HospitalInspections.org

Based on observation, interviews and documentation review the facility failed to provide care in a safe setting for 1 of 1 patient (patient #1) when the correct emergency equipment was not available on the crash cart when the patient experienced a cardiac arrest.
Findings include:

A review of patient #1's medical record established that she was admitted with diagnoses including schizo-affective disorder, obstructive sleep apnea and hypertension. A progress note dated June 10, 2011 at 10:35 p.m. by nurse (B) indicated that when he attempted to check patient #1's blood glucose at approximately 8:50 p.m. he found her to be unresponsive and CPR was initiated. A progress note by physician (D) on June 10, 2011 at 9:24 p.m. reflected that CPR was being completed and attempts were made to assess a rhythm with the crash cart monitor but this was unsuccessful because the pads would not connect to the crash cart monitor. Staff obtained the AED machine on the unit and could not detect a shockable rhythm. The cardiac arrest record for patient #1 dated June 10, 2011 reflects that no adult patches were available.

Nurse (B) was interviewed on June 29, 2011 at 3:40 p.m. and stated that the wrong pads were present on the crash cart for the crash cart monitor so the AED was obtained from another location on the unit. Nurse (B) clarified during the interview that patient #1 was found unresponsive at 7:55 p.m. not 8:50 p.m. as noted in his progress note.

Physician (C) was interviewed on June 30, 2011 at 10:16 a.m. and confirmed that the pads on the crash cart did not fit the crash cart monitor. Physician (C) stated that an AED was obtained from another location on the unit and that this did not cause a delay in service to patient #1. Physician (C) stated that patient #1 was never found to have a shockable rhythm throughout the code.

Physician (D) was interviewed on June 30, 2011 at 9:20 a.m. and confirmed that the pads on the crash cart did not fit the crash cart monitor. He stated that the pads were needed to see if there was a shockable rhythm for patient #1. Physician (D) stated that the AED on that unit was obtained to assess rhythm and a shockable rhythm was not found. He stated that chest compressions continued while the AED was obtained and that it took a very short period of time to obtain the AED.

During the site visit two crash carts on the behavioral health units were observed as well as two on medical surgical floors. All of the crash cart checklists had been checked by nursing staff daily.

The policy and procedure titled Emergency Carts/Defibrillators dated October, 1997 indicates that a licensed staff member (RN, RT, PT, etc.) as designated by the Manager is responsible for checking the crash cart, oxygen cylinder levels, defibrillator, and documenting compliance on crash cart checklist.
This policy also indicates that all carts will be opened and checked for contents once monthly and following each use.