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Based on observation, interview, and record review, the facility failed to have refrigerated electrolyte solutions stored and available for use should a malignant hyperthermia crisis occur. This deficient practice had the potential to affect any patient susceptible to malignant hyperthermia receiving general anesthesia. Findings include:

During an observation and interview on 8/29/23 at 9:26 a.m., the surgical department malignant hyperthermia emergency supplies were examined, and no refrigerated fluids were found. Staff member AA said she was not aware of any refrigerated fluids within the department. The surgical department was observed to have a poster from the Malignant Hyperthermia Association posted on the wall above the malignant hyperthermia container. The poster stated to cool the patient by infusing cold intravenous fluids and lavage of open body cavities with cold saline.

During an interview on 8/29/23 at 11:20 a.m., staff member B stated the facility followed the Malignant Hyperthermia Association guidelines for supplies and medication recommended for a malignant hyperthermia crisis. Staff member B stated she was not aware of any refrigerated electrolyte fluids stored in the facility.

During an interview on 8/29/23 at 1:39 p.m., staff member L said there were no refrigerated electrolyte fluids available for a malignant hyperthermia crisis, and the facility would use ice to cool a patient.

Review of a facility policy, "Management of Patient with Malignant Hyperthermia", last revised 3/2022, showed: " ...Infusion of iced saline solutions as fast as one (1) liter per 10 minutes for 30 minutes may be required...Lavage of the stomach, bladder and rectum is possible using large quantities of cold saline..."

Based on observation, interview, and record review, the facility failed to ensure the kitchen floor was maintained in a clean and sanitary condition, and failed to ensure the walk-in freezer was free of ice buildup. These deficient practices had the potential to affect the quality of food being served to patients within the facility. Findings include:

1. During an observation and interview on 8/29/23 at 7:57 a.m., there was brown/black debris observed stuck in the corners and on the perimeter of the floor in the kitchen. Staff member DD stated kitchen staff cleaned the floors.

During an interview on 8/29/23 at 8:30 a.m., staff member CC stated the flooring was old and staff had tried to scrape off the debris, but it appeared to have a layer of wax.

Review of facility policy, titled "Environment" showed, "1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, lighting, and ventilation..."

2. During an observation on 8/29/23 at 7:58 a.m., the facility freezer was inspected. Ice and frost buildup were observed on the walk-in freezer door.

During an interview on 8/29/23 at 7:59 a.m., staff member CC and DD stated the ice buildup on the freezer occurred when the humidity was high. Staff member CC stated it had been reported to maintenance several times.

During an interview on 8/30/23 at 10:00 a.m., staff member EE stated the freezer was set to cycle defrost at night. Staff member EE stated humidity causes the increase of ice build-up on the freezer door. Staff member EE stated there were increased problems during times when the humidity was high.

Based on interview and record review, the facility failed to ensure physician orders were signed off as completed for 2 (#s 30 and 38) of 5 sampled patients. Findings include:

Review of patient #30's medical record, dated 8/28/23, showed the patient had pre-op orders that were noted by an RN, but they were not dated or timed. The post-op orders were not signed, dated, or timed by an RN.

Review of patient #38's medical record, dated 7/3/23, showed the patient had post-op orders that were not signed, dated, or timed by an RN.

During an interview on 8/30/23 at 2:15 p.m., staff member B stated physician orders were to be signed, dated, and timed by the RN responsible for caring for the patient.

Based on interview and record review, the facility failed to assess anesthesia risk for outpatient procedures for two (#s 30 and 38) of 5 sampled surgical patients. Findings include:

Review of patient #30's history and physical, completed by staff member F, dated 8/28/23, failed to show an anesthesia risk evaluation was completed for the patient for cataract surgery.

Review of patient #38's history and physical, completed by staff member F, dated 7/3/23, failed to show an anesthesia risk evaluation was completed for cataract surgery.

During an interview on 8/30/23 at 2:15 p.m., staff member B stated she was not aware an anesthesia risk evaluation needed to be documented for all surgical patients receiving local anesthesia.

Based on observation and interview, the facility failed to change soiled gloves before touching clean supplies or perform hand hygiene when donning and doffing procedural gloves, and failed to educate staff on high level disinfection of endoscopes. These deficient practices had the potential to affect all patients having surgical procedures. Findings include:

1. During an observation and interview on 8/29/23 at 8:17 a.m., staff member BB was observed removing a biopsy forceps package from a clean mayo stand containing other packages, with his contaminated gloves. Staff member BB replaced the package on the mayo stand with the clean packages. He did not change gloves.

2. During an observation on 8/29/23 at 8:19 a.m., staff member B was observed removing her soiled gloves and replacing the gloves. She did not wash her hands or use hand sanitizer prior to replacing her gloves. Hand sanitizer was not observed in operating room two.

During an interview 8/29/23 at 10:03 a.m., staff member B stated she had noticed hand sanitizer was not available in operating room two. Staff member B stated the facility had just completed updates and must have removed and not replaced the hand sanitizer.

3. During an observation and interview on 8/29/23 at 9:06 a.m., staff member AA was observed while performing high level disinfection of a colonoscope. After cleaning the colonoscope, staff member AA placed the scope in MetriCide solution. The scope was submerged in the solution, but the solution did not cover the deflection control knobs. Staff member AA stated she had been trained to only use 2 ½ gallons of solution, and it did not always cover the deflection control knobs. Staff member AA then poured another gallon of solution into the container until the colonoscope was fully submerged.