HospitalInspections.org

Based on bylaws review, agreement review, document review, and staff interview, the Critical Access Hospital's (CAH's) medical staff failed to recommend and the governing body failed to approve the appointment/reappointment and privileges for 2 of 5 physicians (Physicians #1 and #2) reviewed who provided services to the CAH through telemedicine. Failure of the medical staff to recommend and the governing body to approve appointments/reappointments and privileges of telemedicine medical staff members placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the "Medical Staff By-Laws Linton Hospital" occurred on 03/07/22. These bylaws, effective 06/24/19, stated,
". . . Article III Membership . . .
Section 4. Procedure of Appointment . . .
4. On receipt of the report of the Credentials designee, the Medical Staff shall recommend to the governing body that the application be accepted, deferred, or rejected and if accepted, the privileges to be granted. . . .
6. The governing body shall either accept the recommendations of the Medical Staff or shall refer it back for further consideration . . .
9. Group telemedicine agreements: The credentialing process of [name of hospital #1, city, state] is accepted by the Linton Medical Staff for group contract for radiology telemedicine and for all other providers the Linton Hospital employs by contract through [name of hospital #1]. . . ."

Review of the governing body's "Bylaws of the Linton Hospital of Linton, North Dakota" occurred on 03/07/22. These bylaws, dated 01/03/22, stated,
". . . Article V Medical Staff
Section 1. The Board of Directors shall appoint a medical staff . . ."

Reviewed on 03/09/22, the CAH's "Credentials Verification Agreement" with Hospital #1, dated 06/01/12, stated,
". . . Whereas, [name of hospital] has an organized medical staff consisting of physicians who have medical staff status and clinical privileges granted by the Board of Directors of [name of hospital] in the medical specialty of cardiology . . .
Now, therefore, . . . the parties agree as follows:
1. [name of hospital] shall verify for Receiving Party upon request that [name of hospital] has credentialed a particular physician . . .
6. . . . The credentials verification information to be provided by [name of hospital] under the provisions of this Agreement shall be evaluated by the Receiving Party in accordance with Receiving Party's applicable policies, procedures, and rules. . . ."

Reviewed on 03/09/22, the CAH's "Credentials Verification Agreement" with Hospital #1, dated 09/18/12, stated,
". . . Whereas, [name of hospital] has an organized medical staff consisting of physicians who have medical staff status and clinical privileges granted by the Board of Directors of [name of hospital] in the medical specialty of radiology . . .
Now, therefore, . . . the parties agree as follows:
1. [name of hospital] shall verify for Receiving Party upon request that [name of hospital] has credentialed a particular physician . . .
6. . . . The credentials verification information to be provided by [name of hospital] under the provisions of this Agreement shall be evaluated by the Receiving Party in accordance with Receiving Party's applicable policies, procedures, and rules. . . ."

Reviewed on 03/09/22, the undated lists of telemedicine providers from Hospital #1 for electrocardiogram interpretation and after-hours radiology imaging interpretation included Physicians #1 and #2.

Upon request on 03/08/22 and 03/09/22, the CAH failed to provide evidence the medical staff recommended and the governing body approved telemedicine appointment/reappointment and privileges for Physicians #1 and #2.

During interview on 03/08/22 at 9:10 a.m., an administrative radiology staff member (#4) confirmed Hospital #1 provided electrocardiogram and after-hours radiological interpretation telemedicine services for the CAH.

During interview on 03/09/22 at 10:25 a.m., a staff member (#5) responsible for credentialing confirmed the CAH did not have evidence the medical staff had recommended and the governing body approved the telemedicine appointment/reappointment and granting of privileges for Physicians #1 and #2.

Based on observation, policy and procedure review, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to perform surgical procedures in a safe manner for 1 of 1 surgical unit by not following their malignant hyperthermia policy. Failure to maintain a complete supply of Dantrolene and sterile water for possible malignant hyperthermia as per facility policy, limited the facility's ability to treat surgical patients in the event of a malignant hyperthermia crisis.

Findings include:

Review of the policy, "Malignant Hyperthermia" occurred on 03/08/22. This policy, revised 03/18/16, stated, ". . . Because malignant hyperthermia is a rare condition which must be treated quickly, guidelines are necessary to treat patients appropriately and rapidly when the crisis occurs. Equipment/Supplies Needed: Dantrolene - 36 vials. Sterile water for injection - 154 vials of 20 cc. . . ."

An undated article from the Malignant Hyperthermia Association, found at mhaus.org, stated, ". . .The following anesthetic agents are known triggers of MH [Malignant Hyperthermia]: Inhaled General Anesthetics . . . Succinylcholine (warning) [skeletal muscle relaxant]. A second article posted 2018, page 26, stated, "Most MH cases are triggered by the administration of a volatile anesthetic agent with or without succinylcholine, but in a small percentage of cases MH appears to be triggered by succinylcholine alone in the absence of a volatile agent. Events reported to the North American Malignant Hyperthermia Registry (NAMHR) were triggered by succinylcholine alone . . . . Dantrolene [muscle relaxant] must be available for all anesthetizing locations where MH trigger agents are used. Furthermore, MHAUS [Malignant Hyperthermia Association of the United States] recommends that centers stock a minimum of 36 20-mg vials of Dantrium [Dantrolene] or Revonto (total dose 720-mg), or three 250-mg vials of Ryanodex (total dose 750-mg). These amounts of dantrolene were originally determined by the analysis of MH event data showing that some cases of acute MH required up to or more than 10-mg/kg body weight, and therefore, these total dose amounts would suffice for the majority of average-sized patients that develop MH. . . ."

Observation of the surgical unit on 03/08/22 at 7:20 a.m., with a surgical nurse (#2), identified a vial of succinylcholine in the medication fridge and 18 vials of Dantrolene with 50 vials of sterile water for the facility Malignant Hyperthermia kit in a locked cupboard.

During interview on 03/08/22 at 8:00 a.m., a surgical nurse (#2) confirmed the 18 vials of Dantrolene and 50 vials of sterile water completed the facility's current Malignant Hyperthermia kit.