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Based on observation, staff interview, and document review it was identified the Critical Access Hospital (CAH) uses succinylcholine (a medication used as a muscle relaxant during surgical procedures and intubation (a procedure where a tube is placed into the patients airway to manage breathing) and failed to follow professional guidelines for stocking the emergency medication Dantrium/Revonto (a medication used to treat Malignant Hyperthermia, which is a condition associated with the use of the muscle relaxing medication succinylcholine). (Refer to C-0203). Failure to have Dantrium/Revonto could cause patient harm or death in the event of Malignant Hyperthermia.

An Immediate Jeopardy (IJ - a situation that has or is likely to cause patient harm) was identified on 12/04/2017 at 4:15 PM when Pharmacy Staff D confirmed the facility stocks and uses succinylcholine and they do not stock Dantrium/Revonto. Chief Executive Officer Staff F, Medical Director Staff B, Pharmacist Staff E were notified. Staff B, Staff E, and Staff F decided to remove succinylcholine from their formulary and implement a policy to use an alternative medication for intubation and any procedures performed at the hospital requiring the use of a muscle relaxant.

The facility removed the IJ with the removal of succinylcholine on 12/4/2017 at 4:30 PM and when Staff B put the new intubation procedure in place that did not include succinylcholine at 4:45 PM.

Based on observation, staff interview, and document review, the Critical Access Hospital (CAH) failed to ensure emergency medications were readily available in the emergency department (ED) by failing to have medication on hand to treat Malignant Hyperthermia (a rare life-threatening condition causing a severe high body temperature triggered by medications that act as depolarizing muscle relaxants such as succinylcholine (a muscle relaxant administered in ED's when breathing is compromised requiring intubation (a procedure where a tube is placed into the patients airway to manage breathing) and to provide anesthesia during surgical procedures). Failure to have enough of the rescue drug Dantrium/Revonto immediately available for use has the potential for delays in responding to a medical emergency causing a worsening of a patient's condition or death.

Findings include:

- Pharmacy Formulary Document reviewed on 12/4/2017 at 4:15 PM revealed the facility stocked the medication succinylcholine 200 milligrams/10 milliliters.

Pharmacy Staff D interviewed on 12/4/2017 at 4:15 PM confirmed they stocked succinylcholine and that it is used for surgical procedures and for emergency intubation of patients. Staff D also confirmed the facility did not stock Dantrium/Revonto.

Chief Executive Officer (CEO) Staff F and Chief of Staff B interviewed on 12/4/2017 at 4:20 PM indicated they would immediately remove the succinylcholine from stock and use other medications for intubation and surgical procedures.

Hospital Document reviewed on 12/4/2017 at 4:30 PM directed, "To all medical staff, as of today December 4, 2017; the Succinylcholine 200mg/10ml will be temporarily removed from use. For rapid sequence intubation, we will use Etomidate (a short-acting intravenous anaesthetic agent used for the induction of general anesthesia and sedation for short procedures such as reduction of dislocated joints, tracheal intubation, and cardioversion), Midazolam (a medication used for anesthesia, procedural sedation, trouble sleeping, and severe agitation. It works by inducing sleepiness, decreasing anxiety, and causing a loss of ability to create new memories), and Fentanyl (an opioid which is used as a pain medication and together with other medications for anesthesia). Reversal agents are on hand for these medications.

CEO Staff F interviewed on 12/5/2017 at 11:15 AM confirmed they would not return succinylcholine to their formulary unless they had 36 vials of Dantrium/Revonto on hand.

Malignant Hyperthermia Association of the United States website reviewed on 12/4/2017 directed, the patient experiencing a Malignant Hyperthermia (MH) episode must be stabilized before being transported. Stabilization of an MH episode may take 30 minutes or more with multiple doses of Dantrium/Revonto because, in some cases, MH progresses with explosive rapidity. The full 36 vials of Dantrium/Revonto is inexpensive insurance against patient injury or death and a malpractice claim, which the facility will lose. The full 36 vials of Dantrium/Revonto should be available within five minutes of the diagnosis of MH.

Based on observation, staff interview, and document review the Critical Access Hospital (CAH) failed to ensure a backflow prevention system (a device used to ensure water and other contaminants do not backup into the sink or icemaker) is in place at the point of water connection for one of two kitchen sinks and one of one ice makers located in the staff dining room. This deficient practice has the potential to allow dirty water to reenter the sink contaminating items being prepared in the skin.

Findings include:

- Kitchen observed on 12/5/2017 at 2:00 PM revealed a prep sink without evidence of a backflow preventer or an air gap.

Maintenance Staff H interviewed on 12/6/2017 at 11:00 AM acknowledged one of the kitchen sinks lacked a backflow prevention device.

Quality/Risk Manager Staff A interviewed on 12/6/2017 at 11:00 AM confirmed the icemaker located in the dining room lacked a backflow prevention device.

Policy review on 12/6/2017 at 1:00 PM revealed the facility failed to develop a policy requiring a backflow prevention system on the kitchen sinks and icemakers.

The FDA Food Code 2009 read in part: 5-202.13 Backflow Prevention, Air Gap.
An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or non-FOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). P

Based on observation and staff interview the Critical Access Hospital (CAH) failed to ensure one of four fire doors (located between the nurses station and the patient rooms) latched properly when tested, failed to ensure the emergency generator had a safety stop, failed to ensure the staff stored one of eight oxygen cylinders in a secured manner (clean storage room), and failed to ensure one of eleven metal junction boxes (maintenance room) had an approved cover. These deficient practices have the potential to place all patients and staff at risk for injury.

Findings include:

- Fire door located between the nurses station and patient rooms observed on 12/5/2017 at 12:40 PM revealed the door failed to close securely and independently.

Maintenance Staff H interviewed on 12/5/2017 at 12:40 PM confirmed the magnetized fire doors are required to close independently.

The facility failed to provide a policy directing staff to ensure fire doors close independently.
NFPA Standard: Swinging doors normally held in the open position and equipped with automatic closing devices shall be operated at frequent intervals to ensure proper operation. NFPA 80, 1999 15-2.4.2


- Emergency Generator observed on 12/5/2017 at 12:45 PM revealed the facility lacked a generator safety stop.

Maintenance Staff H interviewed on 12/5/2017 at 12:45 PM indicated they did not have a generator safety stop and did not know one was required.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110 3-5.5.6*
NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. 1999 NFPA 110 A-3-5.5.6


- Clean Storage room observed on 12/5/2017 at 12:30 PM revealed one oxygen cylinder stored unsecured on the floor. This has the potential to become a projectile which could harm staff patients, or visitors if the valve is damaged.

Maintenance Staff H interviewed on 12/5/2017 at 12:30 PM confirmed the oxygen cylinders should be stored in the rack located in the storage room.

Policy titled "Oxygen Cylinder Storage" reviewed on 12/5/2017 at 3:45 PM directed, The E tanks are stored in racks in the clean storage room. The racks are labeled full and empty and tanks are stored accordingly. When in use the tanks are to be in a cart.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2


- Maintenance Room observed on 12/5/2017 at 1:15 PM revealed a junction box lacking an approved cover.

Maintenance Staff H interviewed on 12/5/2017 at 1:15 PM indicated they had taken the cover off and had not replaced it yet.

NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).

Based on credentialing file review and staff interview the Critical Access Hospital (CAH) failed to ensure their credentialing file documentation was completed for 1 of 10 medical staff (Staff G). This deficient practice places patients at risk in receiving care from unqualified professionals. The deficient practice has the potential to allow Medical Staff to practice without designated appointment/privileges.

Findings:

- Physician Assistant Staff G's personnel file reviewed on 12/4/2017 at 12:34 PM revealed a Recommendation and Approval Form failed to have the granting of specific privileges selected. The Governing Body failed to choose the reappointment designation.

Quality/Risk Manager, Staff A, interviewed on 12/6/2017 at 8:30 AM confirmed the Recommendation and Approval Form was incomplete. Staff A indicated it was missed by the Governing Body.

Medical Staff Bylaws reviewed on 12/7/2017 at 9:00 AM directed, that all appointments to Medical Staff shall be made by the Governing Body after receiving a recommendation from the Medical Staff Committee and shall be to one of the following categories of the staff.

Based on observation, staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure a system for removing outdated supplies from central supply and in the emergency room. This deficient practice puts all staff and patients at risk for an unsafe and unsanitary environment free of bacteria causing illness and diseases.

Findings include:

- Central Supply room observed on 12/4/2017 at 2:00 PM revealed the following outdated supplies:
Six - one gallon jugs of sterile water with an expiration date of 11/18/2017
27 - 110ml (milliliter) containers of sterile water with an expiration date of 2/2017

- Emergency Room #1 observed on 12/4/2017 at 12:50 PM revealed the following outdated supplies:
Two Epigaxis Balloons (a device paced into the nose to help stop nose bleeds) with an expiration date of 11/2017
Twenty Polysorb suture kits with an expiration date of 9/2017

Quality/Risk manager staff A interviewed on 12/4/2017 at 1:30 PM confirmed all expired supplies should be discarded.

Materials management Staff U interviewed on 12/4/2017 at 2:30 PM confirmed outdated supplies should not be available for patient use.

Policy titled "Expired supplies" reviewed on 12/6/2017 at 4:00 PM directed, Items will be removed prior to their expiration date and destroyed.

Based on interview, record review and policy and procedure review the Critical Access Hospital (CAH) failed to ensure a nursing care plan was completed in one of 35 records reviewed (Patient # 30). Failure to ensure care plans are completed puts all patients at risk for lack of direction, continuity of care and discharge individualized for each patient according to their health care needs.

Findings include:

- Patient 30's medical record review on 12/5/2017 at 9:00 AM revealed the patient was admitted with a diagnosis of pulmonary embolism (a blood clot in lungs) on 10/4/2017 and discharged on 10/5/2017. The medical record lacked an individualized nursing care plan.

Staff A interviewed on 12/5/2017 at 1:00 PM confirmed each patient is required to have an individual nursing care plan and did not know why it was not completed.

Policy "Nursing Admission History and Assessment" reviewed on 12/5/017 at 2:00 PM directed, complete a nursing care plan from the nursing diagnosis generated from nursing assessment. All nursing diagnoses are to be a clinical judgement about the patient response to actual or potential health problems or life processes.

Based on medical record review and staff interview the Critical Access Hospital (CAH) failed to ensure five of 35 medical records (Patient #'s 2, 3, 4, 5, and 21) contained a signed admission History and Physical (H&P) seven days prior or 48 hours after patient admission date. Failure to provide an admission history and physical has the potential for poor patient outcomes.

Findings include:

- The H&P examination for patient #2, admitted 8/9/2017 revealed Staff G, Physician Assistant (PA) completing the H&P on 8/10/2017 and Staff B, MD authenticating the H&P on 9/2/2017 (24 days late).

- The H&P examination for patient #3, admitted 6/15/2017 revealed Staff G, PA completing the H&P on 6/16/2017 and Staff B, MD authenticating the H&P on 7/21/2017 (26 days late).

- The H&P examination for patient #4, admitted 10/20/2017 revealed Staff G, PA completing the H&P on 10/21/2017 and Staff B, MD authenticating the H&P on 11/14/2017 (25 days late).

- The H&P examination for patient #5, admitted 6/8/2017 revealed Staff G, PA completing the H&P on 6/9/2017 and Staff B, MD authenticating the H&P on 6/30/2017 (21 days late).

- The H&P examination for patient #21, admitted on 9/1/2017 was signed 10/3/2017 (33 days late).

Quality/Risk Manager Staff A interviewed on 12/6/2017 at 3:00 PM confirmed patient admission history and physical should be completed seven days prior or 48 hours after patient admission date.

Medical Staff Bylaws reviewed on 12/6/2017 at 4:00 PM directed, a comprehensive history and physical shall be written or dictated within 24 hours of admission.

Policy "Medical Record Content and Completion Requirements" directed, during the admission, but no more than 30 days before and no later than 24 hours after admission.

Based on staff interview, medical record and document review the Critical Access Hospital (CAH) failed to ensure physician orders were authenticated (the process or action of proving or showing something to be true, genuine or valid) for verbal orders in three (Patient #'s 3, 4, and 23) of 35 medical records reviewed. Also, the CAH failed to ensure the Discharge Summary was signed within 30 days after discharge in one (patient #29) of 35 medical records reviewed. Failure to authenticate orders places patients at risk for receiving medications, treatments and care that is unsafe with the potential of causing harm. Failing to sign a discharge summary places a patient at risk for poor continuity of care.

Findings include:

- Patients # 3 and 4 records reviewed on 12/6/17 revealed Patient # 3 and 4 were admitted to the Life Care Unit (LCU) on 6/15/2017 and discharged on 6/30/2017. The record revealed verbal orders failed to be signed within the timeframe as follows:

The verbal order for patient #3, given on 6/29/17 revealed Physician Staff R authenticated the order on 9/8/17 (71 days late).

The verbal order for patient #4, given on 10/26/17 revealed Physician Staff R authenticated the order on 11/13/17 (18 days late).


- Patient #23's record reviewed on 12/5/2017 at 12:00 AM revealed verbal orders for Ativan (used for anxiety) and Lyrica (used to treat nerve pain from diabetes, shingles, spinal cord injury, and fibromyalgia) medication as needed by the patient were not authenticated.

- Patient #29's record reviewed on 12/5/2017 at 9:00 AM revealed the patient was discharged on 7/20/2017 and the discharge summary signed on 8/31/2017 (12 days late).

Quality/Risk manager Staff A interviewed on 12/6/2017 at 3:00 PM confirmed verbal orders are to be authenticated and discharge summaries are to be signed to within 30 days.

Medical Staff Bylaws reviewed on 12/6/2017 at 4:00 PM directed, No medical record shall be filed until complete and all entries in the record shall be dated, time of entry noted and authenticated by the appropriate individuals.

Policy titled "Verbal, Telephone, Faxed and Written Order Processing" directed, A verbal/telephone order must be authenticated by the qualified healthcare professional within 72 hours or the 1st day the provider returns to work.