HospitalInspections.org

Based on the facility policy and procedure, observation and staff interviews, it was determined that the facility failed to have available on site medication used in life- saving procedures. Specifically, Dantolene (muscle relaxant) on site when Succinylcholine (triggering agent for Malignant Hyperthermia-life threatening condition) is being administered.

Findings were:

Review of the facility policy entitled Malignant Hyperthermia (MH) and Succinylcholine Use, No Policy Number, No Effective Date, No Approval Date, revealed that Succinylcholine (muscle relaxant) given intravenously (IV) to facilitate tracheal intubations (insertion of a small hollow tubing through the mouth into the trachea, to assist in maintaining an open airway) to provide skeletal muscle relaxation during mechanical ventilation in the emergency room. Further review of the policy revealed that Succinylcholine could alone when given with anesthesia gases may cause malignant hyperthermia (Malignant hyperthermia is a severe reaction to a dose of anesthetics. The reaction is sometimes fatal. It is caused by a rare, inherited muscle abnormality. Infrequently, extreme exercise or heat. malignant hyperthermia is possibly a fatal syndrome that can be caused by Succinylcholine. Symptoms may include fast heartbeat, fast breathing, high body temperature, or spasm or stiffness of the jaw or other muscles). The policy revealed the the following treatments for MH:
a) fluid and electrolyte replacement with normal saline (intravenous fluids)
b) Cardiac monitor
c) Cool patient
d) Place normal cold normal saline bags around patient
e) Place ice bags next to saline, place bags and ice packs on the neck on the neck, groins and axilla
f) Wet patient with cool water and use fans over patient
g) Immerse hand and forearms in cold water
h) Facilitate transport, notify receiving facility of patient condition and status of MH.
Observation at 6/11/2013 at 12:15 p.m of the facility pharmacy with (employee file # 4), the Pharmacist was asked if Dantrolene (Dantrolene is a muscle relaxant. Dantrolene is used to treat muscle spasticity, stiffness and spasms caused by conditions such as a spinal cord injury, stroke, cerebral palsy, or multiple sclerosis. Dantrolene is also used to prevent muscle stiffness and spasms caused by malignant hyperthermia.) was stocked in the facility for use during a MH crisis. The Pharmacist stated that Dantrolene was not stocked in the facility. He/she stated that if a patient had a MH crisis, the staff would place cool saline bags and ice on the patient and call their receiving hospital, inform them that the patient was experiencing a MH crisis and transfer the patient. The Pharmacist stated that the receiving hospital was only thirty (30) miles away.
Observation on 6/12/13 at 9:45 a.m. of the Emergency Department (ED), the surveyor asked (personnel file #16) if the ED had a MH cart (cart stocked with emergency supplies that may be needed during an MH crisis, which may include medications, urine catheter kit, intravenous catheters, intravenous fluids, syringes, infusion sets). The ED nurse stated that the ED department had a MH kit and proceeded to show the surveyor the kit. Observed underneath a desk in the nurse's station was a box covered with dust that contained a Foley catheter kit, IV catheters, 1 cc syringes and an IV infusion set. The nurse stated that the kit would be used in the event of a MH crisis. The nurse was asked if Dantrolene was stocked in the ED for use in the event of a MH crisis and he/she stated that he/ she was unaware of Dantrolene being stocked in the ED. The nurse stated that they would contact the receiving hospital and transfer the patient, because it was only about 30 minutes away.
The Pharmacist confirmed there was no Dantrolene in the facility.

Based on review of the facility policy and procedures, observation and staff interviews, it was determined that the facility failed to follow their policy and procedures related to controlling infections and communicable diseases.

Findings were: (I have more to add. Do not change anything yet.)

Review of the facility policy entitled Infection Control, Standard Precautions, Airborne Droplet and Contact Precautions, effective: 06-01-01 revealed that in all instances, Respiratory Therapy personnel would follow universal precautions for all patients. Disposable equipment would be disposed of in a regular trash bag.

During the tour of the facility Radiology Department on 06/12/13 at 11.25 a.m. with (employee file # 15-Radiology Technician RT), surveyor observed that an open single use oxygen connection tubing was attached to the wall oxygen outlet in the following areas of the Radiology Department. Those areas included the following locations: CAT scan room, mammography room, ultrasound room, and the x-ray room. The RT was asked if the oxygen tubing was changed after each patient use. He/she stated that the tubing was connected to the nasal cannula of multiple patients to conserve individual patient's oxygen tank use, and was not changed between patients.

Review of the manufacturers instruction on the oxygen tubing package revealed that the oxygen connection tubing was for single use only.

Findings were confirmed by the radiology technician.

During a facility tour with the procedure room RN (employee #13) on 6/12/13 at 9:30 am, it was observed that the facility's procedure room, which stored sterile items, did not contain a device for monitoring temperature and humidity.
During an interview with the RN at the time of discovery, when the surveyor asked if the procedure room's temperature and humidity was monitored and recorded, the RN stated "no", and that he/she was unaware of the requirement.
Review of facility policies failed to reveal a policy which addressed temperature and humidity in the procedure room.

Based on review of the facility's policies and procedures, medical records, observations on a tour of the Emergency Department (ED) on 06/12/2013 at 9:45 a.m. and staff interview, it was determined that the facility failed to have a notice, conspicuously posted in the ED, advising patients entering the ED, that the facility did not have a doctor of medicine (MD) or a doctor of osteopathy (DO) present in the hospital twenty-four (24) hours per day, seven (7) days a week, and which informed patients how the facility would meet the medical needs of any patient with an emergency medical condition. Review of seventeen (17) medical records revealed that the facility failed to obtain a signed acknowledgement from admitted patients and outpatients requiring anesthesia which informed them of the lack of MD and DO coverage 24/7.

Review of the facility's policies and procedures revealed that the facility failed to have a policy which addressed the written notice and posting requirements.

During a tour of the facility's ED on 06/12/2013 at 9:45 a.m. in the company of the director of nurses, it was noted that the facility failed to provide a conspicuously posted notice to patients entering the ED advising them of the lack of MD or DO coverage 24/7 and how their medical needs would be met.

Review of seventeen (17) medical records revealed that thirteen (13) of the seventeen (17) medical records reviewed (patients admitted after the effective date of 03/15/2013), failed to contain a signed acknowledgement (from admitted patients and outpatients requiring anesthesia) that the patients understood that a MD or DO might not be present during all hours that services were provided to him or her.

During an interview on 06/11/2013 at 2:00 p.m. in the facility's boardroom, the chief operating officer (CEO) (employee #14) stated that the facility was unaware that this notice and written acknowledgement were required at the present time. The CEO drafted an acknowledgement form for inpatients and required outpatients to sign, and he/she posted the required notice in a conspicuous area of the ED.