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Based on observation, documentation review, and interview it was determined that for 1 of 2 crash carts on the Cardiac Telemetry Unit (6 East), the Hospital failed to ensure the Charge Nurse supervised the assigned nurse to complete the crash cart checks. This has the potential to affect the safety of 43 patients on census as of 10/19/2021.

Findings include:

1. On 10/19/2021 approximately between 10:30 AM - 12:15 PM, an observational tour of the East 6 - Cardiac Telemetry Unit was conducted along with Charge Nurse (E #4), Nurse Manager (E #5) and Director of Nursing (E #9). During the tour, the following was observed:

-The Adult Crash Cart on side B of the Unit was last checked by the nurses on 10/17/2021 by the night shift. The crash cart on side B lacked the verification and checks by the nurses on 10/18/2021 both during the night shift and day shift.

2. On 10/19/2021 at approximately 11:00 AM, the Hospital document titled, "Daily Nursing Assignment Sheet on East 6" dated 10/18/2021, was reviewed and included, two (2) Registered Nurses (RNs) (1 day shift and 1 night shift) assigned to check the crash cart.

3. On 10/19/2021 at approximately 11:50 AM, the Hospital's policy titled, "Crash Carts" dated 10/17/2017, was reviewed and included, "...to have emergency equipment standardized and readily available for all patient care areas...The RN or designee will complete a daily crash cart check ...The Charge Nurse on each unit where the crash cart is stationed will assure that the crash cart is checked and stocked daily..."

4. On 10/19/2021 at approximately 11:55 AM, the Job Description of the Registered Nurse dated 04/09, was reviewed and included, " ...Promotes a safe environment by employing safety practices and procedures as outlined by departmental hospital policy...manage unit activities as assigned..."

5. On 10/19/2021 at approximately 11:15 AM, the Charge Nurse (E #4) was interviewed. E #4 stated that it is essential to complete the crash cart checks on a daily basis for patient safety.

6. On 10/19/2021 at approximately 11:25 AM, the Director of Nursing (E #9) was interviewed. E #9 stated that there were nurses assigned both during the night shift and day shift to do the crash cart checks. E #9 stated that she had to check to find out why it was not done.

Based on observation, document review and interview it was determined that for 2 of 2 medication pyxis reviewed, the Hospital failed to ensure the medication discrepancies were reviewed and resolved per standards of practice and staff policy as required.

Findings include:

1. On 10/19/2021, between 10:30 AM - 12:15 PM, an observational tour of the East 6 - Cardiac Telemetry Unit was conducted along with Charge Nurse (E #4), Nurse Manager (E #5) and Director of Nursing (E #9). During the tour, the following was observed:

-The Medication supply pyxis on side A of the East 6 Unit had twelve (12) medication discrepancies incidents dated 09/20/2021 - 10/18/2021, that were unresolved.

-The Medication supply pyxis on side B of the East 6 Unit had ten (10) medication discrepancies incidents dated 09/26/2021 - 10/13/2021, that were unresolved.

2. On 10/19/2021, at approximately 11:45 AM, the Hospital policy titled, "Controlled Substances Handling Policy and Procedures" dated 03/19/2021, was reviewed and included, " ...E. All Pyxis pockets are inventories once every 7 days by 2 licensed RNs ...All discrepancies are investigated and resolved immediately ...If unable to resolve a discrepancy, the PIC [Pharmacist In-Charge] or their designee from Pharmacy Department will be notified immediately ..."

3. On 10/19/2021 at approximately 11:15 AM, the Charge Nurse (E #4) was interviewed. E #4 stated that she was not sure why the medication discrepancies were not resolved. E #4 stated that while wasting any narcotic/controlled substance medication it should be witnessed by another nurse in real time and then it would not cause any type of discrepancies.

4. On 10/19/2021 at approximately 11:20 AM, the Nurse Manager (E #5) was interviewed. E #5 stated that she does not know why the medication discrepancies were not resolved in real time. E #5 stated that she will definitely look into it.

5. On 10/19/2021 at approximately 11:35 AM, the Advanced Pharmacy Technician (E #6) and the Pharmacy Operations Manager (E #7) were interviewed. E #6 stated that medication discrepancies were notified to the Nurse Manager (E #5) daily. E #7 stated that the medication discrepancies must be resolved immediately within 24 hours. E #7 stated that if the discrepancies are over 24 hours Pharmacy notifies the Charge Nurse (E #4) and the Nurse Manager (E #5) to resolve it with the nurses who caused the medication discrepancy.