HospitalInspections.org

Based on review of facility documents, observation and staff interview (EMP), it was determined that the facility failed to maintain a safe environment within the hospital.

Findings include:

Review on September 13, 2011, of the facility's "ISS Environmental Services ES-002" policy, last approved March 22, 2011, revealed "Purpose This policy provides an overview of the guidelines for the operations of the Environmental Service Zones of the Hospitality division. Statement of Procedure ... Housekeeping Standards [name of contracted vendor] provides environmental services necessary to maintain a sanitary, safe, and comfortable environment. ... the following environmental services standards provide a clean, safe, orderly, comfortable, and attractive environment: A. Accepted practices and procedures are used to keep free form offensive odors, accumulations of dirt, rubbish, dust and safety hazards. ..."

Observation on September 13, 2011, of the loading dock area, where food products were unloaded, revealed two hanging lights with a heavy accumulation of dirt, dust and dead bugs on the light fixtures and extending to approximately 18 inches around the light fixtures.

Interview on September 13, 2011, at 11:30 AM with EMP8 confirmed that the loading dock was used to unload food products from delivery trucks and that the food products were then transported to the refrigerator, freezer and dry food storage in the kitchen. Further interview with EMP8 confirmed there was dirt, dust and dead bugs on the light fixtures and extending to approximately 18 inches around the light fixtures. EMP8 also confirmed the dirt, dust and dead bugs could fall onto the packaged food and would be transported to the refrigerator, freezer and dry food storage in the kitchen.

Based on review of facility documents, observation, and staff interview (EMP), it was determined that the facility failed to ensure drugs and supplies required for emergency treatment of malignant hyperthermia (a rare life-threatening condition that is usually triggered by exposure to certain drugs used for general anesthesia) were readily available.

Findings include:

Review on September 14, 2011, of the facility's "Surgical Support Services Anesthesia Malignant Hyperthermia Response" policy, approved March 3, 2011, revealed "Purpose: To meet the needs of the patient who is Malignant Hyperthermia [MH] susceptible or who is unknown risk of developing Malignant Hyperthermia. I. Process ... B. Pharmaceutical agents necessary to treat syndrome will be available on all campuses. ... III. Intra-operative Preparedness - availability of equipment and supplies to treat MH A. Treatment Guidelines and MH Hotline number is readily available within the OR. B. Pharmaceuticals 1. Dantrolene (a medication used to treat muscle spasms) 36 vials of Dantrolene are kept in each operating room ... 2. Preservative-free sterile water for injection ... for Dantrolene reconstitution. 3. Sodium Bicarbonate, Mannitol, Lasix, Dextrose 50%, Regular Insulin, Calcium Chloride, Lidocaine, Procainamide, and Beta-Blockers are available in each operating Room suite or Anesthesia workroom. C. Cooling Supplies 1. Access to ice machine and plastic bags for ice. 2. 60 ml syringes/irrigation sets for lavage. 3. NG tubes. 4. Bladder irrigation catheters - age appropriate sizes. D. Other Equipment 1. Syringes to dilute Dantrolene 2. Angiocaths 3. Blood pump 4. CVP kits 5. Transducer kits 6. Urimeter 7. Anesthesia breathing circuit 8. Fresh sodalime and/or ability to change anesthesia machine 9. Blood specimen tubes, ABG kit, and specimen cups for laboratory and diagnostic testing. ..."

Observation on September 14, 2011, of the facility's operating room (OR) suite hall revealed one storage tote containing 36 vials of Dantrolene, 44 vials of Preservative-free sterile water; four 60 millimeter (ml) syringes; four contrast removal values and a Dantrium drug fact sheet.

Further review revealed the three-way Foley, NG (naso-gastric) tubes, urine specimen containers, invasive intravenous (IV) supplies, IV pump with tubing, CVP (central venous pressure) kits, transducer kits, blood specimen tubes, ABG (arterial blood gas) kits, the urometer and sodalime were located in various areas of the OR suite which included the back hall, the anesthesia work room, and the clean core of the OR suite.

Interview with EMP6 and EMP7 on September 14, 2011, at approximately 10:45 AM confirmed the facility did not have a designated malignant hyperthermia cart to contain all the supplies needed to meet the needs of the patient who is Malignant Hyperthermia [MH] susceptible or who is unknown risk of developing Malignant Hyperthermia. The interview further confirmed that all the required drugs and supplies needed for a patient suffering from MH were not readily available and that the OR staff would be required to go to the back hall, the anesthesia work room and the clean core of the OR in order to obtain the necessary drugs and supplies to treat the life-threatening condition of malignant hyperthermia.