Failure to Maintain Emergency Equipment Causes Delay in Care
Penalty
Summary
The facility failed to ensure that emergency equipment, specifically two crash carts, was maintained in safe operating condition, resulting in a delay in emergency care for a resident. According to the facility's Emergency Equipment Check Policy, crash carts are to be checked daily, with outdated or opened items replaced and missing items restocked promptly. However, review of the crash cart checklists for multiple months revealed frequent lack of documentation of checks and repeated notations that no items were available on the carts. Additionally, there were missing checklists for entire months, indicating a systemic failure to follow the established policy for emergency equipment maintenance. A resident with diagnoses including dementia, COPD, and dysphagia experienced respiratory distress and required emergency intervention. During the event, staff were unable to access high-flow oxygen from the crash cart because the necessary oxygen key was missing. Staff had to search for several minutes before a key was located, during which time only a low-flow oxygen concentrator was available. The resident's oxygen saturation was critically low, and the delay in accessing high-flow oxygen contributed to the inability to provide timely emergency care. Whole pills were found in the resident's mouth and throat, indicating a possible aspiration event. Interviews with staff confirmed the absence of the oxygen key on the crash cart and the lack of proper documentation and checks of emergency equipment. Both the Nursing Home Administrator and the Director of Nursing acknowledged the failure to maintain the crash carts in safe operating condition, which directly resulted in a delay in emergency care for the resident. The deficiency was cited under 28 Pa Code: 201.14(a) Responsibility of licensee.