HospitalInspections.org
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METHODIST FREMONT HEALTH
OPERATING ROOM POLICIES
Tag No.: A0951
NOT CORRECTED FROM INSPECTION DATED 11/20/2015
Based on review of the MH (Malignant Hyperthermia) Protocol Education/Training report form and Administrative staff interview; the hospital failed to ensure all hospital identified staff were provided with the MH protocol education and training to provide emergent care of a patient in a MH crisis. This failed practice had the potential to affect all surgical patients using inhaled general anesthetics and Succinycholine Chloride (A short-acting depolarizing skeletal muscle relaxant). The average number of surgical procedures performed at the hospital on a monthly basis is 263.
Findings are:
A. Review of the MH Protocol Education/Training report form (due date 12/1/15 through 12/31/15) revealed completed training for all identified staff at 87.10%.
B. Interview with the Vice President Chief Nurse Executive at 3:00 PM on 12/31/15 confirmed that all staff did not complete the required initial MH Protocol Education/Training.