HospitalInspections.org

Based on observation, interview, testing, manufacturer's guidelines review, and policy review, the provider failed to ensure one of two registered nurses (RN) (C) had been able to perform a manual safety check on one of two defibrillators. Findings include:

1. Random observations on 7/12/16 from 10:10 a.m. through 11:10 a.m. of the emergency department and the nurses' station revealed a defibrillator located in each of those areas.

Review of the emergency department and nurses' station crash cart check lists schedule from 6/1/16 through 7/12/16 revealed:
*The defibrillators had been checked by the nursing staff twice a day.
*A defibrillator test strip had been run during each of those checks. The staff had documented "y" or "yes" to confirm a test strip had been run.
*The nursing staff had documented with a "----" or "pass" to confirm the results of the strip test and support a successful joules test.
*No documentation to support:
-The nursing staff had completed any manual safety checks on the defibrillators.
-The competency and capability of the nursing staff to use the defibrillator in manual mode.
-The test strip results were randomly supported with manual safety checks of the defibrillators to ensure the continued safety of their patients.

Review of the provider's LifePak 15 inservice regarding the type of defibrillator they had revealed the nursing staff had not been educated on the defibrillator since 1/14/15.

Review of the provider's 6/16/16 Nursing Staff Meeting Agenda revealed no documentation to support the staff had completed any LifePak 15 defibrillator training.

Interview and testing on 7/13/16 at 11:15 a.m. with registered nurse (RN) D revealed:
*The defibrillators had been checked by the nursing staff twice a day to ensure proper functioning.
*She confirmed the staff had only run a test strip from the defibrillators to check for a "pass" or "fail" of the machines. The "pass" on the test strips would have reflected a proper functioning defibrillator.
*The staff would not have completed any manual checks on the defibrillators.
*The nursing staff recently had an equipment fair meeting in June. That meeting included training on the defibrillators.
*The nursing staff had training on the defibrillators every two years when they completed their advanced cardiac life support course.
*She had been capable of completing a manual check on the defibrillator upon request from the surveyor.

Interview on 7/13/16 at 11:30 a.m. with RN C revealed:
*She confirmed the staff checked the defibrillators for proper functioning twice a day.
-That check had only included running a safety test strip.
*She had stated "We do manual safety checks on the defibrillators."
*She agreed the crash cart check lists had not supported any documentation of manual safety checks completed by the staff.
-She had stated "That form doesn't have a place to document a manual check."
*She refused to do a manual safety check on the defibrillator at the nurses' station upon request from the surveyor.
-She had stated "I did not attend the equipment fair meeting, so I don't remember how to do it."

Interview on 7/13/16 at 12:30 p.m. with the chief nursing officer (CNO) revealed:
*She had:
-Confirmed the documentation of the crash cart check lists did not support any manual safety checks on the defibrillators.
-Stated "Some nurses do manual safety checks and some do not."
*The staff were educated yearly on the defibrillators that included a competency test in manual mode.
*She confirmed:
-The provider had not ensured the staff had been educated on the defibrillators for over a year.
-The nursing staff meeting in June 2016 had included equipment training, however it had not included defibrillator safety checks and operation of the machine.
-The nursing staff had determined what equipment they wanted to be educated on during their last meeting in June 2016.
*She had no documentation to support any competency tests were completed by the nursing staff to ensure they could use the defibrillator in manual mode.
*She would have expected:
-The nursing staff to complete a manual safety check on the defibrillators if the test strip had failed.
-All the nursing staff to have been able to complete a safety check on the defibrillators in manual mode.

Review of the provider's April 2013 LifePak 15 Monitor/Defibrillator Manufacturer's guidelines revealed:
*"It is important to understand defibrillator operation."
*No documentation to support how often the nursing staff should have performed manual safety checks on the equipment.

Review of the provider's July 2015 Crash Cart policy revealed:
*"The defibrillator is tested and # of joules noted and recorded every 24 hours approximately 6 a.m. by the night charge nurse."
*No documentation to support how often the staff should have:
-Completed manual safety checks on the LifePak 15 defibrillators.
-Been trained on the proper use and functions of the LifePak 15 defibrillators.

Based on observation, interview, testing, manufacturer's guidelines review, and policy review, the provider failed to ensure one of two registered nurses (RN) (C) had been able to perform a manual safety check on one of two defibrillators. Findings include:

1. Random observations on 7/12/16 from 10:10 a.m. through 11:10 a.m. of the emergency department and the nurses' station revealed a defibrillator located in each of those areas.

Review of the emergency department and nurses' station crash cart check lists schedule from 6/1/16 through 7/12/16 revealed:
*The defibrillators had been checked by the nursing staff twice a day.
*A defibrillator test strip had been run during each of those checks. The staff had documented "y" or "yes" to confirm a test strip had been run.
*The nursing staff had documented with a "----" or "pass" to confirm the results of the strip test and support a successful joules test.
*No documentation to support:
-The nursing staff had completed any manual safety checks on the defibrillators.
-The competency and capability of the nursing staff to use the defibrillator in manual mode.
-The test strip results were randomly supported with manual safety checks of the defibrillators to ensure the continued safety of their patients.

Review of the provider's LifePak 15 inservice regarding the type of defibrillator they had revealed the nursing staff had not been educated on the defibrillator since 1/14/15.

Review of the provider's 6/16/16 Nursing Staff Meeting Agenda revealed no documentation to support the staff had completed any LifePak 15 defibrillator training.

Interview and testing on 7/13/16 at 11:15 a.m. with registered nurse (RN) D revealed:
*The defibrillators had been checked by the nursing staff twice a day to ensure proper functioning.
*She confirmed the staff had only run a test strip from the defibrillators to check for a "pass" or "fail" of the machines. The "pass" on the test strips would have reflected a proper functioning defibrillator.
*The staff would not have completed any manual checks on the defibrillators.
*The nursing staff recently had an equipment fair meeting in June. That meeting included training on the defibrillators.
*The nursing staff had training on the defibrillators every two years when they completed their advanced cardiac life support course.
*She had been capable of completing a manual check on the defibrillator upon request from the surveyor.

Interview on 7/13/16 at 11:30 a.m. with RN C revealed:
*She confirmed the staff checked the defibrillators for proper functioning twice a day.
-That check had only included running a safety test strip.
*She had stated "We do manual safety checks on the defibrillators."
*She agreed the crash cart check lists had not supported any documentation of manual safety checks completed by the staff.
-She had stated "That form doesn't have a place to document a manual check."
*She refused to do a manual safety check on the defibrillator at the nurses' station upon request from the surveyor.
-She had stated "I did not attend the equipment fair meeting, so I don't remember how to do it."

Interview on 7/13/16 at 12:30 p.m. with the chief nursing officer (CNO) revealed:
*She had:
-Confirmed the documentation of the crash cart check lists did not support any manual safety checks on the defibrillators.
-Stated "Some nurses do manual safety checks and some do not."
*The staff were educated yearly on the defibrillators that included a competency test in manual mode.
*She confirmed:
-The provider had not ensured the staff had been educated on the defibrillators for over a year.
-The nursing staff meeting in June 2016 had included equipment training, however it had not included defibrillator safety checks and operation of the machine.
-The nursing staff had determined what equipment they wanted to be educated on during their last meeting in June 2016.
*She had no documentation to support any competency tests were completed by the nursing staff to ensure they could use the defibrillator in manual mode.
*She would have expected:
-The nursing staff to complete a manual safety check on the defibrillators if the test strip had failed.
-All the nursing staff to have been able to complete a safety check on the defibrillators in manual mode.

Review of the provider's April 2013 LifePak 15 Monitor/Defibrillator Manufacturer's guidelines revealed:
*"It is important to understand defibrillator operation."
*No documentation to support how often the nursing staff should have performed manual safety checks on the equipment.

Review of the provider's July 2015 Crash Cart policy revealed:
*"The defibrillator is tested and # of joules noted and recorded every 24 hours approximately 6 a.m. by the night charge nurse."
*No documentation to support how often the staff should have:
-Completed manual safety checks on the LifePak 15 defibrillators.
-Been trained on the proper use and functions of the LifePak 15 defibrillators.