Failure to Maintain Emergency Crash Cart Supplies and Daily Checks
Penalty
Summary
The facility failed to ensure that basic life support equipment and procedures were consistently available and followed prior to the arrival of emergency medical personnel, as required by physician orders and residents’ advance directives. Specifically, Emergency Cart 1 was found to be missing an Ambu bag, a critical device for providing ventilation to residents who are struggling to breathe or have stopped breathing. Staff interviews revealed that the absence of the Ambu bag was justified by the presence of Ambu bags in residents’ rooms and in the central supply closet, but this did not align with facility policy, which required an Ambu bag to be present on the emergency cart itself. Additionally, the facility did not maintain proper daily inventory checks on Emergency Cart 2. Review of the emergency cart’s daily check-off logs showed multiple days where no inventory check was completed. Staff interviews indicated confusion and lack of clarity regarding responsibility for checking the emergency carts, with some nurses believing it was a shared responsibility and others stating it was assigned to specific staff. The facility’s policy required daily checks and immediate restocking after use, but this was not consistently followed. Further interviews with nursing and administrative staff revealed inconsistent understanding of the procedures for maintaining emergency carts. While some staff stated that night shift nurses were responsible for daily checks, others believed central supply was responsible for monthly checks and restocking. The Director of Nursing was not aware of the specific policy regarding daily checks and could not articulate the associated risks. The lack of clear assignment and adherence to policy resulted in emergency carts not being reliably stocked and ready for use, potentially delaying emergency care.