HospitalInspections.org

Based on observation, document review and staff interview the hospital failed to follow professional standard of practice guidelines for the use of Succinylcholine (a medication used to cause muscle relaxation and a triggering agent for Malignant Hyperthermia (MH) (the general signs of a MH crisis include increased heart rate, muscle rigidity and/or fever that may exceed 110 degrees F along with muscle breakdown. Severe complications include: cardiac arrest, brain damage, internal bleeding or failure of other body systems, and death) when they failed to have the antidote Dantrium/Revonto (the only currently accepted specific treatment for MH) available within 10 minutes.

The cumulative effect of this systemic failure places all susceptible patients at risk for a MH crisis. Failure to have Dantrium/Revonto available to treat MH could lead to patient harm or even death.

Findings include...

- Observation during the tour of the nursing unit on 02/19/18 at 3:00 PM, Administrative Staff B, Registered Nurse (RN), explained the hospital has a "rapid response" emergency box used to intubate (place a breathing tube) a patient if they needed a secure airway. Staff B further stated that the hospital used the "rapid response" box earlier today. Hospital Staff had to intubate Patient #6 in room 101. Observation in room 101, Patient #6 had a breathing tube in place and was on a ventilator (breathing machine). Observation of the "Rapid Response" emergency box in the room revealed used equipment and syringes. Administrative Staff A and Staff B stated that the physician used the medication Succinylcholine during the intubation of Patient #6. When asked about whether the hospital had the antidote for MH since they use the triggering agent Succinylcholine, Staff A and Staff B stated that they were unaware the hospital needed to have the medication (Dantrium/Revonto) in stock in the event the patient has a MH crisis. They explained they do not have the emergency medication available at the hospital. Later, Pharmacy, Staff L confirmed the hospital did not have Dantrium/Revonto in stock and available for use.

Surveyors identified an Immediate Jeopardy (IJ - a situation in which the provider ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient on 02/19/18 at 3:00PM and notified Administrative Staff A that an IJ existed at the hospital related to the use of Succinylcholine without the antidote for MH present in the hospital. Staff A notified the hospital's regional and corporate team and they decided that Succinylcholine would no longer be used in the hospital. The hospital immediately placed their entire stock of Succinylcholine (four vials) in a locked cabinet, in the locked pharmacy, so it was no longer available for use (the hospital destroyed the vials of Succinylcholine on 02/21/18 at 8:26 AM). The hospital sent a letter (via email) immediately to the physicians working in the next 24 hours (Emergency Room physicians, who provide in-house care for medical issues and emergencies and Physician Staff O and P) that stated Succinylcholine would no longer be used in the hospital for intubation and the medication Vecuronium ( a paralyzing agent) would be used instead. The hospital removed the IJ on 02/19/18 at 6:00 PM when they locked the vials of Succinylcholine in the pharmacy, and informed the physicians working in the next 24 hours that Vecuronium would be used instead. The hospital sent a letter (via email) with this information to the rest of the medical staff on 02/20/18.


According to the Malignant Hyperthermia Association of the United States, Succinylcholine administration has been associated with acute onset of malignant hyperthermia, a potentially fatal hypermetabolic state of skeletal muscle. Malignant hyperthermia frequently presents as intractable spasm of the jaw muscles which may progress to generalized rigidity, increased oxygen demand, tachycardia [fast heart rate], tachypnea [fast breathing] and profound hyperpyrexia [life-threatening fever]. Successful outcome depends on recognition of early signs, such as jaw muscle spasm, acidosis, or generalized...Intravenous Dantrium is recommended as an adjunct to supportive measures in the management of this problem...All facilities where depolarizing muscle relaxants (Succinylcholine) are administered, should stock Dantrium and it must be available for all anesthetizing locations within 10 minutes of the decision to treat for MH. Stock a minimum of 36 - 20 milligram (mg) vials of Dantrium/Revonto. To treat an MH episode, an initial dose of Dantrium at 2.5 mg/kilogram (kg) is recommended, with a suggested upper limit of 10 mg/kg. If a patient of average weight (approximately 70 kg) were to require Dantrium at the upper dosing limit, then at least 700 mg of Dantrium would be needed.

Based on observation and staff interview, the hospital failed to ensure expired medications were removed from patient use in the pharmacy. This deficient practice has the potential to place all patients at risk to receive expired medications.

Findings include...

- Observation in the pharmacy on 02/21/18 at 8:30 AM, five bags of Magnesium (an important mineral in your body) - 1 gram mixed in 100 milliliters of normal saline (salt water solution) with an expiration date of 11/17.


Interview on 02/21/18 at 8:30 AM , Pharmacy Staff L acknowledged the medications were expired, and explained that the pharmacy technologist checks medications in the pharmacy for outdates and the pharmacist double check them.


Hospital policy titled, "INSPECTION OF DRUG STORAGE AREAS" directed, All medication storage areas shall be inspected by personnel familiar with proper storage requirements at least every month with documentation that the following requirements are met...Outdated drugs are promptly removed from stock and returned to the pharmacy.

Based on observation, staff interview, document review and manufacturer's guidelines, the infection control officer failed to ensure hospital personnel followed infection control practices during one of one observed terminal room cleans (Housekeeping Staff R and S); failed to ensure Staff (Staff H, M, R, and S) performed hand hygiene between glove changes during four of sixteen random observations; and failed to ensure two Staff (Staff C and M) removed contaminated gloves before reaching into their uniform pocket in two of sixteen random observations. The hospital failed to ensure the bronchoscope (a tube to look into the lungs) cleaning room separated the decontaminated area of the room from the clean area of the room; failed to ensure the hopper (flushable toilet) had a protective shield over it to prefect splashing of contaminated material and had personal protective equipment (PPE) nearby; and failed to ensure all expired supplies were disposed of in one of two laboratory refrigerators (supply refrigerator) and in one of two medication Rooms (1149). These deficient practices have the potential to spread blood borne pathogens or infectious materials which could cause patient harm or death.


Findings include...


- Manufacturer's guidelines for the use of a [NAME] disinfectant cleaner directed, to disinfect...hard, non-porous environmental surfaces...all surfaces must remain wet for 10 minutes.

Observation on 02/21/18 between 10:16 AM and 10:45AM, Housekeeping Staff R and S cleaning a vacated patient room. Staff R and S using cloths wet with a [NAME] disinfectant solution wiped all surfaces in the room and bathroom. The surfaces remained wet six to seven minutes not the required 10 minutes for total disinfection.


- Manufacturer's guidelines for [NAME] directed, with swab mop applicator, remove water from bowl by forcing over trap...saturate swab mop with [NAME] (one to two ounces) while holding applicator bottles over bowl...allow [NAME] to remain wet on surface at least 10 minutes

Observation on 02/21/18 at 10:25 AM, Housekeeping Staff S cleaning the inside of the toilet bowl using [NAME], sprayed the disinfectant inside of the toilet bowl including under the rim of the bowl, and immediately flushed the toilet. Staff S failed to follow the manufacturer's guidelines; to remove water from the toilet bowl, failed to saturate swab mop applicator with (one to two ounces) of disinfectant, and failed to allow [NAME] to remain wet on surfaces at least 10 minutes.

Interview on 02/21/18 at 10:45 AM, Staff R and S verified they were aware the surfaces must remain wet for 10 minutes to disinfect but were not aware how long the surfaces in the room they cleaned were wet. Staff R and S were not aware of the manufacturer's guidelines for the use of the toilet bowl disinfectant.


- Observation on 02/21/18 between 10:16 AM and 10:45AM, Housekeeping Staff R and S cleaning a vacated patient room revealed Staff S with gloved hands placed a used suction canister in a red "biohazard" bag, exited the patient room (with dirty gloves), walked across the hall to a soiled utility room, using the touch key pad (with dirty gloves) opened the door, deposited the red bag, returned to the housekeeping cart, removed cleaning supplies (with dirty gloves), entered the patient room and continued to clean the room. Staff S failed to remove the contaminated gloves before exiting and/or entering the patient's room, before touching the keypad and the clean supplies. During the cleaning of the patient room, Staff R and Staff S used the same gloves for the entire cleaning process going from contaminated area to clean supply cart multiple times.



- Policy titled "Hand Hygiene" directed, between glove changes and after removing gloves. After any contact with body fluids, dressings, patient linen.

Observation on 02/21/18 at 9:10 AM, Respiratory Therapist (RT) Staff M entered unidentified patient room 136 with gloved hands and started to suction (remove secretions from the patient's mouth and throat) the patient. Staff M exited the patient's room (wearing dirty gloves), retrieved an isolation gown (to cover their uniform) (wearing dirty gloves), entered the patient's room (wearing dirty gloves), and continued to suction the patient. Staff M failed to remove gloves and perform hand hygiene when exiting and /or entering the patient's room.

Observation on 02/21/18 at 11:00 AM, Registered Nurse (RN), Wound Care Nurse, Staff H wearing an isolation gown and gloves entered Patient #2's contact isolation (anyone entering the patient's room and having direct contact with the patient wears gloves and possibly a gown) room. Staff H removed staples from the patient's abdominal wound, cleaned the area around the PEG (percutaneous endoscopic gastrostomy) tube (a flexible feeding tube placed through the abdominal wall and into the stomach, that allows nutrition, fluids, or medication to be put directly into the stomach), and performed a skin assessment. Staff H removed and donned gloves four times during the staple removal and skin assessment without performing hand hygiene between glove changes.


- Observation on 02/21/18 at 9:10 AM, RT Staff M, performing oral suctioning for the unidentified patient in room 136, reached into their uniform pocket and retrieved a small flash light to observe the inside of the patient's mouth. RT Staff M placed the flash light back in their uniform pocket. RT Staff M did not clean or disinfect the flash light after they used dirty gloves to pull it out of their pocket. So, the flash light and RT Staff M's uniform are potentially contaminated.

- Observation on 02/21/18 at 10:00 AM, RN Staff C administering medication to Patient # 22 through their gastronomy tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). After administration of the medications, RN Staff C placed their gloved hands into their pocket to retrieve an alcohol swab. RN Staff C possible contaminated her uniform pocket by reaching in with dirty gloves to retrieve an alcohol swab.

Interview on 02/21/18 at 10:00 AM, Chief Nursing Officer, Staff D acknowledged RN, Staff C should not have reached into their pocket with contaminated gloves.

The hospital failed to provide a policy directing staff members to remove gloves and clean their hands prior to reaching into their pockets.


- Bronchoscope cleaning room observed on 02/21/18 at 7:45 AM revealed a room with two rolling carts sitting next to a hopper without a shield or PPE nearby. The sink to clean the bronchoscope is situated to the left of the hopper, and then to the left of the sink is a dirty, small, clear, hard plastic divider separating the dirty area from the contour space that held the machine used to disinfect the bronchoscope. The clean bronchoscope is then passed through a dirty sliding glass window into the clean room for storage.

Interview on 02/21/18 at 8:00 AM, Respiratory Therapy Manager, Staff E, confirmed there is not a shield over the hopper and the PPE is not located in the room. Staff E acknowledged there was not sufficient physical space between the dirty and clean areas and the pass through window was dirty.


- Observation on 02/21/18 at 8:10 AM, a box of Quality Control Solutions for In Vitro Diagnostics (used to ensure the equipment is working properly) with an expiration date of 01/04/18 in the Laboratory supply refrigerator.

Interview on 02/21/18 at 8:10 AM, Respiratory Therapy Manager, Staff E, confirmed it is their responsibility to perform inventory on their laboratory supplies and acknowledged the solution was expired.


- Observation on 02/21/18 at 8:53 AM, two packages of micron filter IV tubing (IV tubing with a filter attachment) with an expiration date of 11/17, each of them rubber banded to a vial of IV Amiodarone (cardiac medication) in the High Risk medication cabinet of Medication Room #1149.

Interview on 02/22/18 at 8:53 AM, Pharmacy Staff L, acknowledged the expired supplies, and stated, "I guess we need to enter the date into the Med-Dispense machine (automated medication dispenser) based on the vial or the attached supply, which ever expires sooner."

Based on lack of documents for review and staff interview the hospital failed to provide emergency preparedness training at least annually for all hospital staff, volunteers, and individuals providing on-site services under arrangement (radiology technicians). This lack of training program places all hospital staff, contracted radiology technicians and volunteers at risk for not having the knowledge needed to report a fire, to protect patients in case of an emergency, or how to evacuate patients.

Findings include...

During an interview on 02/21/18 at 2:00 PM, Administrative Staff A and Administrative Staff T explained the hospital provides initial emergency preparedness training for hospital staff but not to the radiology technicians or volunteers and do not provide annual emergency training for hospital, radiology technicians or volunteers annually.

As of 02/21/18, the hospital failed to provide any documentation of an annual training program for all its staff, contracted radiology technicians, and volunteers.