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Based on observation, interview and review of the Malignant Hyperthermia Association of the United States (MHAUS), the facility failed to ensure the required life-saving medications were available when administering Succinylcholine (paralytic) in the emergency department (ED). These failures had the potential to affect patients that presented to the ED and given Succinylcholine in an emergency. The facility census was 1.

Findings included:

1. Observation on 05/31/23 at 10:30 AM, in the ED crash cart, showed the medication Succinylcholine.

2. During an interview on 05/31/23 at 2:15 PM, Staff F, Pharmacist, stated that the emergency department (ED) carries the medication Succinylcholine (paralytic) and they do not have any medications to counter and/or treat malignant hyperthermia [a life-threatening, but treatable reaction to all of the inhalation anesthetics and Succinylcholine (a muscle relaxant/paralytic)].

3. Review of the MHAUS recommendations, dated 2016, showed that when patients were given Malignant Hyperthermia (a life-threatening, but treatable reaction to all of the inhalation anesthetics and Succinylcholine (a muscle relaxant/paralytic) triggering anesthetics, the only antidote used to reverse the reaction was the medication Dantrolene (medication that uncouples the heat-generating mechanism in the muscles).

4. Upon request, the facility failed to provide a policy for Malignant Hyperthermia.

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when staff failed to:
- Perform hand hygiene before and after glove use, after retrieving and administering medications for one patient (#4 ) of one observed for 10 oral medications and one intravenous (IV) medication;
- Follow aseptic technique (a process free of germs or bacteria) during sterile compounding of an immediate-use medication; and,
- Remove rust (reddish brown bacteria that may contribute to hospital-associated infections), dirt and oil build up from the kitchen area.

These failed practices had the potential to expose all patients, visitors and staff to cross- contamination and increased the potential to spread infection. The facility census was 1.

Findings included:

MEDICATION ADMINISTRATION
1. Review of the facility's policy titled, "Standard Precautions," dated 12/16/22, showed the direction for staff to perform hand hygiene when moving from a contaminated site to a clean site during patient care.

Observation on 05/31/23 at 9:09 AM, showed Staff D, Licensed Practical Nurse (LPN), prepared and administered medications for Patient #4. Staff D performed hand hygiene, put on gloves and performed a Finger Stick Blood Sugar (FSBS, a method of blood sugar monitoring) test on the patient. Wearing the same gloves worn to conduct the FSBS test, Staff D scanned the patient's identification band and the 10 bar codes off the individual packaged medications. After Staff D completed the scanning of the medications, Staff D removed each medication from the single medication package and placed the medications into a medication cup. Wearing the same gloves, Staff D administered the medications to the patient.

During an interview on 05/31/23 at 9:41 AM, Staff D, LPN, stated:
- Staff received competencies related to infection control and hand hygiene yearly.
- Staff was expected to perform hand hygiene anytime staff enter a patient room and upon exiting.
- Staff was expected to change gloves between tasks.
- Staff was expected to perform hand hygiene after glove removal and before re-gloving.

2. Observation on 05/31/23 at 12:05 PM, in Patient #4's room, Staff D, LPN, gave IV Zosyn (Antibiotic) and showed that Staff D:
- Washed hands and put on gloves;
- Touched contaminated computer;
- Touched the patient;
- Wiped the IV site with alcohol; and
- Started the IV Zosyn.
The computer was a contaminated object that contaminated the medication administration.

During an interview on 05/31/23 at 4:16 PM, Staff J, Registered Nurse (RN), Director of Nursing (DON), stated the expectation of staff was to remove gloves after staff performed a FSBS test on a patient and perform hand hygiene and re-glove before staff prepared and administered medications to a patient.

During an interview on 06/01/23 at 10:30 AM, Staff G, Infection Preventionist, stated that staff should have changed gloves and washed hands between clean and dirty areas.

STERILE COMPOUNDING
3. Review of the facility's policy titled, "Sterile Medication Preparation (compounding) for Parenteral Administration (Laminar Flow Hood)," dated 03/06/23, showed:
- All sterile medications were to be prepared by a Registered Nurse (RN) or Pharmacist after passing an aseptic technique skill assessment that included a direct visual observation and evaluation of their competency with reassessment/retraining to be performed annually.
- The medication room controlled area must be maintained to allow effective cleaning, disinfection and to minimize the risk of contamination.
- The controlled areas must be clean and well-lit.
- Essential materials used for aseptic preparations should be disinfected before entering the Laminar Air Flow Hood.
- The Laminar Air Flow Hood must be certified to ensure compliance every six months and the Pharmacist should follow up with a review.

Review of the facility's policy titled, "Sterile Medication Quality Assurance," dated 03/06/23, showed that the environment controls encompasses the admixture area, equipment, facilities and supplies with the work area of the Laminar Air Flow Hood frequently cleaned with continual monitoring and supervision against bacterial contamination.

Review of the Laminar Air Flow Hood certification, showed the last time the hood was certified was 05/2022.

Review of the cleaning logs for the Laminar Air Flow Hood, showed completed logs for the last three months.

Observation on 05/31/23 at 11:45 AM, in the medication room off of the emergency room (ER), showed an unclean receptacle in the back of a Laminar Air Flow Hood and a non-working light.

Observation on 05/31/23 at 11:45 AM, in the medication room off of the ER, inside the Laminar Air Flow Hood (sterile hood), showed Staff C, RN, mixed Zosyn (antibiotic) and failed to perform an aseptic procedure by setting items in the hood before disinfecting the outside of the items and laid a medication label inside the hood and wrote on the label while inside the hood.

Review of the facility's competency documentation, showed the last competency for sterile preparation was 08/2017.

During an interview on 05/31/23 at 11:55 AM, Staff C, RN, stated that they had never been trained to perform admixtures in the hood.

During an interview on 06/01/23 at 10:30 AM, Staff G, Infection Preventionist, stated that:
- They didn't observe any sterile compounding in the hood.
- They felt the company that certified the hood should have cleaned the back receptacle of the hood.
- Staff should have cleaned the essential items prior to placing them in the hood.

During an interview on 05/31/23 at 2:15 PM, Staff F, Pharmacist, stated that:
- They were unaware that the RNs were not completing competencies for admixtures yearly.
- They hadn't observed any staff mixing in the last year.
- They had mentioned to maintenance to replace the light.
- Staff C should have cleaned supplies prior to placing in the hood.

KITCHEN/DIETARY
4. Review of the facility's policy titled, "Infection Control," dated 04/28/23, showed the direction for staff to provide a program that included prevention, surveillance and control procedures related to the hospital environment with evaluation with revision on a continuing basis.

Review of the daily cleaning logs for the last three months were completed with failure to list the can opener in the duties and the monthly extra cleaning logs failed to list any items above to include the vents, electrical box and sprinklers.

Review of the facility's policy titled, "Cleaning - Kitchen Floor Care," dated 11/04/22, showed that plant operations were responsible for cleanings that required use of strippers, buffers, or any special methods.

Review of the facility's policy titled, "Cleaning - Can Opener," dated 11/03/22, showed that the can opener should be clean daily to prevent any cross contamination with the direction for the staff to:
- Remove the opener by lifting the shank out of the base.
- Soak the shank assembly, scrub all parts with a stiff brush with special attention to the blade and the gear.
- Rinse in hot clear water.
- Sanitize and air dry.
- Wipe the base with warm sudsy solution followed by wiping with a sanitizing solution and air dry.
- Lubricate regularly as recommended by the manufacturer.

Observation on 05/31/23 at 11:00 AM, in the kitchen, showed:
- The can opener was unclean with rust.
- Below the dishwasher was rust on the exposed motor.
- Under the sink area the floor, wall and pipes were unclean.
- The corners of the steam table were unclean.
- Above the steam table a large vent with three rusted chains.
- Five sprinklers were unclean with corrosion.
- Four long vents and three smaller vents were unclean with rust.
- One food serving cart wheels were unclean with rust.
- One electrical box was rusted with two tiles on each side of the box missing with adhesive (attracts bacteria) showing.

During an interview on 05/31/23 at 11:00 AM, Staff E, Dietary Manager, stated that they were unable to reach the above areas to clean.

During an interview on 06/01/23 at 9:00 AM, Staff B, Maintenance and Plant Services Manager, stated that unless the staff inform them of necessary cleaning they were unaware.

During an interview on 06/01/23 at 10:30 AM, Staff G, Infection Preventionist, stated that they walk through the kitchen weekly and stated that the rust should have been removed, tiles replaced, can opener cleaned and the steam table cleaned.


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