HospitalInspections.org

Based on a review of documentation, the governing body was not responsible for services furnished in the hospital.

Findings were:

Facility policy & procedure IM1.22 titled "Imaging Procedure - Resuscitation " states, in part, " A crash cart is kept in the CT and X-ray department ...The cart will be checked each morning by a Tech. The tech visually checking the cart must initial the calendar (on side of cart) after ensuring the defibrillators and suction are in working condition and all drawers are locked. If for any reason the cart has been opened, the tech will call respiratory to stock and replenish immediately. A pharmaceutical technician will then verify medication contents and replace the lock ...The x-ray technologist assigned to check the drug tray will visually check the drug tray daily to assure the lock is intact and to assure contents are in good condition. "

A review of the radiology crash cart daily checklist revealed that for the time period of 11-1-10 through 11-8-10, the " Pharm Lock# " column states, " unlocked " , indicating that the medication drawers of the imaging crash cart were unlocked.

The above was confirmed in a meeting with the Chief Financial Officer and the Director of Risk Management on the evening of 1-16-12 in the facility conference room.