Observations
Based on a review of the deceased client chart, facility policies, and other administrative documentation on February 7-8, 2023, the facility failed to follow their Emergency Equipment Policy. The facility failed to document nightly inspections of emergency equipment.
The Emergency Equipment Policy states that emergency equipment is to be inspected nightly by facility staff and documented on the Daily Equipment and Emergency Cart Checklist.
Documentation was missing from the January 2023 Daily Equipment and Emergency Cart Checklist on the following dates: January 1, 4, 8, 9, 10, 13, 16, 18, 20, 22, 23, 24, 25, 27, 28, 29, 30 and 31.
This finding was reviewed with facility staff during the sentinel event investigation.
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Plan of Correction
Based on a review of the deceased client chart, facility policies, and other administrative documentation on February 7-8, 2023, the facility failed to follow their Emergency Equipment Policy. The facility failed to document nightly inspections of emergency equipment.
Every night at the beginning of the night shift (approx. 7 pm), the nursing supervisor will inspect all emergency equipment. The daily equipment and emergency cart check sheet will be completed and signed off on by the nursing supervisor/charge nurse. The inspection includes the following:
1. AED has the green check mark, indicating proper function.
2. Each oxygen tank located on the nursing floor, is at an adequate level.
3. Each oxygen tank has a ambu bag.
4. The emergency box has an intact seal.
5. The entire emergency cart is locked.
6. The EKG machine is plugged in and has paper.
7. The multi dose vials of insulin have an open date and beyond use date.
Every morning at approximately 7 AM, the supervisor/charge nurse will verify the emergency equipment checklist was completed. Monthly the forms will be scanned into the nursing admin files. The scanning will be completed by administrative coordinator, and verified by the Director of QA.
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