Failure to Maintain and Audit Crash Cart Resulting in Delayed Ventilation During Code
Penalty
Summary
The deficiency involves the facility’s failure to ensure that treatment and care were provided in accordance with professional standards, the comprehensive person-centered care plan, and the resident’s Full Code status. An elderly female resident with severe cognitive impairment, multiple chronic conditions including chronic kidney disease, Type II diabetes, dementia, anemia, and a left hip fracture, was admitted with a physician’s order and care plan specifying Full Code status, including initiation of CPR and AED use in the event of cardiac arrest. Despite these orders, the crash cart serving Magnolia and Sage halls, where multiple residents had elected Full Code status, was not maintained in a state of readiness as required by facility policy and the crash cart checklist. On the morning of the medical emergency, a code was initiated for this resident at approximately 6:30 AM. During the resuscitation, RN J and LVN S were unable to timely locate an Ambu bag on the crash cart for Magnolia and Sage halls, resulting in a delay in providing rescue breaths during CPR. Both nurses later stated that all other necessary equipment was present at the time of the code, but the Ambu bag was not readily located. The resident was ultimately pronounced deceased at the facility. Subsequent observation and record review showed that the crash cart used for Magnolia and Sage halls remained in an unusable and contaminated condition after the code. Surveyors observed dirty suction tubing, a suction canister, and a Yankauer suction device containing green fluid, and used AED pads still attached to the AED. An audit of the cart against the facility’s crash cart inventory log revealed missing items, including an O2 mask, suction canister, suction tubing, Yankauer suction device, and AED pads. RN J and LVN S acknowledged that the cart had not been cleaned or restocked after the code and that it would not have been usable in its current condition. Review of the crash cart checklists for January and February showed numerous days without documented daily audits, despite facility policy requiring that crash carts be checked every day and restocked as necessary, and that supplies be re-stocked after each use.
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