HospitalInspections.org

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the CAH failed to ensure that policies/procedures specific to the maintenance of emergency crash carts were followed.
This deficient practice poses a risk to the health and safety of patients, when emergency supplies are not checked to ensure availability in an emergency.

Findings include:

The policy titled "Crash Cart Verification" requires: "...department personnel verify and document once every 12 hours that the non-secured items...are present and that the lock is intact...."

Review of the "Daily Crash Cart Checklists" for the crash cart located in the Observation Unit revealed that from October 1, 2018- January 2, 2019, the cart did not have any checks completed on 49 of 94 days. On 31 of 94 days, only one of the twice daily required checks were completed. On two days, only the lock number for the cart was documented. From January 3, 2019-April 18, 2019, there were no "Daily Crash Cart Checklists" present in the binder were the other forms were located, nor could any other forms be located.

Employee #1 confirmed in an interview conducted on 04/18/19, that no other checklists were present or could be located for either of the crash carts. Regarding the Observation unit, Employee #1 stated that there was a policy that required the crash cart to only be checked on days that the Observation unit was in use. This policy was not provided to the surveyors. Only one date was marked on the form to indicate that the unit was not in use on that day.

Employee #36 stated in an interview conducted on 04/18/19, that the Observation unit was being utilized at least ten days per month. However, documentation was not readily available to track on which days the Observation unit had been utilized.

Review of the monthly crash cart inventory forms for the pediatric crash cart located on the medical/surgical unit revealed that the forms for March and April of 2019 were not present or able to be located.

Review of the pediatric crash cart located on the medical/surgical unit revealed that there were no "Daily Crash Cart Checklists" present in the binder with the monthly inventory forms.

Employee #36 confirmed in an interview conducted on 04/18/19, that the forms provided to the surveyors were the only forms that could be located for either of the crash carts.