HospitalInspections.org

Based on observation, staff interview and review of facility documents, it was determined that the facility failed to ensure implementation of its "Emergency Equipment (Code Cart and Defibrillator) Checking Procedure" policy by ensuring medications within the code cart are not expired.

Findings include:

Reference: Facility policy titled "Emergency Equipment (Code Cart and Defibrillator) Checking Procedure" states, "...Purpose: To establish a process to insure that the crash cart, intubation box and defibrillator(s) are checked daily for expiration dates and functionality. ...Procedure: RN's [Registered Nurses] and RT's Respiratory Therapists] will check the Emergency Equipment/Crash Cart daily for: ...No expired medications (this drawer is maintained by pharmacy)..."

1. On 9/17/2021 at 11:12 AM, a tour of 5th floor LTACH (Long Term Acute Care Hospital) was conducted, in the presence of Staff #2 and Staff #3.

a. At 11:15 AM, a code cart located in the hallway was observed to have an orange sticker on the top drawer. The sticker indicated that a medication within the code cart was to expire; the date 8/31/21 was written on the sticker.

(i) The code cart was opened by Staff #2 and the first drawer contained a sealed medication tray. There was another sticker on top of the medication tray that indicated the first medication to expire was on 1/31/22. Staff #2 confirmed that the sticker should have been placed on the outside of code cart.

(ii) The facility document titled "Top of Code Cart Daily Checklist" located on top of the code cart was reviewed. The checklist stated, "...Please sign after the appropriate date upon completing your daily check. ..." The checklist contained staff signatures from September 1 through September 17, indicating the code cart was checked.

b. At 11:18 AM, a code cart (#2) located in the hallway was observed to have an orange sticker on the top drawer. The sticker indicated that a medication within the code cart was to expire; the date 7/31/21 was written on the sticker.

(i) The code cart was opened by Staff #2 and the first drawer contained a sealed medication tray. There was a document titled "Code Blue Tray" lying on top of the medication tray. The document contained a list of medications with the expiration dates. The following medications expired on 7/31/21: Lidocaine 2% Syringe 100 mg (milligram) / 5 ml (milliliter) quantity 3 and Amiodarone 300 mg / 6 ml quantity 2.

(ii) At 11:20 AM, upon interview, Staff #2 confirmed that when staff perform the daily checklist of the code cart, the sticker should be checked for expired medications.

(iii) The facility document titled "Top of Code Cart Daily Checklist" located on top of the code cart was reviewed. The checklist stated, "...Please sign after the appropriate date upon completing your daily check. ...Year: 2021 Month: September Floor: 5th Floor Crash Cart #: 2 ..." The checklist contained staff signatures from September 1 through September 17, indicating the code cart was checked.

(iv) A request was made to review the daily code cart checklist for August 2021. The "Top of Code Cart Daily Checklist" was provided by Staff #2 and was reviewed. The checklist stated, "...Please sign after the appropriate date upon completing your daily check. ...Year: 2021 Month: August Floor: 5th Floor Crash Cart #: 2 ..." The checklist contained staff signatures from August 1 through August 31, indicating the code cart was checked.

(v) The facility failed to ensure the code cart was checked for expired medications in accordance with the facility policy referenced above.

2. The above findings were confirmed by Staff #2 at the time of discovery.