F0678

F

Failure to Maintain Crash Cart Supplies, Sanitation, and Readiness for CPR

Arlington, Virginia Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to maintain the emergency medical (crash) cart in a sanitary and ready-to-use condition and did not ensure required emergency supplies were present and unexpired on one health care unit. During observation of the crash cart, surveyors found the oxygen tank at only 2% full and noted missing items that were listed as required, including oxygen masks, nasal cannulas, normal saline, a second nonrebreather mask, standard oxygen masks, a blood spill kit, and a second bottle of distilled water. The suction machine on top of the cart was only covered with mesh, allowing air and dust to enter, and the Ambu bag used for resuscitation was not in a protective bag. Multiple items were expired or compromised, including several packets of lubricating jelly (some expired and one with an unreadable date), a suction catheter package with a rip rendering it non-sterile, suction connecting tubing and non-conductive connecting tubing that were past their expiration dates, a box of large gloves that was expired, and an open box of surgical masks that was expired. Bandage scissors required to be in the cart were not present; instead, there were dirty scissors that were not bandage scissors.

Interviews and document review showed that the facility’s process for maintaining the crash cart was not effectively implemented. An LPN stated that the night shift nurse was responsible for ensuring the crash cart was stocked and free of expired items, acknowledged that the oxygen tank was empty, and confirmed that the Ambu bag was open and not sterile and that all supplies should be current and available for emergencies. The DON reported that the night nurse was supposed to check the cart each shift using the Emergency Cart Daily Checklist and restock items from the supply room, and that the cart should be restocked immediately after use. Despite this, the Emergency Cart Daily Checklist documented that the cart had been checked daily over a multi-week period, even though the above deficiencies were present at the time of survey. Review of resident code status on the unit showed that 24 of 25 residents were full code, meaning CPR must be initiated if they stop breathing or their heart stops, and the crash cart would be used in such events. Review of the facility assessment did not show documentation of the required emergency equipment needed to address medical emergencies, as specified in the facility’s CPR Certification policy.