Based on policy and procedure review, Crash Cart check sheets review, and interview, it was determined the facility failed to ensure one of one emergency room (ER) Crash Cart examined was checked every shift by ER personnel. Failure to check the crash cart every shift did not ensure the defibrillators were functional and working in the event they were needed for patient care. The failed practice had the potential to affect any patient whose care required the use of the defibrillator. Findings follow: A. Review of the policy and procedure titled "Crash Cart and Defibrillator Checklist Instructions," received at 1:40 PM on 08/30/18 showed the defibrillator was to be checked every day on each shift, as well as the contents and the medication list. When the above was accurate, the nurse was to sign her name. B. Review of the ER Crash Cart at 8:50 AM on 08/30/18 showed three (07/27/18-07/29/18) of 31 (07/01/18-07/31/18) night shifts were not documented as checked for the month of July. Review of the August checklist showed three (08/16/18, 08/26/18, and 08/29/18) of 28 (08/01/18-08/28/18) night shifts were not documented as checked. During an interview with the Chief Nursing Officer at 8:55 AM on 08/30/18 he verified the above findings. Based on policy and procedure review, clinical record review and interview, it was determined emergency room staff failed to follow policy and procedure in that two (#3 and #4) of twelve (#1-12) patients were not triaged or triaged at the level outlined in policy. Failure to follow the triage policy and procedure did not ensure the patients received the level of care required in a timeframe dictated by the triage assessment. The failed practice had the potential to affect Patients #3 and #4. Findings follow: A. Review of the policy and procedure titled "Triage Priority Classification," received from the Chief Quality Director at 9:00 AM on 08/30/18 showed a brief triage was to be conducted by the nurse, to determine the priority of care necessary and the appropriate area for further evaluation and treatment. Once categorized, all patients assigned an ESI (Emergency Severity Index) score of 1 and 2 were to be escorted to the treatment area and assigned a primary nurse upon triage. Review of the policy and procedure also showed patients who were high risk, confused, lethargic or disoriented, or in severe pain or distress were classified as a ESI Level 2. B. Review of Patient #3's clinical record showed lethargic listed under clinical presentation and an ESI score of 4 assigned by Registered Nurse #1 at 10:37 PM on 06/23/18. Per policy and procedure, the screening of lethargy should have placed Patient #3 at an ESI level of 2. C. Review of Patient #4's clinical record showed a Triage date and time of 8:12 PM on 07/08/18 by RN #3. Review of Patient #4's clinical record showed no ESI level documented. D. During an interview with the Clinical Documentation Improvement Manager at 11:43 AM on 08/30/18 the findings in B and C were verified.

Based on observation, interview and review of policies and procedures, it was determined the Facility failed to assure cleaning of furniture, floors, counter tops and equipment in the Emergency Department was performed per Facility Policy. The failed practice did not assure processes for cleaning and disinfection was integrated into the hospital standard policies and procedures and therefore cleaning and disinfection of surfaces could not be assured. The failed practice affected any patient treated in the Emergency Department. The findings were: 1) Observation on tour of the Emergency Department on 04/15/15 from 1400-1445, revealed: two bottles with blue liquid, one labeled as "NABC (Non-Acid Disinfectant Cleaner)" and one labeled as "Peroxy" on the counter in ER Room #2. RN #1 was asked what the product was used for and she stated "for our equipment and ". There was a cloth covered chair in the triage room that was soiled. 2) Housekeeper #1 was interviewed and stated the NABC was used for counters, walls and furniture disinfection and a Peroxy product is used on the floor. One of the bottles was labeled as Peroxy and was a blue color. Housekeeper #1 stated that it was mislabeled because the Peroxy product was clear, even though it was labeled Peroxy. The cloth furniture is cleaned when it looks dirty per Housekeeper #1. 3) The Environmental Services Director and Director of Maintenance Services reviewed the polices and procedures and manufactures directions for use and confirmed the following: the NABC product is for Bathroom cleaning; The super HDQ L 10 is to be used for hard non-porous services and allowed to remain wet for 10 minutes. Wet mopping is to be done with Super HDQL 10 as well. 4) Review of the Facility Policy "Cleaning supplies and chemicals" stated The Environmental Services Director and the Infection Control nurse will review all products intended for any level of disinfecting. Once the product is select for use, the Infection Control nurse will coordinate the review of the technical and material Safety Data Sheet on hospital grade disinfectant and tuberculosis by the Infection Control Committee and final approval prior to being put into use. Prior to the product becoming available to personnel for use, the Environmental Services Director will ensure the proper use and dilution procedure for the chemical is included in the Environmental Services Department continuing education program and all personnel are trained accordingly." The observations of the cleaning product and policies for use were confirmed at the time of observation by the Environmental Services Director.