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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 facility census was one Acute Care patient, two Swing Bed patients and two 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) patients for a total census of five.

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

Please refer to C-0884 for details.

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). 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 patients and two 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) patients for a total census of five.

Findings included:

1. Observation on 04/02/24 at 9:40 AM, showed the Malignant Hyperthermia box was in a locked room in the surgical services area.

2. During an interview on 04/02/24 at 9:45 AM, Staff B, Registered Nurse (RN), stated the Malignant Hyperthermia box was located in the locked anesthesia room. Staff B stated the Charge nurse on the Medical Surgical unit had access.

3. During an interview on 04/02/24 at 10:34 AM, Staff H, Emergency Department Operations Coordinator, acknowledged ED physicians utilized the medication Succinylcholine (a skeletal muscle relaxant used to relax muscles either during surgery or while on a breathing tube) when a patient required intubation (a tube inserted through a person's mouth or nose, down into their trachea [airway/windpipe], that kept the trachea open so air can get through and connected to a machine that delivers air or oxygen to the patient). Staff H stated the ED did not have a Malignant Hyperthermia kit/cart and Staff H was unsure if another department in the hospital had a Malignant Hyperthermia kit/cart. Staff H stated if another department did have a Malignant Hyperthermia kit/cart, ED staff did not have access to the kit/cart.

4. During an interview on 04/02/24 at 11:24 AM, Staff I, ED Physician, stated if a patient needed to be intubated either Versed (medication used to help a patient relax or sleep before a procedure) or Succinylcholine (paralytic) medication would be administered. Staff I stated the ED did not have a Malignant Hyperthermia kit/cart available.

5. During an interview on 04/02/24 at 11:30 AM, Staff J, ED RN, stated ED staff was unaware if the facility had an in-house Malignant Hyperthermia kit/cart available.

6. During an interview on 04/02/24 at 12:48 PM, Staff F,Medical-Surgical Charge Nurse, stated:
- If the ED staff notified the Medical-Surgical Unit that a patient in the ED required the Malignant Hyperthermia kit/cart, the Medical-Surgical Unit staff would notify pharmacy that a patient in ED needed the Malignant Hyperthermia kit/cart.
- The Charge Nurse on the Medical-Surgical Unit had keys to the Operating Room (OR) that allowed access to the Malignant Hyperthermia kit/cart in OR.
- It would take Staff F a long time to get the locked key for OR to access and retrieve the Malignant Hyperthermia kit/cart.
- The facility had not conducted any drills with staff for either retrieval or the process/procedure to utilize for Malignant Hyperthermia signs and symptoms.

7. During an interview on 04/02/24 at 12:57 PM, Staff A, OR Manager, stated:
- They were not sure if other departments in the hospital knew about the Malignant Hyperthermia kit located in the OR.
- Keys were available per the Medical-Surgical Unit's Charge Nurse with access to the OR and the locked key to access/retrieve the facility's Malignant Hyperthermia kit.
- If ED staff needed the Malignant Hyperthermia kit, ED staff would have to retrieve the key from the Medical-Surgical Unit's Charge Nurse.
- Unsure if the ED had a Malignant Hyperthermia kit in the department.
- They had discussed the kit and procedure to perform treatment with OR staff but had not provided education/training to other departmental nursing staff.

8. 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).


18018

Based on observation, record review, interview and nationally-recognized standards review, the facility failed to perform four (#2, #3, #4 and #5) out of reviewed for fire-risk assessments prior to surgical procedures. These failures placed the surgical patients and staff at an elevated fire risk.The hospital census was one Acute Care patient, two Swing Bed patients and two 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) patients for a total patient census of five.

Findings included:

1. Observation on 4/02/24 at 9:25 AM, for surgical Patient #5, in Operating Room Suite #1, showed no surgical staff performed a fire-risk assessment prior to a cystoscopy.

2. Review of Patient #2's medical record on 03/19/24, showed no documentation of a fire-risk assessment prior to a prostate ultrasound and biopsy.

3. Review of Patient #3's medical record on 12/07/23, showed no documentation of a fire-risk assessment prior to a colonoscopy with biopsy.

4. Review of Patient #4's medical record on 02/27/24, showed no documentation of a fire-risk assessment prior to a left mini-open carpal tunnel release.

5. During an interview on 04/03/24 at 12:40 PM, Staff A, Operating Room Manager, stated staff had not performed fire-risk assessments verbally prior to surgical procedures and subsequently document them.

6. Review of the Association of PeriOperative Registered Nurses (AORN) "Guideline for Fire Prevention Practices," dated 2023, showed the direction for staff to:
- Perform a fire-risk assessment as part of the preprocedural briefing process, to include ignition, fuel, and oxidizer sources present in the OR.
- Include cognitive aids (eg, algorithms, checklists).
- Collaborate on and implement interventions based on the fire-risk assessment.
- Document the fire-risk and the actions taken to address them.
- Prevent contact between fuel sources (eg, drapes, skin antisepsis agents) and ignition sources (eg, electrosurgical devices).
- Prevent pooling of flammable skin antiseptic agents under, on, or near the patient.
- Prevent the pooling of flammable antiseptic agents by:
o placing sterile or clean towels near the surgical preparation site to absorb excess solution from pooling;
o using sterile towels to absorb excess solution from the prepped site;
o removing materials (eg, sterile or clean towels) that become wet with the skin preparation solution before draping; and
o moving flammable antiseptic soaked materials away from ignition sources and outside of the patient care vicinity (ie, at least 6 ft away).
- Allow the skin antiseptic agent to dry before applying surgical drapes. Follow the manufacturer's IFU for dry time.
- Use a water-soluble gel for the patient's head and hair when performing procedures that involve the head of neck.
- Use moistened radiopaque sponges near oxidizer and ignition sources during airway procedures.

The operating room contains several elements of the fire triangle, including oxygen (oxidizer), lasers and electrosurgical devices (ignition sources), and alcohol-based skin antiseptics and surgical drapes (fuel). The perioperative team can help reduce the risk of fire by performing a fire risk assessment and implementing interventions (eg, preventing contact between fuel sources and ignition sources) based on that assessment.

Based on observation, interview, policy review and nationally-recognized standards review, the hospital failed to ensure staff followed infection control policies and infection prevention standards of practice when staff failed to:
- Maintain maintenance and repairs in the surgical areas.
- Maintain cleaning and repairs in the Central Sterile rooms.
- Remove all paper products (particle shedding) from the Central Sterile Clean room.
- Provide maintenance and a rust (reddish-brown oxidation of metal that can harbor bacteria) -free kitchen.
- Remove expired food items from the kitchen.
These failed practices had the potential to expose all patients, visitors and staff to cross-contamination and increased the potential to spread infection. 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 two 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) patients for a total patient census of five.

Findings included:

Surgery and Central Sterile

1. Observation on 04/02/24 at 8:20 AM, in Operating Room #2 (OR #2), showed:
- Two rusted vents;
- Chipped paint with exposted drywall (particle shedding that harbors bacteria) between the floor and wall; and
- Two rusted doorframes with chipped paint.

2. Observation on 4/02/24 at 9:30 AM, in the Endoscopy Cabinet/Sterilizer room, showed behind, under and to the side of the sterilizer, wall damage and door frame damage. Also rust with wall damage around the corner into OR #1.

3. Observation on 4/02/24 at 8:30 AM, in the Central Sterile Clean room, showed:
- Wall damage in four areas;
- Multiple papers and one tissue box (particle shedding) on a desk; and
- Open drywall area under the sink between the pipe and the wall.

3. Review of the hospital's policy titled, "Infection Control Central Sterile," last reviewed on 03/2024, showed the direction for staff to clean the Central Sterile areas daily.

4. Review of three months of the surgery department cleaning logs, failed to show the cleaning of the Central Sterile areas.

6. During an interview on 4/03/24 at 12:40 PM, Staff A, OR Manager, stated staff were expected to turn in maintenance work requests for repairs needed and expected staff to remove all paper products from the Central Sterile clean room.

7. During an interview on 4/03/24 at 3:30 PM, Staff O, Infection Preventionist, stated their hospital followed AORN guidelines and they rounded in the surgical area monthly. They also stated staff was expected to complete a work order for repairs and follow the protocol for a sterile environment in the Central Sterile areas.

8. Review of the APIC "Infection Preventionists Guide to the Operating Room," dated 2018, showed the OR environment requires surfaces which are smooth, cleanable, non-absorptive, and capable of withstanding cleaners and disinfectant solutions. There should be no cracks and crevices where dirt can become trapped. Other materials (e.g., vinyl) can rip or wear in ways which create environmental reservoirs for microorganisms.

9. Review of the AORN "Guideline for Environmental Cleaning," dated 2023, showed the Sterile Processing Areas were to be terminally cleaned each day the areas were used.

Kitchen

10. Observation on 4/01/24 at 2:30 PM, in the kitchen, showed:
- Rusted sink legs;
- Unclean grout behind the sink;
- Unclean ceiling vent and ceiling tiles above the dishwasher;
- One unclean fluorescent light cover;
- Rusted shelving that housed clean dishes;
- Unclean ceiling tiles with cracks and unclean sprinklers in the stove area;
- Four unclean stained ceiling tiles in the cleaning hallway;
- One rusted mixer spindle and base;
- Rusted hanging pots;
- Unclean knife holder;
- Scraped, open drywall near the cook's refrigerator;
- Unclean baseboards;
- Unclean wall with holes and grout separated above the handwashing sink;
- Unclean tubing for the juice machine;
- Cracked wall around a clock;
- Damage on the bottom of the microwave cabinet; and
- Soiled ceiling tiles around the air conditioner.

11. During an interview on 4/01/24 at 2:55 PM, Staff C, Dietary Manager, stated staff was expected to remove the valve of the juice concentrate box, place into hot water and run hot water through the tubing.

12. Observation on 4/01/24 at 2:40 PM, in the kitchen refrigerator, showed the following expired foods:
- Five whipped toppings with expiration dates of 10/2020;
- Five heavy whipping cream with expiration dates of 07/2020;
- One ranch dressing with expiration date of 07/2022; and
- One italian dressing with expiration date of 10/13/23.

13. Observation on 4/01/24 at 2:50 PM, in storage room, 10 honey thickners, with expiration dates of 02/07/22.

14. During an interview on 4/03/24 at 3:30 PM, Staff O, Infection Preventionist, stated they do not perform environmental rounds in the kitchen, they followed the Missouri Food Code and expected staff to complete work orders for repairs needed.

15. 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. Food in unmarked containers or packages, or marked with a time that exceeded six hours shall be discarded.

Based on policy review, record review and interview the facility failed to 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 (#6 and #7) and for two discharged Swing Bed patients (#20 and #21) reviewed for a comprehensive quality of life activities 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 (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and two 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) patients for a total census of five.

Findings included:

1. Review of the facility's policy titled, "Basics and Standards of Care Planning," dated 09/2023, showed in part staff directives:
- To ensure evidence of implementation of an individualized plan of care is contained within the patient's record the outline process will require routine documentation of patient assessment, orders, patient care, and discharge planning as evidenced of care planning within the facility.
- To ensure care planning process included patient assessment, goal setting, intervention(s), referrals to other health care professionals, evaluations of patient responses to treatment. Additionally, this included revision of care and treatment in order to meet the patient's needs as needed.
- To ensure documentation of the patient care plan was embedded in the patient record.
- To ensure the patient's nursing care needs were determined through the patient assessment process.
- To ensure a Registered Nurse (RN) would determine specific patient care needs and the plan for meeting patient needs, to include patient assignments and specific delegation of patient care activities.

2. Review of Patients' Electronic Medical Health Records (EMHR) showed:
- Patient #6 was admitted to the facility's Swing Bed program on 03/17/24, for complaints of weakness;
- Patient #7 was admitted to the facility's Swing Bed program on 03/26/24, for complaints of cerebrovascular accident (CVA - stroke), weakness and respiratory failure;
- Patient #20 was admitted to the facility's Swing Bed program on 03/14/24, for complaints of weakness; and
- Patient #21 was admitted to the facility's Swing Bed program on 03/20/24 for complaints of status post left hip fracture and weakness.

Patient #6's, #7's, #20's, and #21's EMHR showed staff failed to develop a comprehensive activity plan of care for the patients during their stay in the facility's Swing Bed program.

3. During an interview on 04/03/24 at 3:35 PM, Staff O, Director of Nursing, acknowledged the Swing Bed patients did not have an activity plan of care included in the patients' EMHR.