HospitalInspections.org

Based on review of Malignant Hypothermia Association of the United States guideance, observations, and staff interview, the Critical Access Hospital (CAH) failed to maintain readily available malignant hypothermia (MH) reversal medication to treat emergent cases in accordance with acceptable standards of practice. The facility also failed to provide a MH policy and procedure, annual MH drills and training to all staff. This failed practice had the potential to affect all patients who present to the CAH. The facility inpatient visits for FY 2023 were 165, ED visits for FY 2023 were 870.

Findings include:

A. According to Malignant Hypothermia Association of the United States (MHAUS) (last reviewed 2018), "Facilities that stock and have the potential to administer any triggering agent, including succinylcholine without volatile agents, should have dantrolene immediately available .... to administer dantrolene within 10 minutes of the first sign of Malignant Hypothermia (MH), in the event that a patient in that facility develops MH."

B. During observation and tour of surgical services (2/27/2024 at 1:31PM) revealed that the MH cart was located in the surgical area of the facility. The bottom drawer of the MH cart revealed outdated Dantrolene 6 vials per box, 6 boxes total:
-Dantrolene 20mg/vial: (box 1) expired 9/2022
-Dantrolene 20mg/vial: (box2) expired 9/2022
-Dantrolene 20mg/vial: (box 3) expired 9/2022
-Dantrolene 20mg/vial: (box4) expired 9/2022
-Dantrolene 20mg/vial: (box 5) expired 9/2022
-Dantrolene 20mg/vial: (box6) expired 9/2022

C. During observation of the Emergency Department (ED) (2/28/2024 at 9:33AM) revealed the facility failed to have a MH cart in the ED with the required amount of medication (Dantrolene 36 vials or Ryanodex 3 vials: medication to reverse emergent high body temperature in the patient) in the event succinylcholine (medication used before emergent intubation-a tube that goes through the mouth into the airway to provide rescue breaths to the patient) would be used in an emergency.

E. An interview with the Director of Nursing (DON) (2/29/2024 at 8:59AM) revealed the MH cart was no longer used or managed at the facility and misunderstood the need for the MH cart due to Succinylcholine stocked in the CAH. The DON confirmed the CAH lacked evidence of a MH policy or procedure, annual MH drills or training conducted in fiscal year 2023.

Based on observation, interview and record review, the Critical Access Hospital (CAH) failed to provide ongoing preventive maintenance/safety inspections for 6 of 30 patient care equipment. This failed practice had the potential to affect all patients of the CAH. The CAH had 165 inpatient admissions, 25 swing bed admissions, 870 emergency room visits and 888 outpatient specialty clinic visits for the Fiscal year 2023.

Findings include:

A. Tour of the outpatient specialty clinic (2/27/2024 at 9:46 AM) revealed 4 exam tables, a Mindray vital signs monitor and a dremel (used to carefully remove excess skin and overgrown nails that commonly cause infections and inflammation) that did not have a blue numerical sticker to identify any responsibility for safety/tracking of the equipment.

B. Interview with Maintenance Supervisor and Director of Nursing (2/27/2024 at 1:15 PM) revealed that the facility "Puts new equipment on the floor in service for use, before it is tagged and staff leave a list of new equipment for the technician to tag and do safety checks."

C. Review of Bio-Electronics most recent service report of facility equipment service dates and next test due dates (2/28/2024 at 3:00 PM) revealed that the 6 patient care equipment were not listed on the CAH equipment file list.

Based on medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the Important Message from Medicare was received and signed before discharge for 11 out of 20 inpatients (Patients 1, 3, 4, 5, 6, 7, 8, 9, 12, 14, 16) reviewed, and 4 out of 5 swing bed patients (Patients 33, 34, 35, 36) reviewed. The CAH also failed to ensure one 1 out of 20 inpatients and 2 of 5 swing bed patients included a properly executed informed consent. This failed practice had the potential to affect all patients admitted to the CAH. The number of inpatient admissions was 165 and Swing Bed was 25 for fiscal year 2023.

Findings include:

A. Review of Patient 1's medical record (2/27/2024 at 8:16 AM) revealed an inpatient admission of 1/20/2024-1/22/2024 for Hypertensive Urgency (severely high blood pressure with no evidence of end organ damage) and Atrial Fibrillation with Rapid Ventricular Response (RVR) (quivering or rapid, irregular heartbeat). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 3's medical record (2/27/2024 at 8:57 AM) revealed an inpatient admission of 10/6/2024-10/9/2024 for a ground level fall, laceration of head and Anemia (low number of red blood cells) due to blood loss. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 4's medical record (2/27/2024 at 9:27 AM) revealed an inpatient admission of 9/12/2023-9/13/2023 for Atrial Fibrillation with Rapid Ventricular Response (RVR) (quivering or rapid, irregular heartbeat). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 5's medical record (2/27/2024 at 10:06 AM) revealed an inpatient admission of 8/7/2023-8/10/2023 for Confusion and Disorientation. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge and a properly executed informed consent to treat was signed.

-Review of Patient 6's medical record (2/27/2024 at 10:23 AM) revealed an inpatient admission of 8/25/2023-8/26/2023 for Complicated Urinary Tract Infection. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 7's medical record (2/27/2024 at 10:38 AM) revealed an inpatient admission of 8/12/2023-8/14/2023 for Elevated Troponin Level (Protein unique to the heart muscle). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 8's medical record (2/27/2024 at 10:54 AM) revealed an acute inpatient admission of 9/25/2023-9/26/2023 for Chest Pain. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 9's medical record (2/27/2024 at 11:16 AM) revealed an inpatient admission of 10/10/2023-10/13/2023 for Sepsis (body's extreme reaction to an infection) and Acute Bacterial Simple Cystitis (infection of the bladder). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 12's medical record (2/27/2024 at 2:19 PM) revealed an inpatient admission of 11/14/2023-11/20/2023 for Sepsis (body's extreme reaction to an infection) and Cystitis (infection of the bladder). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 33's medical record (2/27/2024 at 3:20 PM) revealed a swing bed admission of 9/6/2023-10/10/2023 for Weakness. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge and a properly executed informed consent to treat was signed.

-Review of Patient 34's medical record (2/28/2024 at 2:45 PM) revealed a Swing Bed admission of 1/25/2024-2/8/2024 for Low Back Pain, Compression Fracture of L2 and Post Concussion Syndrome. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 35's medical record (2/28/2024 at 3:41 PM) revealed a Swing Bed admission of 8/28/2023-9/12/2023 for Status Post Spinal Surgery. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge.

-Review of Patient 36's medical record (2/28/2024 at 4:02 PM) revealed a Swing Bed admission of 11/28/2023-9/12/2023 for Status Post Spinal Surgery. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare notice was received and signed before discharge and a properly executed informed consent to treat was signed.

B. Interview with RN-A (2/28/2024 at 4:00 PM) confirmed that inpatients (Patients 1, 3, 4, 5, 6, 7, 8, 9, 12) and swing bed patients (Patients 33, 34, 35, 36) medical records lacked evidence of an Important Message from Medicare notice received and signed before being discharged. RN-A also confirmed that inpatient (Patient 5) and swing bed patients (Patients 33 and 36) lacked evidence of documentation that a properly executed informed consent was signed.






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C. Review of Patient 14's medical record (2/28/2024 at 1:54PM) revealed an inpatient admission from 2/11/2024 - 2/16/2024 for Colitis (swelling/inflammation of the large intestine/colon-bowel), Chronic Obstructive Pulmonary Disease (COPD) without exacerbation (lung disease), and hypothyroidism (thyroid disease-low levels of the hormone, the body needs supplement to replace). Review of the entire medical record lacked evidence of the Important Message from Medicare notice was received and signed prior to discharge.

Review of Patient 16's medical record (2/28/2024 at 3:01PM) revealed an inpatient admission from 2/26/2024 - 2/28/2024 for acute on chronic respiratory failure with hypoxia (lungs not functioning without interventions that generally require treatments to improve oxygen/gas exchange). Review of the entire medical record lacked evidence of the Important Message from Medicare notice was received and signed prior to discharge.

D. An interview with Registered Nurse (RN)-B (2/28/2024 at 3:15PM) confirmed Patient 14 and 16 medical records lacked evidence of the IMM was received or signed prior to discharge.

Based on medical record review, observations, review of the endoscope reprocessing log and staff interview, the Critical Access Hospital (CAH) failed to track 3 out of 3 endoscopes with an identifying number in the log or electronic medical record (EMR) per patient use to track potential infectious outbreaks per the Centers of Disease Control (CDC) recommendations for 6 out of 6 surgical medical records (Patients 26, 27, 28, 29, 30, 31) reviewed. This failed practice had the potential to affect all patients presenting to the CAH. There were 38 patients who received an upper and/or lower endoscope procedure from 8/23/2023 - 2/24/2024. Fiscal Year 2023 inpatient visits were 165.

This standard resulted in the condition level citation C1300 to also not be met.

Findings Include:

A. Review of Essential Elements of a Reprocessing Program for Flexible Endoscopes-Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) (last reviewed 12/27/2018) revealed the CDC recommendations included that "each endoscope has a unique identifier to facilitate tracking. Tracking should include the ability to determine when specific endoscopes were used for specific patients, loaned to other units or facilities, reprocessed, or repaired. Tracking is also essential for responding to device or product recalls."

B. Review of Patient 26's medical record (2/27/2024 at 7:25AM) revealed that the patient presented to the CAH on 10/3/2023 at 8:44 AM for a planned Colonoscopy (a scope with a camera is inserted into the rectum to view the bowel for irregularities and prevention of potential problems that would require interventions from a healthcare provider.) Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 27's EMR (2/27/2024 at 8:22AM) revealed that the patient presented to the CAH on 12/4/2023 at 6:46 AM for a planned Esophagogastroduodenoscopy (EGD)(a scope with a camera is inserted into the mouth, down the throat into the esophagus to examine the upper gastrointestinal (GI) tract for irregularities and prevention of potential problems that would require interventions from a healthcare provider). Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 28's EMR (2/27/2024 at 1:42PM) revealed that the patient presented to the CAH on 10/31/2023 at 8:45 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 29's EMR (2/27/2024 at 4:35PM) revealed that the patient presented to the CAH on 9/19/2023 at 9:09 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 30's EMR (2/28/2024 at 8:10AM) revealed that the patient presented to the CAH on 12/19/2023 at 9:00 AM for a planned EGD and Colonoscopy. The facility was not able to complete the planned colonoscopy due the bowel not cleared out prior to procedure. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 31's EMR (2/28/2024 at 4:58PM) revealed that the patient presented to the CAH on 2/20/2024 at 7:41 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

C. During an observation of endoscope reprocessing in the surgical area (2/27/2024 at 1:31PM) revealed the CAH has 1 upper endoscope and 2 lower endoscopes that lacked evidence of unique identifiers per scope.

D. Review of the "Disinfection Soak Station Log" from dates 10/18/2022 - 2/20/2024 lacked evidence of the endoscope unique identifiers for the entire reprocessing log.

E. An interview with RN-B (2/27/2024 at 1:31PM) confirmed the endoscopy processing log and EMR lacked evidence of unique identifier to track endoscopes (1 upper and 2 lower) per patient use. RN-B stated that the facility purchased a new lower endoscope (date unknown) and was unaware of the tracking requirements per CDC recommendations.

This resulted in the Condition of Participation for Periodic Evaluation and Quality Assurance not being met.
C-1225
C-1309

Based on record review, staff interview and observations, the facility failed to meet the required Condition of Participation for completion of a Quality Assurance review to include: conducting a data driven Periodic Evaluation of its total program on an annual basis as required to determine if quality of care services were delivered and/or any changes needed. The facility last annual program evaluation was completed for Fiscal year ending 7/31/2020. The facility further failed to ensure Infection Control tracking and monitoring for three (3) 3 of Three (3) endoscopes with an identifying number in the log or electronic medical record (EMR) per patient use to track potential infectious outbreaks per the Centers of Disease Control (CDC) recommendations for 6 out of 6 surgical medical records (Patients 26, 27, 28, 29, 30, 31) reviewed. This failed practice had the potential to affect all patients presenting to the CAH. There were 38 patients who received an upper and/or lower endoscope procedure from 8/23/2023 - 2/24/2024 (6 months). FY 2023 inpatient visits were 165.

Findings include:

A. The facility provided the last completed Annual Program Evaluation for Fiscal Year ending 7/31/2020.

B. Interview with Chief Executive Officer (CEO) (2/27/2024 at 9:45 AM) stated "had received information at a conference in 2020, that the annual evaluation was no longer required and had not completed an annual program evaluation since."

C. Review of Essential Elements of a Reprocessing Program for Flexible Endoscopes-Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) (last reviewed 12/27/2018) revealed the CDC recommendations included that "each endoscope has a unique identifier to facilitate tracking. Tracking should include the ability to determine when specific endoscopes were used for specific patients, loaned to other units or facilities, reprocessed, or repaired. Tracking is also essential for responding to device or product recalls."

D. Review of Patient 26's medical record (2/27/2024 at 7:25AM) revealed that the patient presented to the CAH on 10/3/2023 at 8:44 AM for a planned Colonoscopy (a scope with a camera is inserted into the rectum to view the bowel for irregularities and prevention of potential problems that would require interventions from a healthcare provider.) Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 27's EMR (2/27/2024 at 8:22AM) revealed that the patient presented to the CAH on 12/4/2023 at 6:46 AM for a planned Esophagogastroduodenoscopy (EGD)(a scope with a camera is inserted into the mouth, down the throat into the esophagus to examine the upper gastrointestinal (GI) tract for irregularities and prevention of potential problems that would require interventions from a healthcare provider). Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 28's EMR (2/27/2024 at 1:42PM) revealed that the patient presented to the CAH on 10/31/2023 at 8:45 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 29's EMR (2/27/2024 at 4:35PM) revealed that the patient presented to the CAH on 9/19/2023 at 9:09 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 30's EMR (2/28/2024 at 8:10AM) revealed that the patient presented to the CAH on 12/19/2023 at 9:00 AM for a planned EGD and Colonoscopy. The facility was not able to complete the planned colonoscopy due the bowel not cleared out prior to procedure. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

Review of Patient 31's EMR (2/28/2024 at 4:58PM) revealed that the patient presented to the CAH on 2/20/2024 at 7:41 AM for a planned Colonoscopy. Review of the entire medical record revealed a lack of evidence of documentation that included a unique identifier of the endoscope used for the procedure.

E. During an observation of endoscope reprocessing in the surgical area (2/27/2024 at 1:31PM) revealed the CAH has 1 upper endoscope and 2 lower endoscopes that lacked evidence of unique identifiers per scope.

F. Review of the "Disinfection Soak Station Log" from dates 10/18/2022 - 2/20/2024 lacked evidence of the endoscope unique identifiers for the entire reprocessing log.

G. An interview with RN-B (2/27/2024 at 1:31PM) confirmed the endoscopy processing log and EMR lacked evidence of unique identifier to track endoscopes (1 upper and 2 lower) per patient use. RN-B stated that the facility purchased a new lower endoscope (date unknown) and was unaware of the tracking requirements per CDC recommendations.



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The standard citation C1225 resulted in this condition to also not be met.

Based on review of the last Annual Program Evaluation (Fiscal Year ending 7/31/2020), and staff interview the CAH (Critical Access Hospital) failed to conduct a periodic evaluation of its total program on an annual basis as required to determine if quality of care services were delivered and/or any changes needed. The CAH in fiscal year ending 7/21/23 provided care for 165 inpatients.

Findings include:

A. The facility provided the last completed Annual Program Evaluation for Fiscal Year ending 7/31/2020.

B. Interview with Chief Executive Officer (CEO) (2/27/2024 at 9:45 AM) stated "had received information at a conference in 2020, that the annual evaluation was no longer required and had not completed an annual program evaluation since."

Based on medical record review, review of policy and procedure and staff interview, the CAH (Critical Access Hospital) failed to complete comprehensive assessments for 4 of 4 swing bed residents (Patients 32, 33, 34 and 35) and lacked comprehensive care plans on 1 of 4 swing bed residents (Patient 33) reviewed. This failed practice had the potential to affect all swing bed residents. The facility had 25 swing bed admissions for fiscal year 2023.

Findings include:

A. Review of Resident 32's medical record (2/27/24 at 2:45 PM) revealed a swing bed admission of 1/26/24-2/15/24 for Osteomyelitis (bone infection) of foot, status post amputation (removal of body part) of toe. Review of the entire medical record revealed a lack of evidence of a comprehensive care plan being completed.

- Review of Resident 33's medical record (2/27/24 at 3:20 PM) revealed a swing bed admission of 9/6/23-10/10/23 for weakness. Review of the entire medical record revealed a lack of evidence of a comprehensive assessment being completed.

- Review of Resident 34's medical record (2/28/24 at 2:45 PM) revealed a swing bed admission of 1/25/24-2/8/24 for low back pain, compression fracture of L2 and post concussion syndrome. Review of the entire medical record revealed a lack of evidence that the comprehensive care plan being completed.

- Review of Resident 35's medical record (2/28/24 at 3:41 PM) revealed a swing bed admission of 8/28/23-9/12/23 for status post spinal surgery and spinal abscess (infection) post incision and drainage with revision. Review of the entire medical record revealed a lack of evidence that the comprehensive care plan being completed.

B. Review of policy, "Skilled Nursing-Comprehensive Assessment" (no review date on copy received) stated a comprehensive assessment used to identify patient's problems and needs will be completed no later than 14 days after the date of admission.

C. Review of policy, "Discharge Planning Process" (no review date on copy received) stated the discharge planning team meets once/week, problems are identified by members of the team and a discharge summary care plan is completed withing 7 days.

D. Interview with the RN-D (2/27/2024 at 3:15 PM) confirmed that 4 of 4 swing bed medical records lacked evidence of documentation of a comprehensive assessment and 1 of 4 lacked evidence of documentation of a comprehensive care plan.

Based on record review and staff interview, the facility failed to provide any evidence of testing and training for the facility staff as required for Emergency Preparedness procedures for the previous 4 years including calendar years of 2020, 2021, 2022 and 2023. This failed practice had the potential to affect all patients and staff of the facility. The facility listed 87 employees and provided care in the previous fiscal year ending 7/21/23 for 165 inpatients.

Findings include:

A. Review of the facility documents originally provided (2/27/2024 at 10:45 AM) for staff drills and education on emergency training, included documentation of one live event from 4/2/2023 involving a motorcycle versus multiple vehicle accident resulting in two patients treated in the emergency room and transferred out for further care. 14 staff signed an attendance record of the live event as being involved in delivery of patient care. No formal after action report was written including analysis of the live event therefore, any areas needing to be reviewed or changed for future similar events were lacking the completion of the requirement for facility preparedness analysis of live event to count toward the two events per year for testing requirement. The facility lacked evidence of any full scale community events training, documentation of additional real live events, any table top exercises or mock disaster drills during the 4 year time period.

B. Interview (2/28/2024 at 2:11 PM) with the Chief Executive Officer (CEO) in charge of emergency preparedness
revealed a lack of evidence of any annual emergency preparedness drills, training, or testing were completed at the time of the survey for the previous 4 years including calendar years of 2020, 2021, 2022 and 2023. Additionaly, no written plan for upcoming testing to include facility staff was available at the time of survey.