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Based on review of the facility's Medical Staff Bylaws, credential files, and staff and physician interviews, it was determined that the facility failed to ensure that the quality of care provided by the Certified Registered Nurse Anesthetist (CRNA) was monitored and evaluated.

Findings were:

Review of the facility's Medical Staff Bylaws, revised 12/2009, revealed that the Utilization Review/Quality Improvement Committee would monitor and evaluate the quality of patient care and the clinical performance of individuals with delineated clinical privileges. The Bylaws further indicated that there would be timely response by physician to peer review organization notice of inquiry, action and sanction.

During an interview at 2:05 p.m. on 06/08/2010 in the Administrator's office, the Credentialing Coordinator (staff interview # 3) stated that all credentialed staff had peer review. He/she stated that mid-level personnel (CRNA, PA-physician's assistant) were reviewed by his/her supervising physician.

Review of credential file # 9 failed to reveal documented evidence of review of quality of care/peer review.

During a telephone interview on 06/10/2010 at 10:30 a.m., the physician (credential file #6) stated that he/she did not do formal peer review on the CRNA (credential file #9).

Based on review of facility policies and procedures, medical records, facility tour, and staff and physician interviews, it was determined that the facility failed to have available an emergency kit with the drug Dantrolene to treat patients who developed malignant hyperthermia (the rapid onset of extremely high fever with muscle rigidity occurring during the administration of general anesthesia, precipitated in genetically susceptible persons especially by halothane or succinylcholine) after receiving succinylcholine (a muscle relaxant) during an emergency intubation.

Findings were:

Review of facility policy, entitled Malignant Hyperthermia (MH) Cart, Reference #8058, no date, revealed that the Surgical Services Department would have a cart stocked for the management of malignant hyperthermia (MH) at all times. The policy noted that the cart was to be maintained by the Anesthesia Department, was to be inspected once a month for inventory and expired drugs, and that all surgical services staff were to know the location of the cart. Additionally, the policy revealed that the MH cart was to contain thirty-six (36) 20 milligram (mg) vials of Dantrolene (a muscle relaxant that is the only specific and effective treatment for malignant hyperthermia).

During a telephone interview on 06/09/2010 at 5:20 p.m. in the nurses' station, the Director of Pharmacy (a contracted service) (interview #3) stated that he/she assumed that Dantrolene and the MH kit were in the surgical suite as that was where it belonged. The Director continued that the required amount of Dantrolene would be ordered and in the facility by the end of the week. The Director also stated that he/she was aware that Anectine (succinylcholine) was also available in the Emergency Department. During a second (2nd) telephone interview on 06/10/2010 at 4:15 pm. in the conference room, the Director of Pharmacy stated that he/she would personally remove all Anectine from the facility that evening (06/10/2010) and that the Anectine would not be returned until the Dantrolene arrived at the facility and the malignant hyperthermia kit in place.

During a telephone interview on 06/10/2010 at 10:30 a.m. in the nursing administration office, the internal medicine / gastroenterology physician (credential file #6) stated that he/she was not aware that there was not a malignant hyperthermia kit with Dantrolene in the facility in case of a reaction to the drug Anectine. The physician continued that he/she would not do any further endoscopy procedures until the Dantrolene was available.

Four (4) of four (4) medical records reviewed of patients who had been given succinylcholine while being intubated (tube placed in the windpipe to assist with breathing), (#s 25, 26,27 and 28), revealed that patients #25, 26, and 28 were emergency room patients and that patient # 27 was as a patient on the medical patient care unit.

During the tour of the facility on 06/09/2010 at approximately 2:00 p.m., the surgical / emergency services RN (interview #4) stated that there was not a MH kit with Dantrolene available in the facility, and that he/she was concerned that there was no Dantrolene available for a MH emergency.

Based on review of facility policies and procedures, medical records, facility tour, and staff and physician interviews, it was determined that the facility failed to ensure that medications and supplies were available for treating all emergencies that could occur for the services provided.

Findings were:

Cross refer to C-0202 as it relates to failure of the facility to maintain a malignant hyperthermia kit with the drug Dantrolene available for those patients receiving succinylcholine during an emergency intubation.

Based on review of facility policies and procedures, credential files, observations during facility tour, and staff and physician interviews, it was determined that the governing body failed to ensure that the hospital provided for the safety of patients undergoing anesthesia.

Findings were:

Cross-refer to C-0202 as it relates to failure of the governing body to ensure that the facility maintained proper anesthesia safety precautions in relation to the administration of the drug Anectine (succinylcholine-a muscle relaxant).

Based on review of facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs and pharmaceuticals were not available for patient use.

Findings were:

Review of facility policy, entitled Drug Procurement/Inventory Control: Medication Management-Storage, issue date 04/22/2009, revealed that all drug storage areas within the hospital would be inspected monthly by the Pharmacy Department and that expired, damaged and/or contaminated medications would be removed from drug storage areas within the hospital during the Pharmacy inspection and would be returned to the Pharmacy Department for proper disposal. The policy further noted that expired, damaged and/or contaminated medications would be stored in an isolated area in the Pharmacy Department that had been designated for the storage of such unusable drugs and that the drugs would remain there until proper disposal or pick up could be made.

During a random drug examination in the pharmacy on 06/08/2010 at 11:00 a.m. with a staff pharmacist (staff interview #7), observations revealed the following expired medications available for patient use:
a. Diltiazem (used to treat high blood pressure, chest pain, and certain heart rhythm
disorders) 25 milligrams (mg)/5 cubic centimeters (cc), 44 bottles, with expiration date of 05/10/2010;
b. Augmentin (an antibiotic) 125 mg/5 cc, 1 bottle, with expiration date of 12/2009;
c. Augmentin 250 mg/5 cc, 1 bottle, with expiration date of 4/2010;
d. Merrem (an antibiotic) 1 gram, 75 bottles, with an expiration date of 4/25/2010; and
e. Ampicillin (an antibiotic) 1 gram for injection, 28 bottles, with an expiration date of 01/2010.

During an interview at 11:15 a.m. on 06/08/2010 in the pharmacy, the staff pharmacist (staff interview #7) confirmed that the medications were expired. The pharmacist explained that when the medications were placed into the Pyxis (drug dispensing cabinet) the expiration date would have been noted and that no one checked for expiration dates other than at that time.

Based on review of facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure that patients on cardiac (heart) monitors had their heart rhythms properly observed and that cardiac monitor alarms were properly set.

Findings were:

Review of facility policy, entitled Clinical Alarms, Directive # 03.07, Dated April 2009, Review Date April 2010 revealed that clinical alarms and medical equipment alarm systems would be activated, set properly, and be sufficiently audible to alert staff when the patient needs immediate attention and that cardiac monitor alarms were to be on and audible at all times.

During a tour of the medical/surgical nurses station on 6/10/10 at 5:40 p.m. with the interim Director of Nursing (DON-employee #1), observations revealed one (1) patient's heart rhythm on the telemetry monitor screen. The interim DON explained that the area did not have the ability to run strips or hear any alarms, and that the patients were monitored in the Emergency Department (ED). The interim DON further stated that the nurses in the ED were responsible for monitoring the patient's rhythm, responding to alarms, and running strips, although there was not a designated person to do so.

During a tour of the ED on 6/10/10 at 5:45 p.m. with the interim DON, observations revealed one (1) patient on the telemetry monitor with the alarm noted to be turned off. Once the alarm status was pointed out, the interim DON began adjusting the alarm to turn it back on. The unidentified RN working in the area confirmed that there was not a designated person to monitor patients, stating that whoever was around the desk would respond to alarms. When asked why the alarm was turned off, he/she denied it being off, and said it had been alarming all day.

Based on review of facility policies and procedures, personnel files, and staff interview, it was determined that the facility failed to ensure that personnel maintained annual competency for ten (10) of fifteen (15) sampled personnel files (#s 2, 3, 4, 6, 8, 10, 11, 12, 13 and 15).

Findings were:

Review of facility policy, entitled Competency and Licensure, policy number 15.03, reviewed January 2010, revealed that all staff would complete a competency assessment as part of the orientation process and that ongoing competence was validated yearly as part of the appraisal process.

Ten (10) of fifteen (15) personnel files reviewed (#s 2, 3, 4, 6, 8, 10, 11, 12, 13 and 15) lacked documented evidence of annual competency evaluation.

During an interview at 2:00 p.m. on 06/09/2010 in the Human Resources Director's office, the Human Resource Director (interview #2) stated that because of staff turn over recently, some of the employees had not had their annual competency. The Human Resource Director also stated that competencies were done annually along with the employee evaluation by the employee's manager.

Based on review of facility policies and procedures, medical records, and staff interview, it was determined that the facility failed to ensure that each Medicare inpatient received the Important Message from Medicare.

Findings were:

Review of facility policy, entitled Procedure: Providing Medicare Inpatients with A An Important Message from Medicare, issued 9/98, reviewed 5/2010, failed to reveal evidence that the facility had followed their policies and procedures to address the Medicare requirements at 42 CFR Part 405.1205, Notifying Beneficiaries of Hospital Discharge Appeal Rights, by providing inpatients who were Medicare beneficiaries with two (2) copies of the Important Message (IM) from Medicare, which informed Medicare beneficiaries and/or their representatives of the beneficiaries' rights as a hospital inpatient.

Nine (9) of twenty (20) medical records reviewed of Medicare patients (#s 1, 2, 8, 9, 11, 17, 18, 19, and 20) lacked documentation that the facility had provided Medicare inpatients with the Important Message from Medicare as required.

During an interview at 10:15 a.m. on 06/09/2010 in the hospital's conference room, the Registration/Admissions Supervisor (staff interview # 1) stated that the facility was aware that they were to provide Medicare inpatients with a copy of the Important Message from Medicare, but did not know when the practice stopped. He/she was sure that the IM was not on any of the requested medical records that he/she reviewed.