Failure to Maintain Crash Cart Supplies and Staff Competency During CPR Event
Penalty
Summary
The facility failed to ensure that emergency equipment on the crash cart was maintained and operational, resulting in staff being unable to perform adequate respirations during CPR for a resident who experienced cardiac arrest and had emesis obstructing the airway. The crash cart on the affected wing was missing multiple essential emergency supplies, including a Yankauer suction catheter, suction tubing, suction canister, electric cord, CPR board, and tongue depressors. Staff interviews and observations confirmed that these items had been used during a previous code event and were not replaced, and the crash cart checklist was either missing or not properly completed, with staff signing off without verifying the actual contents. The resident involved had a complex medical history, including Guillain-Barre Syndrome, dysphagia following cerebrovascular disease, gastrostomy status, dementia, pulmonary embolism, and GERD. The resident was dependent on enteral feeding and at risk for aspiration, with care plan interventions to mitigate this risk. On the day of the incident, the resident was found unresponsive, and a code blue was initiated. During the resuscitation attempt, staff discovered that the necessary suction equipment was not available or functional, which delayed their ability to clear the resident's airway of vomit and perform effective ventilation. Staff had to retrieve missing supplies from another unit, further delaying emergency response efforts. Interviews with nursing staff and the DON revealed that agency nurses had not been formally trained on the use of the suction machine, and there was no documentation of such training. The DON was unsure if the orientation checklist included suction equipment, and it was confirmed that the crash cart was only restocked after the survey team arrived. The responsibility for stocking the crash cart was unclear, with central supply, the ADON, and the UM all mentioned as points of contact for equipment concerns. The memory care unit's crash cart was described as outdated and not actively used, and the process for routine checks and restocking was not followed, contributing to the deficiency.