HospitalInspections.org

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation, interviews with Employee Identifier (EI) # 2 and EI # 3 and review of facility policies and the standards from the Malignant Hyperthermia Association, it was determined the facility failed to ensure there were 36 vials of Dantrolene Sodium available for possible treatment of Malignant Hyperthermia (MH). This had the potential to affect all surgical patients.

Findings include:

Review of the standards from the Malignant Hyperthermia Association of the United States revealed the following documentation, "The full 36 vials of dantrolene should be available within five minutes of the diagnosis of MH (Malignant Hyperthermia).

Facility Policy #2036

Management of Patient with Malignant Hyperthermia

Bulleted item: If malignant hyperthermia is suspected, the following steps are taken:

".....Administer Dantrium (dantrolene sodium) IV (intravenous)...As a large quantity may be necessary, a sufficient supply must be available. Vials are available in the Surgical Services Department, and in the anesthesia work-room. Additional vials will be obtained by the Pharmacy from outside sources, if needed..."

Surgical Services

"Dantrium is kept in the malignant hyperthermia cart at both the Ambulatory Surgery Center (ASC) and DMC (Dale Medical Center)......"

A tour of the surgical suite on 7/28/10 at 8:40 AM revealed only 18 vials of Dantrolene were available in the Hyperthermia Cart.

An interview with EI # 2, the Certified Registered Nurse Anesthetist (CRNA) on 7/28/10 at 9:45 AM verified there were only 18 vials of Dantrolene in the hospital. EI # 2 stated that this hospital shared Dantrolene with an ambulatory surgery center (ASC) which was 5 miles away. He/she stated that the hospital keeps 18 vials of Dantrolene and the ASC keeps 18 vials of Dantrolene for a total of 36 vials between the two facilities. The surveyor concluded that with only 36 total vials between the two facilities if either facility had to obtain the 18 vials from the other facility one would be without any Dantrolene for longer than 5 minutes as travel to and from either facility would take longer than 5 minutes.

An interview with EI # 3, the Chief Nursing Officer on 7/28/10 at 10:00 AM verified that the there is no policy regarding the number of vials that should be kept at the hospital.
He/she confirmed that there should be 36 vials on site.

Based on review of 30 emergency room records, hospital policy and interview with Employee identifier (EI) # 1, the ER (Emergency Room)director, it was identified that the emergency room physician failed to document the condition of the patient on discharge in 8 of 30 emergency room (ER) records. This effected ER records # 1, 2, 3, 5, 6, 7, 8 and 10.

Hospital Policy

Discharges from the Emergency Department

It shall be at the discretion of the attending emergency department physician when a patient may be discharged from the Emergency Department. Time of departure and the patient condition must be documented on the medical record on each patient...

Findings include:


The following medical records did not have documentation by the physician of the patient's condition on discharge: ER record # 1,2,3,5,6,7,8 and 10.

An interview with EI # 1, the ER director on 7/29/2010 at 2 P.M. verified the condition of the patient on discharge had not been documented by the physician on the 8 medical records.