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Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or Quality Improvement Organization (QIO) evaluate the quality and appropriateness of the diagnosis and treatment furnished to the CAH's inpatients by physicians for 7 of 7 quarters reviewed (January 2022 - September 2023). Failure to have a network hospital or QIO evaluate the quality and appropriateness of the diagnosis and treatment provided by physicians limited the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the policy "Peer-to-Peer Review for Quality of Care" occurred on 12/19/23. This policy, dated 08/2021, stated, "Policy: To maintain quality of care . . . St. Andrew's Medical Staff will take part in periodic provider Peer Review which will be performed either by Medical Staff physicians, or by a third party under contract as required by regulation. Procedure: I. Chart selection A. On a quarterly basis, chart selection will be completed by the Medical Record Director/Designee selecting a random sample of: a. 2 inpatient charts from each physician . . . II. Routing of Charts for Peer Review A. After selection of the charts, the Medical Records Director/Designee will route the charts in the following manner: a. Physician charts will be routed to [name of network hospital], or other tertiary facility as dictated by contract. . . ."

Reviewed on 12/19/23, the 2022-2023 peer review records failed to include evidence a network hospital or QIO evaluated the quality and appropriateness of the diagnosis and treatment furnished to the critical access hospital inpatients by physicians. Upon request on 12/20/23, the CAH failed to provide further evidence of these evaluations.

During interview on 12/20/23 at 8:15 a.m., an administrative health information management staff member (#3) confirmed the CAH had failed to send out records of physicians providing hospital inpatient treatment/care to a network hospital or QIO for evaluation to ensure provision of quality and appropriate diagnosis and treatment in 2022-2023.

During interview on 12/20/23 at 8:30 a.m., an administrative staff member (#1) confirmed physicians provided treatment/care to the CAH's inpatients and the CAH had not sent inpatient records for evaluation by a network hospital or QIO.

Based on observation, policy and procedure review, inventory form, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to follow their malignant hyperthermia policy and professional standards. Failure to maintain a complete supply of Dantrolene or Ryanodine for possible malignant hyperthermia as per facility policy, limited the facility's ability to treat patients in the event of a malignant hyperthermia crisis.

Findings include:

Review of the policy, "Malignant Hyperthermia Cart" occurred on 12/20/23. This undated policy, stated, "The Surgical Services Department will have a cart stocked for the treatment of malignant hyperthermia at all times. . . . The malignant hyperthermia cart will be inspected once a month or immediately following a MH [malignant hyperthermia] crisis for inventory . . . DRUGS: Dantrolene 36 vials . . ."

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 [milligram] 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 [killogram] 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 12/18/23 at 4:02 p.m., with a surgical nurse (#5) and administration nurse (#2), identified 12 vials of Dantrium (Dantrolene) 20 mg and 1 vial of Ryanodex 250 mg in a locked Malignant Hyperthermia cart.

Observation of the emergency room the afternoon of 12/19/23 with a facility nurse (#6) and administrative nurse (#2), identified 4 vials of Succinylcholine 200mg/ml (milliliters) in the locked Pyxus refrigerator. A Device Inventory Form observed in the emergency room identified Succinylcholine 200mg/10ml quantity 4.

A Pharmacy Expiration Tracking for the operator room Malignant Hyperthermia Cart identified "Dantrolene 20mg 6 boxes with expiration dates of 02/25 and 11/25.

During interview the afternoon of 12/19/23, an administrative nurse (#2) confirmed the facility failed to maintain a complete Malignant Hyperthermia kit.

Based on observation, review of a professional reference, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff stored utensils in a way that prevented cross-contamination of foods in 1 of 1 kitchen. Failure to remove utensils from storage bins containing dried goods has the potential to result in cross-contamination of foods and/or illness.

Findings include:

The facility failed to provide a copy of their policy addressing infection control practices in the kitchen as requested.

The SERVSAFE Manager, 7th Edition Revised, pages 4.2, 5.10, and 6.2, stated, ". . . Pathogens . . . can be spread from food or unwashed hands to prep areas, equipment, utensils, or other food. . . . you need to store items in a way that prevents cross-contamination. . . . No matter what type of food you are prepping, you should . . . Make sure . . . utensils are clean and sanitized. . . ."

Observation of the kitchen on 12/18/23 at 2:35 p.m. and 12/19/23 at 8:35 a.m., showed staff left scoops in storage bins containing flour, rice, and sugar.

During an interview on 12/20/23 at 9:30 a.m., a dietary staff member (#4) agreed staff should not leave scoops in storage bins containing dried goods.