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Based on observation, interview, record review, and review of facility documents, the facility failed to meet the Conditions of Participation for Emergency Services by failing to ensure appropriate medications and equipment used for life-saving measures were immediately available putting all patients at risk who require emergency services (Refer to C203 regarding medication availability in the Emergency Department and C202 for availability of emergency equipment).

Findings include:

Observation of the facility's Emergency Department (ED) medication room on 11/18/19 at 10:15 AM, in the presence of the day shift ED Trauma Nurse Coordinator (Trauma RN) revealed two vials of succinylcholine chloride (a rapid-acting paralytic used to ensure a patient does not "fight" the intubation in an emergency) in each of two locked Rapid Sequence Intubation (RSI) kits. The RSI kits did contain two vials of Vecuronium, an alternative rapid-acting paralytic for use in RSI. Inspection of the ED medication room and pharmacy revealed Dantrolene was not available.

During an interview with the Trauma RN on 11/11/19 at 10:15 AM, he/she stated he/she was aware of the need for Dantrolene in the facility and stated , "I don't know why we don't have it."

During an interview with the Pharmacist on 11/18/19 at 10:35 AM, the Pharmacist stated that he/she was unaware of the Malignant Hyperthermia Association of the United States (MHAUS) statement on the need for Dantrolene to be immediately available in the event the use of succinylcholine chloride caused a rare side-effect called malignant hyperthermia (a potentially life-threatening fever and muscle rigidity). The Pharmacist stated that he/she was unaware that Dantrolene was used to reverse this side-effect.

During a telephone interview with the Trauma Medical Director (ED MD) on 11/18/19 at 10:40 AM, the ED MD stated he/she was unaware of the MHAUS statement. The ED MD stated, "We will remove the succinylcholine and use just the Vecuronium," for RSI.

Observation of the facility's removal of the two vials of succinylcholine chloride from the RSI kits and placement of these vials in the pharmacy "lock box" was conducted on 11/18/19 at 11:00 AM by the Pharmacist, the Trauma RN and the surveyor.

The facility was requested to provide a list of the names of any and all patients who had received administration of succinylcholine chloride for the current year. A computer report was provided showing no patients had received succinylcholine chloride from 01/01 19 to the current date.

Immediate Jeopardy (IJ) was formally determined to exist on 11/18/19 at 1:06 PM under 42 CFR 485.618 Emergency Services at C-0200 following conference with the State Agency. The Chief Executive Officer (CEO) was notified of the identified IJ due to the presence of succinylcholine chloride and absence of dantrolene in the facility on 11/18/19 at 1:55 PM, and of the need for a Plan of Removal to be put in place immediately to remove the IJ.

An acceptable Plan of Removal was provided on 11/18/19 at 9:00 PM and consisted of the following steps:

1.The only two vials of succinylcholine chloride in the facility were removed and permanently discarded on 11/18/19 at 4:00 PM.

2.A new policy explaining that succinylcholine chloride will no longer be used in the facility was developed and approved on 11/18/19 at 4:00 PM

3.A new procedure for the use of Vecuronium for RSI was developed and approved on 11/18/19 at 4:10 PM

4.Education was provided to all available appropriate staff on 11/18/19 at 4:00 PM, with 62% of staff members completing the education at this time. The Plan of Removal stated no staff members would be allowed to return to work prior to completion of this education.

5.A Quality Assurance (QA) monitoring plan was outlined to ensure compliance with the Plan of Removal on 11/18/19 at 4:00 PM. This included audits of the inpatient pharmacy and ED to ensure compliance, with initial audits three times per week for the first two weeks, then (after %100 compliance), monthly for three months, then (after %100 compliance) quarterly until determined by the QA committee and Chief of Staff that the audits may be discontinues. The audits were to be completed by the Chief Nursing Officer (CNO) and audit reports were to be reported to the QA committee.

The State Survey Agency officially accepted the Plan of Removal on 11/18/19 at 9:00 PM. The on-site surveyors validated all steps of the Plan of Removal on 11/19/19 at 8:30 AM and the CEO was notified of the acceptance. At this time the IJ was considered removed.

Based on document review, interview, and policy review, the facility failed to ensure emergency equipment was checked daily to assure availability for immediate use. This failure could result in a delay of staff response during an emergency, placing all emergency and in-patients at risk of negative outcomes.

Findings Include:

Review of the "ER [emergency room] Crash Cart Check," on 11/19/19 at 2:40 PM showed the cart had not been checked on the following days and shifts: day shift 09/13/19, night shift 09/25/19, day shift 09/2819, day shift 11/06/19, and day shift 11/07/19.

Review of the "ACU [acute care unit] Crash Cart Check," on 11/19/19 at 2:55 PM showed the cart had not been checked on the following days and shifts: night shift 11/03/19, night shift 11/07/19, and day shift 11/19/19.

Review of the "ER2 [Procedure Room] Crash Cart," on 11/19/19 at 3:10 PM showed the cart had not been checked on the following days and shifts: day shift 11/05/19, day shift 11/06/19, day shift 11/07/19, day and night shifts 11/15/19, day and night shifts 11/16/19, day and night shifts 11/17/19, and day shift 11/18/19.

During an interview and review of the above documents with the Chief Nursing Officer (CNO) on 11/20/19 at 11:55 AM, the CNO reported there were three emergency carts [crash carts] in the facility, one in the Emergency Room (ER), one in the Procedure Room, and one in the inpatient nursing area. The CNO stated nursing staff were required to check each cart once per shift for functionality of the equipment on the top of the cart, meaning the suction and the defibrillator (device used to "shock" a life-threatening cardiac rhythm or absence of rhythm). The CNO confirmed the crash carts had not been checked per policy.

Review of facility policy titled, "Emergency Crash Cart and Equipment Maintenance," last revised 11/01/11, documented, "Each shift will check the defibrillator and portable suction on each crash cart."

Based on observation, interview, and document review, the facility failed to ensure it maintained a supply of medication to reverse a potential life-threatening side effect of another medication used by the facility during emergencies. Failure to anticipate the need for care of medication side-effects during medication administration had the potential to negatively impact all patients presenting to the facility for emergency care.

Findings include:

Observation of the facility's Emergency Room (ER) in the presence of the Trauma Nurse Coordinator (Trauma RN) on 11/18/19 at 10:15 AM revealed the presence of two Rapid Sequence Intubation (RSI) kits (used when a patient requires immediate insertion of an endotracheal tube to maintain an airway and/or provide supplemental oxygen). Each kit contained a vial of succinylcholine chloride (a rapid acting muscle relaxant used on patients requiring RSI to prevent the patient from struggling against the intubation procedure). When questioned, the Trauma RN stated that he/she was aware of the need to also have dantrolene
(used to counteract a possible side-effect of succinylcholine chloride called Malignant Hyperthermia (MH), a life-threatening medical crisis which causes high fever and skeletal rigidity) in the facility. The Trauma RN stated, I don't know why we don't have it."

During an interview with the facility Pharmacist on 11/18/19 at 10:35 AM, the Pharmacist stated he/she was unaware dantrolene needed to be available whenever succinylcholine chloride is administered.

During a telephone interview with the facility Trauma Medical Director (Trauma MD) on 11/18/19 at 10:40 AM, the Trauma MD stated he/she was unaware dantrolene needed to be available whenever succinylcholine chloride is administered. The Trauma MD stated the succinylcholine would be removed from the facility and staff would be required to use the alternative rapid-acting muscle relaxant, Vecuronium, already in the facility's RSI kits.

Review of the facility's undated, "Rapid Sequence Intubation Quick Guide," and "Rapid Sequence Intubation Worksheet" documented, "Paralyze patient with one of the following: a.Succinylcholine ...b.Vecuronium (with suggested dosages and rates of administration given)."

The facility was unable to provide a policy related to RSI, the use of succinylcholine chloride during RSI, or the need for the availability of dantrolene in the Emergency Department. During the interviews on 11/18/19, the Trauma RN, Pharmacist, and Trauma MD were referred to the national standard of care as outlined in the Malignant Hyperthermia Association of the United States (MHAUS) website recommendation, which states in part, " ...in a small percentage of cases MH appears to be triggered by succinylcholine alone ...Facilities that stock and have the potential to administer any triggering agent, including succinylcholine ...should have dantrolene immediately available (i.e., the ability to administer dantrolene within 10 minutes of the first sign of MH) in the event that a patient in that facility develops MH.

Based on observation, interview, record review and document review, the facility failed to meet the Conditions for Coverage for Number of Beds and Length of Stay by failing to ensure the 25 certified beds were allotted to acute care and/or swing bed patients. This failure had the potential to cause a lack of beds available to all patients in the Critical Access Hospital (CAH) geographic region who required acute in-patient or swing bed medical care.

Findings include:

The facility was found to have allotted 20 of the 25 certified beds to Long Term Care patients (Refer to C0211).

Based on observation, interview, record review and document review, the facility failed to ensure all certified beds were allotted to either in-patient or swing bed patients. This failure decreased the number of beds available for in-patient and/or swing bed levels of medical care and had the potential to jeopardize the availability of such beds needed by patients in the geographic region of the Critical Access Hospital (CAH).

Findings include:

Upon entrance to the facility on 11/18/19 at 9:00 AM, the nursing unit entered was observed to have multiple patients sitting in a lounge/day area wearing street clothing or pajamas and robes.

During entrance conference on 11/18/19 at 9:15 AM, the Chief Executive Officer (CEO) stated the patients in the nursing unit observed by surveyors was called the Extended Care Unit (ECU), considered a long-term care unit, and contained 20 of the 25 beds of which the CAH was certified. The CEO stated there were currently 17 patients residing in the ECU. The CEO stated the remaining five beds under the certification were allotted to in-patients and/or swing bed patients, adding, "We basically have a five-bed hospital here."

During an interview with the Chief Financial Officer (CFO) on 11/19/19 at 8:35 AM, the CFO stated the ECU has been operating under the same licensure as the CAH since January of 2005. The CFO stated the ECU beds receive no reimbursement monies from Medicare and patients admitted to the ECU are either Medicaid, private insurance, or private pay patients. The CFO confirmed the 20 beds in the ECU are considered part of the 25 beds certified as CAH beds by Centers for Medicare and Medicaid (CMS).

During an interview with the Chief Nursing Officer (CNO) on 11/19/19 at 2:10 PM, the CNO defined the swing bed status patient as one transitioning from an acute (sudden and severe) in-patient status lasting at least three days and "not quite ready to go home." The swing bed patient would require skilled nursing care such as intravenous (IV) medications and/or fluids, perhaps complex wound care, and physical and/or occupational therapy (all services which would be included in the hospital stay). The CNO stated a swing bed patient is not considered a resident. The CNO stated patients in the ECU are considered long term care patients, are considered residents of the facility and receive primarily Activities of Daily Living (ADL, for example bathing, dressing, and toileting) nursing care. The CNO stated the ECU patients do not receive skilled nursing care, and receive only the most minor nursing interventions, such as simple wound care and oral medications. The CNO stated all laboratory, radiological studies, rehabilitation services (physical, occupational and speech therapy), and specialty consultations for ECU patients are done as outpatients. The CNO stated the patients in ECU consider the facility as their home and expect to live in the unit for the remainder of their lives, therefore discharge planning is not routinely done for them.

During an interview with the ECU Director (Director) on 11/19/19 at 3:30 PM, the Director defined swing bed patients as, "here for rehab (physical and/or occupational therapy) to regain strength or to heal from surgery." The Director stated that swing bed patients receive these services in-house with the goal of enough improvement for discharge home. The Director stated that the nursing care goals for ECU patients are, "maintaining and supporting to keep the current level and then support through decline and end of life care." The Director stated patients in the ECU are "long term care" patients, receiving a lower level of care than either in-patients or swing bed patients. The Director stated that if an ECU patient developed an acute illness requiring a different level of care such as IV therapy or complex wound care, they would either be admitted to the in-patient unit or receive treatment on an outpatient basis.

During an interview with Patient (P)12, a resident of the ECU, on 11/18/19 at 2:10 PM, P12 stated that he/she has been at ECU for over 2 years and staff does assist with bathing and stand nearby for toileting in the event he/she needs assistance. P12 stated he/she does not think that the staff checks his/her vitals daily but will if he/she is "feeling bad." P12 stated he/she thinks the physician visits monthly. P12 stated that he/she does not receive physical therapy and stated he/she does consider the ECU to be his/her home.

During an interview with P16, a resident of the ECU, on 11/18/19 at 2:20 PM, P16 stated, "I live here, this is my home." P16 stated that he/she does not receive physical therapy, but, "a nurse walks with me." P16 stated he/she has been a resident of the ECU for "a few months."

Review, with the Director, of P3's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 09/03/19 with a diagnosis of "fatigue." The Director stated P3 receives no skilled nursing care.

Review, with the Director, of P4's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 02/20/17 with a diagnosis of "intellectual disabilities." The Director stated P4 receives no skilled nursing care.

Review, with the Director, of P5's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 09/13/13 with a diagnosis of "dementia." The Director stated P5 receives no skilled nursing care.

Review, with the Director, of P6's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 10/18/16 with a diagnosis of "low back pain and dementia." The Director stated P6 receives no skilled nursing care.

Review, with the Director, of P7's the medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 04/18/18 with a diagnosis of "muscle weakness." The Director stated P7 receives no skilled nursing care.

Review, with the Director, of P8's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 10/17/12 with a diagnosis of "CVA (cerebral vascular accident or stroke)." The Director stated P8 receives no skilled nursing care.

Review, with the Director, of P9's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 03/25/16 with a diagnosis of "CVA." The Director stated P9 receives no skilled nursing care.
Review, with the Director, of P10's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 07/27/18 with a diagnosis of "CVA." The Director stated P10 receives no skilled nursing care.

Review, with the Director, of P11's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 10/18/11 with a diagnosis of "HTN (hypertension/high blood pressure." The Director stated P11 receives no skilled nursing care.

Review, with the Director, of P12's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 08/29/17 with a diagnosis of "pain R (right) shoulder." The Director stated P12 receives no skilled nursing care.

Review, with the Director, of P13's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 08/02/16 with a diagnosis of "dementia." The Director stated P13 receives no skilled nursing care.

Review, with the Director, of P14's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 07/05/19 with a diagnosis of "Alzheimer's disease." The Director stated P14 receives no skilled nursing care.

Review, with the Director, of P15's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 10/18/19 with a diagnosis of "muscle weakness." The Director stated P15 receives no skilled nursing care.

Review, with the Director, of P16's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 07/16/18 with a diagnosis of "GERD (gastroesophageal reflux disease/reflux)." The Director stated P16 receives no skilled nursing care.

Review, with the Director, of P17's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 12/05/18 with a diagnosis of "muscle weakness." The Director stated P17 receives no skilled nursing care.

Review, with the Director, of P18's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 06/01/12 with a diagnosis of "osteoarthritis (arthritis)." The Director stated P18 receives no skilled nursing care.

Review, with the Director, of P19's medical record, a current resident of the ECU, the "Admission Record" showed an admission date of 03/12/18 with a diagnosis of "COPD (chronic obstructive pulmonary disease)." The Director stated P19 receives no skilled nursing care.

The facility was unable to provide a policy related to bed usage.

Review of the facility's letter received by the facility CEO, from the Survey, Quality and Standards Branch, Division of Medicaid and State Operations, dated 08/02/00, documented the facility received designation as a CAH, effective 07/18/00. The letter stated, "Per regulation, you may operate no more than 25 beds (with no more than 15 used for acute inpatient care at any one time ..." The letter also stated, "Haxtun Hospital District has also been approved to provide post-hospital skilled nursing facility care as specified in ..." During a follow-up interview with the CEO on 11/21/19 at 10:15 AM, and after review of the letter noted above, the CEO agreed the letter did not address the ECU beds as approved or disapproved for certification.

Base on the onsite investigation, completed December 11, 2019, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code Tags 321, 324, 353, 521, 711, 712 and 918.