Failure to Routinely Inspect and Maintain Crash Carts
Penalty
Summary
The facility failed to ensure that crash carts were routinely inspected and properly maintained, as required by facility policy. Observations revealed that crash carts in multiple halls were either unlocked, missing essential equipment such as ambu bags, or had Automated External Defibrillator (AED) pads improperly stored. Review of crash cart sign-off sheets showed that checks were inconsistently performed, often by only one nurse, and not on every shift as required. In some cases, there was no documentation indicating that the contents of the crash carts had ever been checked, and when the lock was changed, content checks were not always completed. Interviews with staff confirmed that crash carts were not checked nightly and that required documentation and verification of cart contents were lacking. Review of the crash cart checklist further revealed that several required items were not initialed as present in the cart. Facility policy mandates daily inspection of crash carts by designated nursing personnel, with deficiencies to be reported and corrected immediately, but these procedures were not followed. This deficiency had the potential to affect all residents identified as Full Code, as the facility census included 87 residents, with 47 identified as Full Code.