceeded to enter the patient care unit.

(iv) Staff #6 explained that Patient #10 proceeded to walk down the hallway of the unit and enter patient room number #535, which was occupied by Patient #2. Patient #10 was not a designated visitor of Patient #2. This was not in accordance with Reference #1 listed above and Patient #2 was not provided with a safe environment.

(v) On 1/16/20 at 10:24 AM, Staff #2 explained that on 1/13/20 at approximately 7:21 AM, a staff member looked out a window on the neonatology unit located on the third floor of the facility and observed a person lying on the roof top of the Women's and Children's building. Security was notified and while on the rooftop, a window above the patient was noted to be open. Staff #2 indicated that the open window was patient room #535. The person lying on the rooftop was later identified as Patient #10. Staff #2 confirmed that Patient #10 was transported to a trauma center. This was not in accordance with Reference #1 listed above and Patient #10 was not provided with a safe environment.

(vi) On 1/16/20 at 12:45 PM, Staff #6 explained that staff interviews were conducted with staff members from the CPCU/5B unit following the incident. Staff #6 confirmed that the Nursing Assistant assigned to Patient #2 in room #535 on the evening shift (3:00 PM - 11:30 PM) on 1/12/20 had observed that the window was cracked open but had failed to report it to nursing personnel.

2. The above findings were confirmed by Staff #1 and Staff #2.

Based on a review of two (2) of three (3) medical records of patients who were physically restrained, review of policy and procedure, and interview with administrative staff, it was determined that the use of restraint is not in accordance with a written modification to the patient's plan of care within a timeframe specified by hospital policy for Patient #1 and Patient #14.

Findings include:

Reference: Policy and procedure titled, "Restraint Management: Medical-Surgical, Non-Behavioral" states: "....
PROCEDURE: .....E. Monitoring/Care of the Patient While in Restraint: .....7. Modify the patient's plan of care related to the use ofrestraint [sic] ....."

1. The above referenced policy failed to specify the timeframe for revision of the plan of care for a patient who is physically restrained.

2. Review of the medical record of Patient #1 revealed that the patient was initially physically restrained in soft bilateral wrist restraints for interference with care and treatment beginning at 4:45 AM on 1/17/20. The order was time limited to 24 hours and was continuously renewed through 1/20/20. There was no evidence in the medical record that the patient's written plan of care was revised at any time.

3. Review of the medical record of Patient #14 revealed that the patient was initially physically restrained in soft bilateral wrist restraints for interference with care and treatment beginning on 1/13/20 at 5:00 PM. The order was time limited to 24 hours and was continuously renewed until 9:20 AM on 1/17/20. There was no evidence in the medical record that the patient's written plan of care was revised at any time during this time frame.

4. Administrator #1 agreed with the findings.

Based on a review of policy and procedure and the medical records of two (2) of two (2) patients who were physically restrained for medical reasons (Medical Records #1 and #14) and interview with administrative staff, it was determined that the use of restraint was not in accordance with the order of a physician or other licensed practitioner in accordance with hospital policy.

Findings include:

Reference: Policy and procedure titled, "Restraint Management: Medical-Surgical, Non-Behavioral" states: "POLICY: .....4. The maximum duration for a medical/surgical non behavioral restraint order purpose is 24 hours. 5. The attending physician or LIP (licensed independent practitioner) shall evaluate the restrained patient once every 24 hours and determine the need for continued restraints. 6. Continued use of restraint beyond the timeframe ordered must be authorized by Licensed Independent Practitioner (LIP) based on a face to face examination of the patient to determine clinical justification and the least restrictive type of restraint needed to manage the situation. ..... PROCEDURE: .....F. Early Termination and Discontinuation of Restraint ..... 4. If restraints are removed for any reason (even if within the current order timeframe) based on a change in risk or behavior, a new order is necessary based on anew [sic] assessment of risk and associated behaviors. This applies whether or not the risks and demonstrated behaviors necessitating reapplication of restraint are the same or are new. ....."

1. Review of the medical record of Patient #1 revealed:

a. A "Daily Assessment Inquiry" form dated 1/17/20 at 4:45 AM stated: "Restraints Initiated."

b. A LIP order in the medical record entered at 5:03 AM on 1/17/20 authorized the use of bilateral soft wrist restraints until 5:03 AM on 1/18/20.

c. The next restraint order, after the 1/17/20 order entered at 5:03 AM, was entered at 7:35 AM on 1/18/20 for bilateral soft wrist restraints until 7:35 AM on 1/20/20.

d. Nursing documentation indicated that the patient was continuously in restraints between 4:45 AM on 1/17/20 and 7:35 AM on 1/20/20.

(i) The patient had already been in restraints for 18 minutes when the initial order was entered for an additional 24 hours. There was no physician order covering the initial 18 minutes that the patient was restrained.

(ii) There was no restraint order in the medical record covering the use of restraints for the 2 hours and 32 minutes between the expiration of the original order and the next order.

2. Review of the medical record of Patient #14 revealed:

a. A RESTRAINT ORDERS sheet stated that at 5:00 PM on 1/13/20, the patient was ordered to be restrained in bilateral soft wrist restraints for "Up to 24 hours" for "Pulling at tube(s)/dressing/drains." The next restraint order after the 1/13/20 order entered at 5:00 PM was entered at 7:59 PM on 1/14/20 for bilateral soft wrist restraints until 7:59 AM on 1/15/20.

(i) There was no restraint order in the medical record covering the use of restraints for the 2 hours and 59 minutes between the expiration of the original order and the next order.

b. A restraint order dated 1/17/20 at 9:20 AM authorized the use of bilateral soft wrist restraints until 9:20 AM on 1/18/20. A "Group Note" at 2:00 PM on 1/17/20 stated: "patient being weaned off sedation, calm and monitoring closely, trial restraints off at this time." A "Daily Focus Assessment Report" entry stated that at 8:00 PM on 1/17/20, the patient's upper extremities were restrained.

(i) There was no new order for restraints until 3:32 PM on 1/18/20.

3. Administrator #1 agreed with the findings.

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Based on observation, interviews with administrative staff, review of policy and procedure, and review of related documentation, it was determined that the facility failed to be constructed and maintained to ensure the safety of patients and to provide facilities appropriate to the needs of the patient community.

Findings include:

1. The facility failed to ensure the overall hospital environment was maintained for the safety and well-being of the patients, staff, and public (Cross refer to Tag A 701).

2. The facility failed to ensure that facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality (Cross refer to Tag A 724).

A. Based on observation, staff interview and document review, it was determined that the facility failed to ensure the hospitals risk assessment includes windows that open on upper floors of the facility.

Findings include:

1. On 1/21/20 at 2:35 PM, a review of the hospital's Environmental Risk Assessment, dated 4/24/18, lacked the identification of windows that open on upper floors of the hospital as a potential safety risk.

a. During an interview at 11:00 AM, Staff #8 confirmed that patient windows on the 5th floor can open to create an approximate seven (7) inches wide opening when screws are loose or missing.

b. During an interview at 11:05 AM, Staff #8 confirmed the window in occupied patient Room #535 was found open on 1/13/20.


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B. Based on staff interview and document review, the facility failed to ensure the implementation of security measures in accordance with facility documents.

Findings include:

Reference #1: Facility document titled, "Safety & Security Post Orders" states: "... Location: Emergency Department Main Entrance Coverage: 24/7 General Duties: Security personnel will be responsible for visitor control at the Emergency Department Main Entrance. Specific Duties: Request identification upon entrance to the facility of ALL visitors entering the Emergency Department, Maintain an accurate visitor log book. ... Inform the Security Operations Center (SOC) upon arrival of any government/state agency. (Police, ...)"

Reference #2: Facility document titled, "Lieutenant Check List" states: "... Keep an eye on your guards ...Leaving post without proper relief ..."

1. Upon interview and review of facility video recorded surveillance conducted with Staff #1 and Staff #2 on 1/16/20 at 1:14 PM, the following was revealed:

a. On 1/12/20 at 9:34 PM and 9:39 PM, there was no security personnel observed at the assigned post in the Emergency Department (ED) Main Entrance lobby.

(i) Staff #2 confirmed that Staff #37, the ED security officer, was not present in the ED entrance lobby from 9:32 PM until 9:43 PM.

2. Upon interview with Staff #1 on 1/22/20 at 12:20 PM, the following was revealed:

a. Staff #1 explained that the "Lieutenant Check List" contained the duties to be carried out by the security department shift supervisor. Staff #1 indicated that the shift supervisor was aware that Staff #37 was not at his/her post on 1/12/20 from 9:32 PM until 9:43 PM and that he/she was not provided relief.

(i) Staff #1 confirmed that all security personnel are to be provided relief before leaving their assigned post.

b. Staff #1 confirmed that on 1/12/20 at 10:23 PM, the local police department arrived at the facility. Staff #1 stated that Staff #37 did not inform the Security Operations Center upon their arrival.

3. The above findings were confirmed by Staff #1 and Staff #2.

Reference #3: Facility document titled, "1st Shift Console Operator Check List" states: "... Get properly briefed by the previous Console Operator...**Note: At any time that an incident occurs and has footage review to support the incident, the footage must be booked marked and downloaded no matter what time it is. It is your responsibility to complete ALL your duties during your shift.** ..."

Reference #4: Facility document titled, "[security company name] Security Employee Manual" states: "... 2.3 Chain of Command, All security Officers employed by ... Security must follow the Chain of Command, ... A typical Chain of Command includes the following: Security Officers report to the shift supervisor ..."

1. Upon interview with Staff #2 on 1/16/20 at 2:00 PM, the following was revealed:

a. On 1/12/20 at 9:52 PM, a call was placed by Staff #36 to a security officer (Shift Console Operator) in the Security Operations Center to report that the individual who accompanied Patient #10 to the Emergency Department was unable to locate him/her.

b. Staff #2 explained that after the call was received from Staff #36, the Shift Console Operator began to review facility recorded video surveillance and was able to identify that Patient #10 was in the facility.

(i) Staff #2 then proceeded to explain that another incident had occurred at the facility at approximately the same time the call was received in regard to Patient #10's whereabouts. The Shift Console Operator stopped the review related to Patient #10 and then proceeded to review footage from the other incident that had occurred. Staff #2 explained that the Shift Console Operator did not continue review of surveillance related to Patient #10 and that he/she had thought that the patient left the facility.

c. Staff #2 explained that on 1/12/20 at 10:00 PM, during change of shift, the outgoing Shift Console Operator did not provide clear communication related to Patient #10 to the oncoming Shift Console Operator. Staff #2 confirmed that the outgoing officer stated to the oncoming officer, "We are just looking for a ... in a blue sweatshirt" and that continued video surveillance review was not conducted by the oncoming shift.

2. On 1/22/20 at 1:15 PM, Staff #1 confirmed that the Shift Console Operator who received the call from Staff #36 did not book mark or download the video surveillance footage that he/she visualized of Patient #10 during his/her shift on 1/12/20. Staff #1 also confirmed that the Shift Console Operator did not report the information related to Patient #10 to the shift supervisor.

3. The above findings were confirmed by Staff #1 and Staff #2.

A. Based on a tour of two (2) of two (2) patient care units, review of hospital policies and procedures, and interview with administrative staff, it was determined that facilities and supplies are not maintained to ensure an acceptable level of safety and quality.

Findings include:

Reference #1: Policy and procedure titled, "Pediatrics" states: "I. POLICY: .....Toy Cleaning: a. Toys will be cleaned with a hospital-approved disinfectant, rinsed thoroughly and allowed to air dry. ....."

Reference #2: The "Frequently Asked Questions" section of the website of the manufacturer of Super Sani-Cloths, PDI (pdihc.com) states: "..... Can Sani-Cloth® Germicidal Disposable Wipes be used on toys?
Sani-Cloth wipes are available in EPA-Registered formulations that are approved and labeled for use on hard, non-porous toys. The products clean and disinfect in a one-step process, unless visibly soiled. Once disinfected, toys should be rinsed with potable water (tap water) to remove any residue and allowed to air dry. According to the Association for Professionals in Infection Control and Epidemiology (APIC), the recommended procedure for disinfecting toys is "Toys should be cleaned/disinfected between patients, especially those that are visibly soiled, mouthed, or used by patients in isolation. Toys should be washed thoroughly; disinfected with a non-toxic, low-level disinfectant and air dried completely." Infection control experts recommend only washable toys for sharing. .....
toys that cannot be cleaned and disinfected should not be shared."

Reference #3: Policy and procedure titled, General Employee Overview of the Saint Peter's Healthcare System Infection Prevention & Control Program" states: ".....III. PROCEDURE: .....4. Cleaning of Patient Care Equipment - The Super Sani-Cloth (Registered) Plus Germicidal Disposable Cloth can be safely used to disinfect hard non-porous surfaces (i.e., phones, computer, keyboards) ..... 6. Refrigerators - ..... Keep refrigerators clean .....
7. Storage of Supplies - Storage areas must be kept clean, organized and free of clutter. Store supplies 18 inches from the ceiling and 8 inches off the floor. .....10. Patient Care Areas/Nursing Stations - Keep areas organized, neat and free of clutter. No eating or drinking is allowed in any nursing station. No eating or drinking is allowed in any patient care areas where there is the potential for exposure to blood, body fluids or other potentially infectious material. ....."

Reference #4: Policy and procedure titled, "Security of Drugs, Needles, and Syringes" states: "PURPOSE: To ensure appropriate security for all medications, needles, and syringes. .....B. NEEDLES AND SYRINGES
All needles and syringes are to be stored in a locked storage area until immediately prior to use."

1. A tour of the Emergency Department on the morning of 1/17/20, accompanied by Administrators #5 and #7 revealed:

a. Nourishment Area (Hallway):

(i) There was a white crystal substance on the shelf beneath the microwave oven.

(ii) There was sugar residue at the bottom of a wall dispenser containing packets of sugar.

b. Pod C Charge Nurse Station:

(i) There was heavy dust, dust clumps, and grit beneath a rolling metal cabinet.

(ii) There was heavy dust, dust clumps, grit, and hair under a metal cabinet beneath the counter. There were crumbs in the bottom drawer of the cabinet.

(iii) There was heavy dust, dust clumps, and grit under a metal cabinet beneath the counter. An unlocked drawer in the cabinet contained an assortment of needles and syringes. Staff #32, a registered nurse, who was seated in the nurse station stated that if he/she has to leave the area that he/she does not lock the cabinet containing the syringes and needles.

(iv) There were two 5-pound weight plates stuck to the floor under the counter.

(v) There were clumps of dust and tangled hair on the casters of a chair.

c. Pod A Registrar Area:

(i) There was heavy dust and dust clumps under the counter.

(ii) A hard drive and a Powervar Power Conditioner beneath the counter were covered heavily in dust and dust clumps. The power cords and Velcro straps holding the two pieces of equipment to a metal dolly were also heavily coated in dust. There was a crumpled paper towel, an opened salt packet, a bag containing pretzel sticks, plastic caps, paper scraps and other refuse on the rear of the dolly.

(iii) A corrugated cardboard box of copy paper was on the floor under the counter.

d. Pod A Nurse Station:

(i) A candy wrapper, dust, plastic caps, hair, and a used alcohol pad were under a cabinet beneath the counter.

(ii) A dried alcohol pad was stuck to the wall.

(iii) On the counter behind a computer was a coat of dust, candy wrappers, and paper scraps.

e. Pod A Hallway: A side rail pad laying on the floor beneath the blanket warmer had an approximately 6 inch by 1 inch tear exposing the foam interior.

f. Pod A Point of Care Testing Area: The January 2020 "Department of Laboratory Medicine and Pathology Point of Care Testing Clinitek Status + Analyzer Maintenance And Action Log" sheet included the instructions: "Routine cleaning of test table and calibration strip inspection: (To be performed each day analyzer is in use for patient testing)." There were no entries on the log to indicate that the test table was cleaned, and the calibration strip was inspected on January 2, 5, 10, or 11.

g. Pod A and C Clean Utility Room: Corrugated boxes were set atop unfinished 2X4s on the floor. Unfinished wood is an uncleanable surface and there was no clearance beneath the wood to clean the floor.

h. Pod B Pharmacy Desk:

(i) There was dust behind and beneath a cabinet under the counter.

(ii) There were 7 syringes in an unattended pigeon hole storage bin.

i. Pod B Medication Room:

(i) A wall cabinet containing syringes and Vaccutainers also had a metal beverage cup with a plastic cover. Inside of the cup was a liquid that smelled like brewed coffee. The liquid in the cup had a film of black and green mold atop it. When the liquid was poured out, clumps of black and green mold were visible in the cup and in the sink.

2. A tour of the Pediatric Unit on the afternoon of 1/17/20, accompanied by Administrators #5 and #7 revealed:

a. Hallway: There was a syringe atop an unattended cart.

b. Play Room:

(i) There was dust on the floor beneath and behind the folding toy cabinet.

(ii) There were unfinished wooden toys (i.e., cars, trains, etc.) in the folding toy cabinet. When questioned by the surveyor how the wooden toys were cleaned, Staff #30 stated that Super Sani-Cloths are used to clean all of the toys. Per the manufacturer's instructions for use, only non-porous toys may be cleaned with the wipes. Unfinished wood is a porous surface.

c. Stairwell: There was peeling paint and plaster on the wall and pieces of plaster, plaster residue, and paint on the floor visible through the emergency exit door window.

d. Clean Utility Room: There were 20 corrugated cardboard boxes of supplies on the floor.

e. Patient Room RM291G: The ceiling vent was heavily encrusted with dust.

f. Nurse Station:

(i) There was heavy dust, paper scraps, and a small plastic medication bag under a metal cabinet.

(ii) There was a bag of pretzels, wrappers, heavy dust, dust clumps, caps, and cellophane beneath and behind the printer.

(iii) There was heavy dust and dust clumps under a hard drive an on the hard drive cord.

(iv) There was a candy wrapper, a used tissue, and dust beneath and behind a printer on a counter.

(v) The floor behind and beneath the shredder box had chads and dust on it.

g. Pantry:

(i) There was a coat of dust atop the refrigerator.

(ii) There was hair, crumbs, paper scraps, and grit in two drawers containing saltine packets.

(iii) There was heavy dust, clumps of dust, grit, a mop head, an empty push-pop wrapper, tacky stains, dried stains, straws, paper scraps, a package of cereal, and other refuse beneath and behind the Ice Pop Freezer. The back of the freezer had heavy tacky staining on it. The wall behind the freezer had similar stains on it.

(iv) The ceiling vent was encrusted with dust.

h. Residents Area:

(i) Drawers on the floor with a printer atop them had heavy dust and other refuse inside and behind them. The drawers were stuck to the floor.

(ii) There were corrugated boxes of paper on the floor.

(iii) A brown pill, chocolate chip cookie pieces and crumbs, dust, dust clumps, and other refuse were observed under a rolling cabinet beneath the counter.

(iv) There was heavy dust atop the counter.

i. Medication Room:

(i) There were yellow plastic bins on a shelf with brown raised stains on them.

(ii) There was a coat of dust atop the refrigerator.

(iii) There was heavy dust on the floors and power cords.

(iv) The ceiling vent was encrusted with dust.

B. Based on a review of the code carts on two patient care units and interview with administrative staff, it was determined that equipment is not maintained to ensure an acceptable level of safety and quality.

Findings include:

Reference: The instructions on the Code Cart Checklist (12 hour shifts) form states: ".....
Your signature on this list indicates that you have checked each cart for the following:
1. Cart number being checked.
2. Intact lock & all drawers secure.
3. Expiration date is in compliance.
4. Cardiac board in place.
5. O2 tank full. (Needle indicator in green)
6. a. Defibrillator* is tested unplugged at manufacturer's recommended joules.
b. Test strip shows that this amount was delivered.
c. Ensure defibrillator plugged in and battery light on.
7. Central alarm monitor check: all alarms on and at least 50% audibility or at least three bars sound level.
.....
ADULT CODE CART - Red intubation tray in place and date in compliance.
....."

1. Review of the A Pod Adult Emergency Department Code Cart Checklists for the month of January 2020 (7A-7P & 7P-7A) revealed:

a. There were no entries made on the 7A-7P Checklist indicating that any of the required checks were done on January 2, 3, 8, and 9.

b. On January 4, the 7A-7P Checklist indicated that Cart #48 was replaced with Cart #12 and remained as the code cart until at least January 7. The 7P-7A Checklist contained entries that Cart #48 was still in use on January 4 and 5.

2. Review of the C Pod Adult Emergency Department Code Cart Checklists for the month of January 2020 (7A-7P & 7P-7A) revealed:

a. There were no entries made on the 7A-7P Checklist indicating that any of the required checks were done on January 2.

b. The "Central Alarm Monitor" section of the 7A-7P Checklist for January 21 contained the written entry "N/A" (Not Applicable) and "BROKEN (IN REPAIR)" on the 7P-7A Checklist. Administrator #1 stated during interview that "N/A" is not an acceptable entry.

c. The "Central Alarm Monitor" section of the 7A-7P Checklist for January 22 contained no entry and a "O" on the 7P-7A Checklist.

3. The "Central Alarm Monitor" section of the B Pod Adult Emergency Department 7A-7P Checklist for January 5 contained the written entry "O."

4. Administrator #1 agreed with the findings.