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Based on observation and interview, the hospital failed to ensure that necessary emergency medications were available in a timely manner, by failing to ensure that a full loading dose of dantrolene (a drug used in the emergency treatment of a Malignant Hyperthermia event) was available at the hospital.

Failure to ensure that a full loading dose of dantrolene is available at the hospital risks delay in providing life-saving treatment to patients who are experiencing a Malignant Hyperthermia (MH) emergency.

Findings include:

1) The Malignant Hyperthermia Association of the United States (MHAUS) recommends:
"Thirty-six (36) vials of dantrolene will allow for initial stabilization and treatment while more vials are being acquired to continue treatment, as needed....The patient experiencing an MH episode must be stabilized before being transported. Stabilization of an MH episode may take 30 minutes or more with multiple doses of dantrolene because, in some cases, MH progresses with explosive rapidity. The full 36 vials of dantrolene is inexpensive insurance against patient injury or death and a malpractice claim, which the facility will lose. The full 36 vials of dantrolene should be available within five minutes of the diagnosis of MH."

2) Inspection of the surgery department's MH emergency treatment cart found that 12 vials of dantrolene were available in the cart.

3) The surgery department nurse manager stated that there was an agreement with a metropolitan hospital approximately 35 miles away to provide the remaining dantrolene to make up the full 36 vial stabilization dose.

Based on observation and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings include:

Refer to deficiencies written on the
CRITICAL ACCESS HOSPITAL
MEDICARE RECERTIFICATION
LIFE SAFETY CODE SURVEY
dated 08/12/10.

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1. Based on observation, interview, and review of facility policies and procedures, the facility failed to ensure that staff members performed hand hygiene before and after direct patient contact, and after glove removal according to acceptable standards of practice for infection control and facility policy for 2 of 4 staff members observed (Staff Members #11, #12).

Failure to follow acceptable standards of practice for infection control risks transmission of communicable diseases to patients and staff members.

Reference: "Guidelines for Hand Hygiene in Health-Care Settings" (MMWR RR-16, October 2002; Centers for Disease Control and Prevention

Findings:

a. The facility's policy and procedure entitled "Hand Hygiene" (Reviewed January 2010) read as follows: "1. All hospital personnel will wash or sanitize their hands before and after each direct contact with patients or patient care items." "4. The use of gloves does not negate the need for hand hygiene before and after using gloves."

b. The following observations were made by Surveyor #13692:

1) On 8/11/2010 at 8:00 AM, Staff Member #11 did not perform hand hygiene after removing his gloves following administration of an inhaler to Patient #2.

2) On 8/11/2010 at 8:20 AM, Staff Member #13 did not perform hand hygiene prior to performing a physical assessment and administering medication to Patient #3.

c. An interview with the facility's Infection Control Coordinator (Staff Member #13) on 8/13/2010 at 10:30 AM confirmed that the staff members did not follow facility policies and procedures for hand hygiene.


2. Based on observation, interview, and review of facility policies and procedures, the facility failed to ensure that staff members performed hand hygiene after glove removal according to acceptable standards of practice for infection control and facility policy for 1 of 4 staff members observed (Staff Member #10).

Failure to follow acceptable standards of practice for infection control risks transmission of communicable diseases to patients and staff members.

Reference: "Guidelines for Hand Hygiene in Health-Care Settings" (MMWR RR-16, October 2002; Centers for Disease Control and Prevention

Findings:

a. The facility's policy and procedure entitled "Isolation Precautions: Transmission Based" (Reviewed January 2010) read as follows: "Gown and Gloves: Put on gloves after hand hygiene for potential contact with infective materials, surfaces, or patients."

b. On 8/10/2010 at 2:00 PM, Surveyor #13692 observed that Staff Member #10 did not wear gloves while administering medication to Patient #1 through a saline lock.

c. An interview with the facility's Infection Control Coordinator (Staff Member #13) on 8/13/2010 at 10:30 AM confirmed that the staff member should have worn gloves to administer medications through the patient's saline lock, which could have been contaminated by blood during insertion.

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