HospitalInspections.org

Based on observation, interview and review of the Malignant Hyperthermia Association of the United States (MHAUS), the hospital failed to ensure the required life-saving medications were readily accessible when administering Succinylcholine (a muscle relaxant/paralytic) in the emergency department (ED).

The severity and cumulative effects of these failed practices resulted in the hospital's non-compliance with 42 CFR 485.618 Conditions of Participation (CoP): Emergency Services.


Please refer to C-0884 for details.

Based on interview and review of the Malignant Hyperthermia Association of the United States (MHAUS), the hospital failed to ensure the required life-saving medications were readily accessible when administering Succinylcholine (a muscle relaxant/paralytic) in the emergency department (ED). This failure had the potential to affect all patients that presented to the ED and given Succinylcholine in an emergency. The facility census was one Acute Care patient, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of four.

Findings included:

1.During an interview on 04/23/24 at 10:30 AM, Staff E, Pharmacist, stated they did not have any Malignant Hyperthermia antedote medications and they do give Succinylcholine.

2.During an interview on 04/23/2024 at 12:25 PM, Staff G, Registered Nurse, stated if a rapid intubation is initiated, the nurse grabs the medication kit and the provider will determine medication. They are unaware if the Malignant Hypertermia protocol is in place for Succinylcholine use. They were aware it is an adverse reaction that can occur with Succinylcholine, but they had never experienced it.

3.During an interview on 04/23/2024 at 3:05 PM, Staff H, Emergency Provider, stated Succinylcholine is the drug of choice due to the short acting parallactic and before we had the ventilator, we had to manually bag patients. They believe the protocol following rapid intubation is to check vital signs every 15 minutes and that includes a tempature check. If someone had symptoms of Hyperthermia, staff would start an ice bath and attempt to cool the patient. Staff H states they are aware of the Malignant Hyperthermia from Succinycholine treatment but has never encountered it in practicing medicine.

4.Review of the MHAUS recommendations, dated 2016, showed that when patients were given Malignant Hyperthermia (a life-threatening, but treatable reaction of the inhalation anesthetics and Succinylcholine triggering anesthetics), medication, the only antidote used to reverse the reaction was the medication Dantrolene (medication that uncouples the heat generating mechanism in the muscles).

Based on observation, interview, record review, the Missouri Food Code and nationally-recognized standards review, the hospital failed to ensure staff maintained a sanitary environment was preserved through maintenance and cleaning that would not harbor bacteria or transmit infections in the kitchen, Central Sterile areas and patient shower room.These failures had the potential to expose patients, visitors, and staff to cross-contamination, increased the potential to spread infection and had the potential to affect the qualitly of the cleaning enzymes used to clean instruments. The hospital census was one Acute Care patient, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of four.

Findings included:

Kitchen
1. Observation on 04/24/24 at 10:00 AM, in the kitchen, showed:
- Missing tiles with glue exposed (sticky substance that attracts bacteria) under sink 1;
- Missing tiles with rust under and around ice machine;
- Rust spots on boarder above the steam table;
- Chipped paint and rusted areas on cabinet at the dishwashing station;
- Missing tile under the dishwasher;
- Rusted trim above the tray return;
- Chipped paint on walls and shelf near the tray return;
- Unclean with rust spots on door to hallway; and
- Rust underneath the handwashing sink.

2. During an interview on 04/24/24 at 10:15 AM, Staff M, Kitchen Manager, stated they expected staff to notify them and initiate a maintenance ticket for any repairs needed.

3. Review of the hospital quarterly Environmental Round's log, showed the last environmental round in the kitchen was 04/2024.

4. Review of the Missouri Food Code for the Food Establishments of the State of Missouri, dated 06/03/13, chapter 6, showed surface characteristics of floors, walls and ceiling surfaces should be smooth, durable, and easily cleanable for areas where food establishment operations were conducted and nonabsorbent for areas subject to moisture such as food preparation areas, walk-in-refrigerators, washing areas, toilet rooms, mobile food establishment servicing areas, and areas subject to flushing or spray cleaning methods.

Central Sterile Rooms
5. Observation on 04/24/24 at 11:05 AM, in the Central Sterile Decontamination Room, showed an unclean rusted sink used to clean instruments.

6. During a telephone interview on 04/24/24 at 11:30 AM, Staff N, Central Sterile Technician, stated in the Decontamination Room they used one ounce of cleaning enzyme and was not measuring the amount of water recommended by the enzyme manufacturer to clean instruments used for procedures in the emergency department.

7. Observation on 04/24/24 at 11:10 AM, in the Central Sterile clean room, showed:
- Two areas of wall damage near the instrument wrapping table;
- Four wrapped sterile instruments with discoloration and rust spots; a
- Double door storage cabinet opened to the emergency room (exposure to contaminants) and opened to the Central Sterile clean room, used to store sterile instruments.

8. During a telephone interview on 04/24/24 at 11:30 AM, Staff N, Central Sterile Technician, stated staff were to put in a maintenance ticket for repairs needed.

9. During an interview on 04/24/24 at 12:00 PM, Staff F, Infection Preventionist, stated they perform environmental rounds in the kitchen and Central Sterile quarterly. They also expected staff to complete a work request for repairs needed and contact them or the Chief Nursing Officer if instruments needed to be taken out of service.

10. Review of the hospital quarterly Environmental Round's log, showed the last environmental round in the Central Sterile area was 02/2024.

11. Review of the Association for Professionals in Infection Control and Prevention (APIC), "Infection Preventionists Guide to the Operating Room," dated 2018, showed the operating room environment (Central Sterile Area) required surfaces that were smooth, cleanable, non-absorptive, and capable of withstanding cleaners and disinfectant solutions with no cracks and crevices where dirt can become trapped. Other materials (e.g., vinyl) can rip or wear in ways that create environmental reservoirs for microorganisms.

Shower Room
KH12. Observation on 04/24/24 at 12:55 PM, in the patient shower room, showed:
- Several broken corners on the ceiling tiles;
- Rust on the ceiling tile frames, door frame, shower faucet, tub drain, and wall mounted sink;
- Dirty shower chair with vinyl seat damage;
- Floor tile missing from shower floor;
- Grout and sealent missing from floor and wall tile joints; and
- A five gallon bucket to collect water from leaking sink.

KH13. During an interview on 04/24/24 at 12:55 PM, Staff F, Registered Nurse, stated expectations is for this area to be free from rust, the shower chair should be free from soil and defects, the floor tiles to be present and sealed/grouted, the ceiling tiles to be clean and free of holes, missing corners, and the sink would be free of rust and not leak.

Based on interview, policy review, record review and Centers for Disease Control and Prevention (CDC) review, showed the hospital leadership failed to ensure antibiotic stewardship activities provided an indication for use on antibiotic orders. These failures had the potential of affecting the measurement of effectiveness of the medications as well as the transparency for staff to determine appropriateness for all patients that presented to the hospital and received medications.The hospital census was one Acute Care patient, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of four.

Findings included:

1. During an interview on 04/23/24 at 10:30 AM, Staff E, Pharmacist, stated they did not have indications for use in the medication orders.

2. During an interview on 04/24/24 at 12:00 PM, Staff F, Infection Preventionist, stated they were starting a system for indication of antibiotic use, but it is not in place at this time.

3. Review of the hospital's policy titled, "Antimicrobial Stewardship Program," last reviewed on 05/26/22, showed the direction for providers to specify the dose, indication, likely duration and apply stop dates or number of doses of the antimicrobial medication.

4. Review of the hospital's Antimicrobial Stewardship Program, approved on 10/05/23, showed the direction for staff to follow the Core Elements set forth by the CDC for Critical Access Hospitals.

5. Review of the CDC "Antibiotic Stewardship Statement for Antibiotic Guidelines - Recommendations of the Healthcare Infection Control Practices Advisory Committee," dated 09/21/17, showed:
- Antibiotic stewardship has become a critical responsibility for all healthcare institutions and antibiotic prescribers. Professional societies and other organizations developing guidelines for management of infectious diseases that include recommendations for antibiotic prescribing also have an important responsibility in incorporating antibiotic stewardship principles in their recommendations.
- An antibiotic stewardship program that incorporates the CDC Core Elements (Hospital Leadership Commitment, Accountability, Pharmacy Expertise, Action, Tracking, Reporting and Education) as appropriate for the type of infection and treatment setting should be cited in guidelines as a valued resource for determining the optimal antibiotic selection, dose, route, and duration of treatment.
- We recommend that guidelines for treatment of infectious diseases include explicit recommendations for antibiotic stewardship relevant to the infections addressed in the guidelines.

Based on policy review, record review and interview the facility failed to perform an activity assessment and develop a comprehensive activity care plan that provided specific individualized activity interest and interventions to stimulate the patient's physical and mental well-being for two current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients (#1 and #6) and for two discharged Swing Bed patients (#7 and #8) reviewed for a comprehensive quality of life activity assessment and activity care plan.
This failed practice had the potential to affect all Swing Bed patients by failing to stimulate their minds, body, and social interests. The facility census was one Acute Care patient, two Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of four.

Findings included:

1. Review of the facility's policy titled, "Swing Bed - Care Plan," dated 05/10/22, showed staff directives:
- All Swing Bed Residents have the right to participate in their care plan throughout their stay.
- The care plan shall include:
- Measurable objectives and timeframes to meet;
- Services provided to attain or maintain physical, mental, and psychosocial well-being; and
- The resident's goals for admission and desired outcomes.
- If there is a change in residents' condition, the provider must complete a new comprehensive assessment and the care plan must be updated by the interdisciplinary team.

2. Review of Patients' Electronic Medical Health Records (EMHR) showed:
- Patient #1 was admitted to the facility's Swing Bed program on 04/18/24, for new right below the knee amputation;
- Patient #6 was admitted to the facility's Swing Bed program on 03/22/24, for intravenous antibiotic therapy for right knee infection status post right knee replacement;
- Patient #7 was admitted to the facility's Swing Bed program on 11/10/23, for complaints of hypercalcemia (a condition in which the calcium level in a patient's blood is too high), esophagitis (inflammation of the esophagus) and weakness; and
- Patient #8 was admitted to the facility's Swing Bed program on 11/21/23 for complaints of status post hip fracture.

Patient #1's, #6's, #7's and #8's EMHR showed staff failed to perform an activity assessment and develop a comprehensive activity care plan for the patients during their stay in the facility's Swing Bed program.

3. During an interview on 04/23/24 at 3:01 PM, Staff B, Registered Nurse, Swing Bed Coordinator, acknowledged the Swing Bed patients did not have an activity assessment or activity care plan included in the patients' EMHR.

During an interview on 04/24/24 at 9:55 AM, Staff A, Chief Nursing Officer, stated the patients admitted to the facility's Swing Bed program did not have an activity assessment or activity care plan included in the patients' EMHR. Staff A stated the facility received information from the Hospital Association during a webinar that the Swing Bed Program was no longer required to perform either an activity assessment or include activities in patients' care plans because the activity requirement was no longer a regulatory requirement for a facility's Swing Bed Program. Staff A stated the facility stopped performing activity assessments and including activities in patients' care plan after receiving information activities were no longer a regulatory requirement for patients admitted to a facility's Swing Bed Program.