Failure to Maintain and Monitor Emergency Crash Cart Supplies and Staff Competency
Penalty
Summary
The facility failed to provide adequate oversight and management of emergency crash carts, resulting in missing and nonfunctional emergency equipment during a code blue event involving a resident. Staff interviews and record reviews revealed that when the resident was found unresponsive, staff attempted to use the crash cart's suction machine but discovered that essential supplies, including suction tubing, a Yankauer, and a canister, were missing. As a result, the suction machine could not be operated, and staff were unable to clear the resident's airway, which was obstructed by vomit and food particles. Attempts to ventilate the resident with an Ambu bag were also unsuccessful due to the airway obstruction. Further investigation showed that the crash cart checklists for March and April had not been properly maintained, with staff signing off on checks without verifying the presence of necessary supplies. The Director of Nursing (DON) was unaware of the crash cart deficiencies during the incident and only learned of the missing supplies after the event. Additionally, it was confirmed that staff, including agency nurses, had not been appropriately trained or assessed for competency in using the suction machine, and there was a lack of routine checks and documentation for emergency cart supplies. The Administrator was not informed of the missing equipment or the incident until several days after it occurred, and did not receive a completed incident report in a timely manner. The Administrator acknowledged that facility policies were not followed, and that the crash cart checklist had been incorrectly signed. The lack of oversight, failure to ensure staff competency, and absence of routine equipment checks contributed to the facility's noncompliance, which was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.