HospitalInspections.org

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the availability of drugs, biologicals, and equipment commonly used in life-saving procedures for prompt use when staff removed 1 of 1 Emergency Room (ER) crash cart from the ER for use on the nursing unit. Removing the crash cart from the ER limited the availability of drugs, biologicals, and equipment used for treatment of life-threatening situations to patients presenting to the ER.

Findings include:

Observation of the nursing unit occurred on 11/18/15 at 10:00 a.m. with a licensed nurse (#4). When asked the location of the nursing unit's crash cart, this nurse stated nursing staff would obtain the crash cart from the ER if needed.

Observation of the ER occurred on 11/18/15 at 12:15 p.m. with an administrative nurse (#2) and showed a crash cart containing a defibrillator and various medications including cardiac glycosides, antiarrhythmics, antihypertensives, analgesics, anesthetics, and electrolytes and replacement solutions used in life-saving procedures. The nurse (#2) confirmed in the event of an emergency on the nursing unit, a staff member would obtain the crash cart located in the ER.

Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH) governing board failed to ensure the medical staff approved the specific clinical privileges for appointment of 5 of 14 physician credentialing files reviewed (Physicians #1, #2, #3, #4, and #5). Failure to ensure the approval of specific clinical privileges for medical staff appointments places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the governing board's "By-laws of First Care Health Center" occurred on 11/17/15. These bylaws, adopted 03/26/02, stated, ". . . Article VIII.
Medical Staff and Operating Limitations
Section 8.01. Organization, Appointment and Hearings. . . .
(a) . . . The Board of Directors shall consider recommendations of the medical staff and appoint to the medical staff the practitioners who meet the qualifications for membership as set forth by the By-laws of the medical staff. . . ."

Review of the "First Care Health Center Medical Staff By-Laws" occurred on 11/16/15. These bylaws, adopted 01/24/13, stated,
". . . ARTICLE XII
Procedure for Appointment and Reappointment . . .
Section 2. Appointment Process
B. . . . After examination of the applicant documents . . . the executive committee shall at its next regularly scheduled meeting determine whether the applicant's request for privileges be approved, rejected, or deferred. A determination to appoint must specifically recommend the clinical privileges to be granted . . .
2. When the recommendation of the medical staff is favorable to the applicant, the chief of staff shall promptly forward it . . . to the administrator, who will then promptly forward it to the governing body for their approval. . . ."

Reviewed November 17-18, 2015, the following practitioners' credentialing records lacked evidence the medical staff approved specific clinical privileges for their appointment to the medical staff: Practitioners #1, #2, #3, #4, and #5.

During interview at approximately 12:30 p.m. on 11/18/15, an administrative staff member (#1) confirmed the medical staff had failed to approve the specific privileges for the medical staff appointments of Practitioners #1, #2, #3, #4, and #5.

Based on observation, review of professional reference, and staff interview, the Critical Access Hospital (CAH) failed to maintain adequate medication stock in accordance with accepted professional principles in 1 of 1 Operating Room (OR) requiring Dantrolene, a medication to treat malignant hyperthermia (MH). Failure to stock the minimum amount of Dantrolene may result in patient injury or death.

Findings include:

The website of the Malignant Hyperthermia Association of the United States (MHAUS) stated, ". . . WHO SHOULD STOCK DANTROLENE AND HOW MUCH? All facilities, including ambulatory surgery centers and offices, where MH triggering anesthetics (isoflurance, desflurane, enflurane, sevoflurane, methoxyflurane, halothane, and succinylcholine) are administered, should stock a minimum of 36 vials of dantrolene, along with the other drugs and devices necessary to treat an MH reaction. . . ."

Observation of the OR and recovery room occurred on 11/17/15 at 5:00 p.m. with two supervisory nurses (#3 and #5). Observation of a supply cupboard in the recovery room (adjacent to the OR) showed 12 vials of Dantrolene. The nurse (#3) stated the CAH shares a supply with another CAH and in the event of MH reaction, a CAH staff member would drive to the other CAH for the other half of the supply.

During an interview on 11/18/15 at 12:00 p.m., an administrative nurse (#2) agreed the CAH should have the entire supply of Dantrolene available in the event of an emergency.

Based on record review, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to assess and document the effectiveness of medications given to patients on an as needed (prn) basis for 3 of 6 active swing bed patients (Patient #1, #2, and #4) reviewed. Failure to evaluate the patient's response to prn medications limited the nursing staff's ability to assess whether the medication achieved the desired effect or if the patients experienced any side effects or adverse reactions from the medication.

Findings include:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, page 862-870, states, ". . . Process of Administering Medications: When administering any drug, regardless of the route of administration, the nurse must do the following: . . . 6. Evaluate the client's response to the drug. . . . In all nursing activities, nurses need to be aware of the medications that a client is taking and record their effectiveness as assessed by the client and the nurse on the client's chart. . . . Skill 35-1 Administering Oral Medications: . . . Evaluation: Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate the effects of the medication on the client. . . ."

The facility failed to provide a policy related to the administration of prn pain medication.

- Review of Patient #1's active medical record occurred on all days of survey and identified the CAH admitted the patient on 08/25/15 for weakness, anemia, and status post humerus fracture. The physician orders included Tylenol 650 milligrams (mg) prn for mild pain.

Review of the medication administration record (MAR), pain assessment, and nurse's notes showed Patient #1 received prn Tylenol at the following times with no response documented:
*09/09/15 at 9:45 p.m.
*09/19/15 at 9:24 p.m.
*09/29/15 at 12:53 p.m.
*10/30/15 at 1:58 p.m.
*11/05/15 at 2:04 a.m.

Patient #1's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn Tylenol.

- Review of Patient #2's active medical record occurred on all days of survey and identified the CAH admitted the patient on 11/14/15 for acute back pain. The physician orders included Toradol 15 mg every 6 hours prn for pain.

Review of the MAR, pain assessment, and nurse's notes showed Patient #2 received prn Toradol on 11/15/15 at 3:59 p.m. Patient #2 rated the pain as a "10" on a scale of 0 (no pain) - 10 (severe pain). The next pain assessment occurred at 8:09 p.m., about 4 hours later.

Patient #2's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn Toradol until 4 hours later.

- Review of Patient #4's active medical record occurred on all days of survey and identified the CAH admitted the patient on 11/12/15 for recovery following a total knee replacement. The physician orders included Tramadol 50-100 mg every 6 hours prn and Oxycodone 5-10 mg every 4 hours prn for pain.

Review of the MAR, pain assessment, and nurse's notes showed Patient #4 received prn medications at the following times with no response documented:
*11/13/15 at 12:46 a.m. (Tramadol)
*11/13/15 at 9:45 a.m. (Oxycodone)
*11/13/15 at 8:46 p.m. (Tramadol)
*11/14/15 at 1:04 a.m. (Tramadol)
*11/15/15 at 7:29 p.m. (Tramadol)

Patient #4's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medications in a timely manner.

During an interview on 11/18/15 at 9:30 a.m., an administrative nurse (#2) stated she expected nursing staff to reassess and document a patient's response to prn pain medications in a timely manner.