Failure to Ensure Daily Emergency Cart Checks and CPR Readiness
Penalty
Summary
The facility failed to ensure that personnel provided basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel, as required by physician orders and the resident's advance directives. Specifically, the facility did not complete daily inventory checks on Emergency Response Cart 1 for a period of time, and the inventory log was found to be incomplete on one occasion, with several critical items such as a backboard, blood pressure cuff, stethoscope, and other supplies not checked off. Interviews with nursing staff and administration confirmed that the night shift was responsible for these checks, but the process was not consistently followed, and the charge nurses were expected to monitor compliance. Staff acknowledged the importance of these checks to ensure all necessary items were available in an emergency. Further review revealed that the facility did not have a policy for Cardiopulmonary Resuscitation (CPR), and the Central Supply Reference Guide required all emergency carts to be checked for expired items. The lack of daily checks and incomplete documentation could result in missing or expired emergency supplies, potentially delaying emergency response care. The deficiency was identified through observation, interview, and record review, and involved Emergency Response Cart 1 on the C hallway.