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Based on policy and procedure review, Crash Cart check sheets review, and interview, it was determined the facility failed to ensure one of one Emergency Room (ER) Crash Cart examined was checked every shift by ER personnel. Failure to check the crash cart every shift did not ensure the defibrillators were functional and working in the event they were needed for patient care. The failed practice had the potential to affect any patient whose care required the use of the defibrillator. Findings follow:

A. Review of the policy and procedure titled "Crash Cart and Defibrillator Checklist Instructions," received at 1:40 PM on 08/30/18 showed the defibrillator was to be checked every day on each shift, as well as the contents and the medication list. When the above was accurate, the nurse was to sign her name.

B. Review of the ER Crash Cart at 8:50 AM on 08/30/18 showed three (07/27/18-07/29/18) of 31 (07/01/18-07/31/18) night shifts were not documented as checked for the month of July. Review of the August checklist showed three (08/16/18, 08/26/18, and 08/29/18) of 28 (08/01/18-08/28/18) night shifts were not documented as checked. During an interview with the Chief Nursing Officer at 8:55 AM on 08/30/18 he verified the above findings.


Based on policy and procedure review, clinical record review and interview, it was determined Emergency Room staff failed to follow policy and procedure in that two (#3 and #4) of twelve (#1-12) patients were not triaged or triaged at the level outlined in policy. Failure to follow the triage policy and procedure did not ensure the patients received the level of care required in a timeframe dictated by the triage assessment. The failed practice had the potential to affect Patients #3 and #4. Findings follow:

A. Review of the policy and procedure titled "Triage Priority Classification," received from the Chief Quality Director at 9:00 AM on 08/30/18 showed a brief triage was to be conducted by the nurse, to determine the priority of care necessary and the appropriate area for further evaluation and treatment. Once categorized, all patients assigned an ESI (Emergency Severity Index) score of 1 and 2 were to be escorted to the treatment area and assigned a primary nurse upon triage. Review of the policy and procedure also showed patients who were high risk, confused, lethargic or disoriented, or in severe pain or distress were classified as a ESI Level 2.

B. Review of Patient #3's clinical record showed lethargic listed under clinical presentation and an ESI score of 4 assigned by Registered Nurse #1 at 10:37 PM on 06/23/18. Per policy and procedure, the screening of lethargy should have placed Patient #3 at an ESI level of 2.

C. Review of Patient #4's clinical record showed a Triage date and time of 8:12 PM on 07/08/18 by RN #3. Review of Patient #4's clinical record showed no ESI level documented.

D. During an interview with the Clinical Documentation Improvement Manager at 11:43 AM on 08/30/18 the findings in B and C were verified.