HospitalInspections.org

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to store succinylcholine (medication used to relax muscles during surgery) according to manufacturer's recommendations for 1 of 1 observed surgical procedure (Patient #1). Failure to ensure succinylcholine is stored according to manufacturer's recommendations could potentially result in patients receiving a medication that does not work in the body as expected, resulting in unintended consequences or side effects. The CAH's administrative staff identified the surgical services staff performed an average of 900 surgical procedures per year.

Findings include:

1. Observations on 02/25/2020 at 10:55 AM, in Operating Room #2 before Patient #1's carpel tunnel surgery, revealed the anesthesia cart contained a 10 milliliter vial of succinylcholine (200 milligrams/milliliter), unopened, dated 02/24/2020.

2. During an interview at the time of the observation, Certified Registered Nurse Anesthetist (CRNA) B stated the CAH staff's practice was to store succinylcholine for up to 28 days outside the refrigerator. CRNA B confirmed the succinylcholine had been removed from the refrigerator on 02/24/2020.

3. Observations on 02/24/2020 at 1:55 PM, during a tour of the Operating Room (OR), an interview with the Regional Director of Surgical Services and Director of Surgical Services revealed the succinylcholine was kept in a monitored, secured refrigerator. Once the staff remove the succinylcholine from the refrigerator, the medication had a shortened expiration date of 28 days from when the CAH staff removed the succinylcholine from the refrigerator.

4. Review of manufacturer's recommendations for the storage of succinylcholine revealed, in part: "Refrigeration of the undiluted agent will assure full potency until expiration date ... Store in refrigerator 2 degrees - 8 degrees C [Celsius]... the multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency."

4. During an interview on 02/25/2020 at 9:50 AM, Pharmacist C confirmed CAH practice was to store succinylcholine outside the refrigerator for up to 28 days. Pharmacist C acknowledged the manufacturer recommended succinylcholine be stored outside the refrigerator for up to 14 days.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure diagnostic imaging (x-ray) staff secured 1 of 2 radiation exposure cords used during patient x-ray procedures. Failure to secure a radiation exposure cord could allow staff access to the x-ray room while performing an x-ray procedure and exposing staff to unnecessary radiation. The CAH x-ray staff reported completing an average of 393 x-rays per month.

Findings included:

1. Observations during tour of the radiology department on 02/26/2020 at 09:45 AM, with the Director of Imaging Services, revealed 1 of 2 unsecured exposure cords which allowed a staff member to enter approximately 8 feet into x-ray room #1 and still activate the x-ray machine.

2. Review of the CAH policy, "Radiation Safety for Patients and Personnel," effective 02/2020, revealed in part, " ...Technologists and other staff must remain behind the control booth during each and every exposure ...."

3. During an interview on 02/26/2020 at 09:45 AM, the Director of Imaging Services confirmed staff failed to secure the radiation exposure cord in room #1 which could allow staff access into the x-ray room during x-ray procedures.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure the surgical staff removed their nail polish from their fingernails prior to surgical hand scrub and before donning gloves for aseptic tasks during 1 of 1 observed surgical procedures (Patient #1). Failure to ensure surgical staff followed approved infection control standards of practice in accordance with the Centers for Disease Control (CDC) recommendations could potentially result in the surgical staff failing to remove bacteria which contaminated their hands during a procedure and potentially transmit the bacteria to another patient, potentially causing a life-threatening infection. The CAH's administrative staff identified the surgical staff performed approximately 900 surgical procedures for the past year.

Findings include:

1. Review of the "Hand Hygiene" policy, effective date 10/2012, revealed in part... "Purpose: Hand washing is the single most important procedure for preventing the transmission of infection and reducing the incidence of health-care associated infections ... Employees working in special care areas such as surgery are to refer to their department manual for scrub procedures."

2. Review of the "Hand Scrub Policy,"(specific to Surgery) effective 05/2019, revealed in part... "Purpose: to provide guidelines to all members of the surgical team regarding hand scrubbing ... Fingernails must be free of nail polish and not excessively long ...(sic)."

3. Observations on 02/25/2020, beginning at 10:50 AM, during Patient #1's carpal tunnel surgery (procedure to relieve constant numbness, muscle weakness or pain in the hand), revealed the following:

--10:50 AM Registered Nurse (RN) A was noted to have nail polish on their fingernails and the nail polish was in disrepair on the left thumb.

--11:07 AM RN A performed hand hygiene prior to donning sterile gloves and prior to performing the pre-surgical disinfecting scrub on Patient #1's hand.


4. During an interview on 02/25/2020 at 11:46 AM, the Regional Director of Surgical Services agreed they expected the surgical staff to perform hand hygiene and remove nail polish from the staff member's fingernails according to the hospital Hand Scrub policy.

5. During an interview on 02/26/2020 at 1:50 PM, the Infection Prevention/Employee Health Nurse/Clinical Quality Coordinator discussed the hand hygiene policy. They clarified the CDC guidelines are used for hand hygiene, nail polish on fingernails and glove usage. They educate hospital staff using the network hospital hand hygiene policy, which references the CDC guidelines. They agreed the surgical staff is expected to perform hand hygiene according to the hospital Hand Hygiene policy and Hand Scrub policy.