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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 four Acute Care patients, zero 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 to discharge the patient) patient 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 four Acute Care patients, zero 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 to discharge the patient) patient for a total census of five.

Findings included:

1.Upon request of the Malignant Hyperthermia medications, Staff D, Director of Surgical Services, stated that they had to call anesthesia to come in to access the room with the medications.

2.During an interview on 02/14/24 at 2:30 PM, upon request of the Malignant Hyperthermia medications, Staff D, Director of Surgical Services, stated the only staff with access to them were the anesthesia group and they had no surgeries that day.

3.During an interview on 02/15/24 at 8:40 AM, Staff K, ED Manager, stated that they used Succinylcholine whenever they intubated patients, and they didn't have access to the Malignant Hyperthermia medications.

4.During an interview on 02/15/24 at 11:00 AM, Staff Q, CRNA, stated that their anesthesia group were the only staff with access to the Malignant Hyperthermia medications.

5.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 interview and record review the facility failed to ensure services provided under contract were reviewed for quality of services. The facility census upon entrance was four Acute Care patients, zero 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 to discharge the patient) patient for a total census of five.

Findings included:

1. During an interview on 02/15/24 at 9:30 AM, Staff A, Chief Executive Officer, stated contracted services did not receive an evaluation of any kind from the governing body or through the quality assurance program. Staff A had looked for a policy related to a review of contracted services and did not find one.

2. Review of governing body meeting minutes and quality assurance meeting minutes for the previous 12 months showed no mention of the quality of contracted services.

Based on policy review, medical record review and interview, the hospital failed to ensure Certified Registered Nurse Anesthetists (CRNAs), completed the informed consents for anesthesia, prior to five surgical patients (#3, #4, #5, #6 and #8) out of seven reviewed. These failures had the potential to effect all patients that presented to the hospital for surgical procedures. The hospital census was four Acute Care patients, zero 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 to discharge the patient) patient for a total census of five.

Findings included:

1.Review of the hospital's policy titled, "Health Information Management Medical Record Content," undated, showed the following information must be documented in the informed consent:
- Patient identity;
- Date when the patient was informed and date signed;
- Nature of the procedure; and
- Name of who will perform the procedure.

2.Review of Patient #3's medical record dated 01/03/24, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to an endoscopy with biopsy procedure.

3.Review of Patient #4's medical record dated 01/08/24, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to a Cataract Extraction with Intraoccular Lens Implant procedure.

4.Review of Patient #5's medical record dated 08/04/23, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to a Cataract Extraction with Intraoccular Lens Implant with I stents procedure.

5.Review of Patient #6's medical record dated 08/16/23, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to a colonoscopy procedure.

6.Review of Patient #8's medical record dated 10/04/23, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to a colonoscopy procedure.

7.During an interview on 02/15/24 at 11:00 AM, Staff Q, CRNA, stated they didn't feel they had to sign the informed consent at the same time as the patient.

8.During an interview on 02/14/24 at 8:15 AM, Staff D, Director of Surgical Services, stated the CRNAs failed to sign the informed consents.

Based on record review, interview, and policy review the facility failed to ensure physicians had been privileged to supervise Certified Registered Nurse Anesthetists (CRNA) for the administration of anesthesia for three (Staff AA, BB and CC) of three physicians reviewed. The facility census upon entrance was four Acute Care patients, zero 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 to discharge the patient) patient for a total census of five.

Findings included:

1. Review of credentialing files for Staff AA, Staff BB, and Staff CC did not show a privilege for supervision of CRNA's was on the privilege form.

2. During an interview on 02/14/24 at 2:00 PM, Staff H, Medical Staff Coordinator, stated the three physicians, AA, BB, and CC performed surgery with the assistance of a CRNA. The privilege form should have included a privilege for the supervision of CRNA's.

3. Review of the undated facility policy titled CRNA Supervision, showed a reference to a federal law that stated CRNA's may administer anesthesia when under the supervision of an Operating Practitioner who is immediately available.

Based on observation, interview, and policy review, the hospital failed to ensure staff followed infection control policies and infection prevention standards of practice when staff failed to provide maintenance and a rust (reddish-brown oxidation of metal that can harbor bacteria) -free environment in the kitchen. This failed maintenance had the potential to expose all patients, visitors and staff to cross-contamination and increased the potential to spread infection. The hospital census was four Acute Care patients, zero 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 to discharge the patient) patient for a total census of five.

Findings included:

1.Observation on 02/13/24 at 2:15 PM, in the kitchen, showed:
- Residue on the ice machine with unclean tape on the front.
- Rusted hinges on the door between the service area and the work kitchen.
- Floors stained with unclean drains.
- Multiple opened cracks in the wall above a sink.
- Rusted ceiling tile borders.
- Broken floor tile in the cooler and freezer.
- A rusted vent to the left of the freezer with an old piece of tape hanging down.
- Two carts with a total of eight rusted wheels.
- Rust and corrosion on the outside of the dishwasher.
- Cracked walls with exposed drywall in the cafeteria.
- One stained ceiling tile in the cafeteria.

2.During an interview on 02/14/24 at 2:30 PM, Staff R, Infection Preventionist, stated they had seen some issues in the kitchen but did not place any work orders for repair.

3.Review of the hospital's policy titled, "Surveillance of Infections," undated, showed the direction for the Infection Control Nurse to conduct environmental rounds on all departments quarterly.

4.Review of the last three months of infection control rounds logs showed no kitchen surveillance.

Based on interview, record review and nationally-recognized standards, the hospital failed to provide a current Infection Control Plan approved by the Governing Body. This failure had the potential to effect all patients and staff that presented to the hospital for treatment. The hospital census was four Acute Care patients, zero 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 to discharge the patient) patient for a total census of five.

Findings included:

1. Although requested, the hospital failed to provide a current Infection Control Plan approved by the Governing Body.

2. During an interview on 02/14/24 at 2:30 PM, Staff R, Infection Preventionist, stated they did not have a current Infection Control Plan.

3. Review of the Centers for Disease Control and Prevention (CDC), titled, "Core Infection Prevention and Control Practices for Safe Healthcare Delivery", dated 11/29/22, showed the required ensurance of the Governing Body's accountability for the success of infection prevention activities in a health care facility.

Based on policy review, document review, record review, and interview, the facility failed to:
- Complete a comprehensive quality of life activities assessment, which identified specific individualized, activity interest for two of 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 (#20 and #21) and for two of two discharged Swing Bed patients (#22, and #23) reviewed for a complete comprehensive quality of life activities assessment.
- Provide specific, individualized activity interests that stimulated the patient's physical and mental well-being for two of two current Swing Bed patients (#20 and #21) and for two of two discharged Swing Bed patients (#22 and #23) reviewed for specific, individualized activity interests.
- Develop a comprehensive activity care plan, which included activity interests and interventions for two of two current Swing Bed patients (#20 and #21) and for two of two discharged Swing Bed (#22 and #23) patients reviewed for a comprehensive activity care plan.
These failed practices had the potential to affect all Swing Bed patients by failing to stimulate their minds, body and social interests. The facility census upon entrance was four Acute Care patients, zero 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 to discharge the patient) patient for a total census of five.

Findings included:

1. Review of the facility's policy titled, "Nursing Care Plan," undated showed in part staff directives:
- To establish a uniform guide for establishing individualized patient nursing care plans.
- The RN (Registered Nurse) is to utilize input from other delegated health care team members in the initiation and the revision of the plan.
- The RN is also responsible for the coordination and implementation of the patient's plan of care following completion of the Admission Assessment.
- The plan is updated and revised periodically based on evaluation of patient progress/achievement of goals.
- The patient/family may be included in the planning, evaluation, and revision of the plan.

2. Review of the facility document titled, "Swing Bed Program," dated 11/23, provided to patients admitted to the facility's Swing Bed Program showed services provided to patients under Activities/Social Services: The hospital will provide for an ongoing program of activities and medically related social services designed to meet the interest and the physical, mental, and psychosocial well being of each patient.

3. Review of Patients' Electronic Medical Health Records (EMHR) showed:
- Patient #20 was admitted to the facility's Swing Bed program on 02/13/24, with complaints of falls at home and weakness;
- Patient #21 was admitted to the facility's Swing Bed program on 01/05/24, with complaints of pneumonia and generalized weakness;
- Patient #22 was admitted to the facility's Swing Bed program on 01/19/24, with complaints of status post right hip fracture/repair; and
- Patient #23 was admitted to the facility's Swing Bed program on 01/28/24 with complaints of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs).

Patients' #20, #21, #22, and #23 EMHR showed staff failed to conduct a comprehensive quality of life activity assessment of the patients to assist in identifying the patients' activity interests and staff failed to develop a comprehensive activity care plan for the patients during the patients stay in the facility's Swing Bed program.

4. During an interview on 02/14/24 at 11:45 AM, Staff P, Registered Nurse (RN), Analytics Nurse, acknowledged the patients admitted to the facility's Swing Bed program did not have neither an activity assessment nor activity care plan in the patients' EMHR.

5. During an interview on 02/14/24 at 12:10 PM, Staff B, RN, Chief Nursing Officer, stated the facility received information from the Hospital Association that the Swing Bed Program was no longer required to perform either an activity assessment or include activities in the patient's care plan because the activity requirement was no longer a regulatory requirement for a facility's Swing Bed Program. Staff B stated the facility stopped performing activity assessments and including activities in patients' care plan after receiving notice activities were no longer a regulatory requirement for patients admitted to a facility's Swing Bed Program.