HospitalInspections.org

Based on record review and interview, the hospital failed to ensure crash carts were prepared for use for two (Emergency Department and Medical Surgical Unit) of two crash cart areas/units.

This failed practice has the likelihood to place patients who are in cardiac arrest at risk of receiving no or delayed life-sustaining treatment in an emergent situation, thereby reducing the possibility of survival.

Review of a policy titled "Crash Carts" read in part, "The Shift Supervisor will be responsible to daily check the integrity of the crash carts in the Medical Surgical and Women's Center areas. They will also discharge the defibrillators on each cart to ensure that they are working correctly. The Emergency Department RN will be responsible to do the same daily checks of the crash carts and defibrillators in the ED."

Finding:

A review of documents titled "SQSS Monitor/crash cart/O2 tanks checks" for the Emergency Department morning (AM) and evening (PM) shifts showed no documentation the crash cart was checked on the following dates:

Emergency Department:

March 2021: 16th PM, 18th PM, 19th AM, 25th AM, 25th PM

A review of documents titled "SQSS Crash Cart Check on Medsurg" for the Medical Surgical Department morning (AM) and evening (PM) shifts showed no documentation the crash cart was checked on the following dates:

Medical Surgical Unit:

March 2021: 1st AM, 4th AM, 5th PM, 6th AM, 9th AM, 16th AM, 26th PM

On 03/30/21 at 12:27 PM, Staff D reviewed the SQSS documentation and stated the following:
1. There were several missed crash cart checks
2. There were morning and evening tasks built into SQSS prompting staff to complete and document crash cart checks twice a day
3. Staff were expected to perform crash cart checks twice a day
4. The risk to patients was "essentially death" were crash cart checks not performed per policy or protocol

Based on observation, record review and interview, the hospital failed to ensure covered storage of clean linens for one (Medical Surgical clean supply room) of one clean supply rooms.

This failed practice has the likelihood to place patients, staff and visitors at risk of exposure to infectious agents.

Review of a policy titled "Nursing Services" read in part, "Prevention of infection is the main goal of the staff...Linen is stored in covered packages in the linen room and on closed shelving in the ER."

During a tour of the Medical Surgical unit on 03/30/21 from approximately 11:35 AM to 12:27 PM, bath towels and adult and pediatric gowns were observed uncovered on storage shelves in the clean supply room.

On 03/30/21 at approximately 12:02, Staff D stated the following:
1. Linens were supposed to be covered to prevent contamination and risk of infection to the patient
2. There was an ongoing issue with keeping them covered
3. No interventions had been attempted to address the issue