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Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) failed to follow professional guidelines for stocking an emergency rescue medication (Dantrolene) when succinylcholine (a medication used to relax the muscles during intubation procedures) is used at the facility (refer to C-0202). Failure to have the rescue medication could cause patient harm or death in the event of Malignant Hyperthermia (a rare condition associated with the use of succinylcholine which causes a rapid rise in body temperature that could become life threatening).

An Immediate Jeopardy (IJ) (a situation that has or is likely to cause patient harm) was identified on 9/27/2016 and the administrative staff was notified. The administrator, having an alternative paralytic avaialable, immediately suspended the use of succinylcholine until the reversal agent Dantrolene could be obtained.
The reversal agent Dantrolene was delivered at 12:35PM on 9/28/2016 and the facility removed the IJ prior to the survey exit.

The Critical Access Hospital (CAH) reported a census of fourteen swing bed patients and no acute inpatients. Based on observations, interview, and policy review, the CAH failed to ensure emergency medications and supplies were readily available in the emergency department (ED) by failing to have medication on hand to treat Malignant Hyperthermia (a rare life-threatening condition causing a severe high body temperature triggered by medications that act as depolarizing muscle relaxants such as succinylcholine (a muscle relaxant administered in ED's when breathing is compromised) and a patient requires intubation (passing of a tube into the airway to establish the ability to breath). Failure to have enough Dantrolene immediately available for use had the potential for delays in responding to a medical emergency causing a worsening of a patient's condition or death.

Findings Include:

- CAH pharmacy tour conducted on 9/27/2016 at 8:45 AM revealed 24 vials of succinylcholine in the pharmacy refrigerator. Further observation of the pharmacy and review of the formulary revealed the CAH did not have Dantrolene to administer as an antidote if malignant hyperthermia occurred as a result of the administration of succinylcholine in emergency procedures.

Pharmacy Staff H interview on 9/27/16 at 9:00 AM confirmed Dantrolene is not listed in the facility formulary and that s/he had not ordered it from the CAH supplier.

Administrative CEO Staff A interview on 9/27/16 at 9:45 AM acknowledged Dantrolene was not part of the CAH formulary and the medication was not supplied in the facility. S/he further confirmed a policy for Dantrolene administration in malignant hyperthermia situations was lacking. Documentation of the last dose of succinylcholine administered in the CAH is documented to have been administered in the Emergency Department in 2014.

Review of policy titled "Rapid Sequence Induction for Intubation" directed "...administer the neuromuscular blocking agent as ordered by the physician immediately after induction agent administration including succinylcholine ... ...antidote: ...treat hyperthermia with cooling measures, restore electrolyte balance, IV fluids, maintain urinary output, Dantrolene may be indicated ..."

Administrative CEO Staff A removed all vials of the succinylcholine from pharmacy stock on 9/27/16 at 3:30 PM.

Administrative CEO Staff A received 36 vials of Dantrolene on 9/28/16 at 12:45 PM and placed in pharmacy stock. Succinylcholine returned to pharmacy stock and policy titled "Malignant Hyperthermia Dantrolene Procedure" was initiated.

The Critical Access Hospital (CAH) reported a census of fourteen swing bed patients and no acute inpatients. Based on observations, staff interview, and policy review, the CAH failed to ensure the laundry staff wear appropriate personal protective equipment (PPE) when handling soiled linens in the laundry room. Failure by laundry staff to wear PPE put them at risk of exposure to infectious agents through contact with soiled linen.

Findings Include:

Assistant laundry manager Staff J interviewed on 9/27/16 at 9:00 AM acknowledged "laundry staff are to wear PPE to include gloves, protective gown, and face mask when handling soiled laundry, especially any laundry brought to the soiled laundry room that is in a yellow or red bag. Those are considered contaminated and staff are to handle them as little as possible."

- Observation revealed the presence of PPE consisting of gowns, gloves, masks. No evidence of shoe covers present in the laundry area.

Policy titled "Handling Contaminated Laundry" directed "...Laundry personnel should handle all linens as infectious. Put on PPE (gloves, gown, shoe covers and face mask)..."

Based on record review and policy and procedure review the Critical Access Hospital (CAH) failed to provide documentation of a physician's signature for the comprehensive history and physical within 30 days of discharge for 1 of 25 medical records reviewed (patient #6). Failure to have the physician's signature within 30 days put the patient at risk for potential complications in their care and recovery after discharge.

Findings include:

Record review on 9/28/16 at 8:00 AM revealed patient #6's comprehensive history and physical form was dictated on 6/25/16 and transcribed on 6/26/16. Patient #6 was discharged on 6/29/16. The comprehensive history and physical was signed and dated by Staff M on 8/9/16 (41 days after discharge).

Administrative Staff A interviewed on 9/28/16 at 10:40 AM verified the policy and procedure states the signatures to the comprehensive history and physicals must be completed within 30 days.

- Policy and Procedure titled "Medical Record Documentation" reviewed on 9/28/16 at 10:50 AM directs " ...Records of patients discharged shall be completed within 30 days following discharge ...