Sullivan County Memorial Hospital

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 36473 Based on observation, interview and review of the Malignant Hyperthermia Association of the United States (MHAUS), the hospital failed to ensure the required life-saving medications were readily accessible when administering Succinylcholine (a muscle relaxant/paralytic) in the emergency department (ED). The severity and cumulative effects of these failed practices resulted in the hospital’s non-compliance with 42 CFR 485.618 Conditions of Participation (CoP): Emergency Services. Please refer to C-0884 for details.”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 36473 Based on interview and review of the Malignant Hyperthermia Association of the United States (MHAUS), the hospital failed to ensure the required life-saving medications were readily accessible when administering Succinylcholine (a muscle relaxant/paralytic) in the emergency department (ED). This failure had the potential to affect all patients that presented to the ED and given Succinylcholine in an emergency. The facility census was one Acute Care patient, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of four. Findings included: 1.During an interview on 04/23/24 at 10:30 AM, Staff E, Pharmacist, stated they did not have any Malignant Hyperthermia antedote medications and they do give Succinylcholine. 2.During an interview on 04/23/2024 at 12:25 PM, Staff G, Registered Nurse, stated if a rapid intubation is initiated, the nurse grabs the medication kit and the provider will determine medication. They are unaware if the Malignant Hypertermia protocol is in place for Succinylcholine use. They were aware it is an adverse reaction that can occur with Succinylcholine, but they had never experienced it. 3.During an interview on 04/23/2024 at 3:05 PM, Staff H, Emergency Provider, stated Succinylcholine is the drug of choice due to the short acting parallactic and before we had the ventilator, we had to manually bag patients. They believe the protocol following rapid intubation is to check vital signs every 15 minutes and that includes a tempature check. If someone had symptoms of Hyperthermia, staff would start an ice bath and attempt to cool the patient. Staff H states they are aware of the Malignant Hyperthermia from Succinycholine treatment but has never encountered it in practicing medicine. 4.Review of the MHAUS recommendations, dated 2016, showed that when patients were given Malignant Hyperthermia (a life-threatening, but treatable reaction of the inhalation anesthetics and Succinylcholine triggering anesthetics), medication, the only antidote used to reverse the reaction was the medication Dantrolene (medication that uncouples the heat generating mechanism in the muscles).”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 36473 Based on observation, interview, record review, the Missouri Food Code and nationally-recognized standards review, the hospital failed to ensure staff maintained a sanitary environment was preserved through maintenance and cleaning that would not harbor bacteria or transmit infections in the kitchen, Central Sterile areas and patient shower room.These failures had the potential to expose patients, visitors, and staff to cross-contamination, increased the potential to spread infection and had the potential to affect the qualitly of the cleaning enzymes used to clean instruments. The hospital census was one Acute Care patient, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of four. Findings included: Kitchen 1. Observation on 04/24/24 at 10:00 AM, in the kitchen, showed: - Missing tiles with glue exposed (sticky substance that attracts bacteria) under sink 1; - Missing tiles with rust under and around ice machine; - Rust spots on boarder above the steam table; - Chipped paint and rusted areas on cabinet at the dishwashing station; - Missing tile under the dishwasher; - Rusted trim above the tray return; - Chipped paint on walls and shelf near the tray return; - Unclean with rust spots on door to hallway; and - Rust underneath the handwashing sink. 2. During an interview on 04/24/24 at 10:15 AM, Staff M, Kitchen Manager, stated they expected staff to notify them and initiate a maintenance ticket for any repairs needed. 3. Review of the hospital quarterly Environmental Round’s log, showed the last environmental round in the kitchen was 04/2024. 4. Review of the Missouri Food Code for the Food Establishments of the State of Missouri, dated 06/03/13, chapter 6, showed surface characteristics of floors, walls and ceiling surfaces should be smooth, durable, and easily cleanable for areas where food establishment operations were conducted and nonabsorbent for areas subject to moisture such as food preparation areas, walk-in-refrigerators, washing areas, toilet rooms, mobile food establishment servicing areas, and areas subject to flushing or spray cleaning methods. Central Sterile Rooms 5. Observation on 04/24/24 at 11:05 AM, in the Central Sterile Decontamination Room, showed an unclean rusted sink used to clean instruments. 6. During a telephone interview on 04/24/24 at 11:30 AM, Staff N, Central Sterile Technician, stated in the Decontamination Room they used one ounce of cleaning enzyme and was not measuring the amount of water recommended by the enzyme manufacturer to clean instruments used for procedures in the emergency department. 7. Observation on 04/24/24 at 11:10 AM, in the Central Sterile clean room, showed: - Two areas of wall damage near the instrument wrapping table; - Four wrapped sterile instruments with discoloration and rust spots; a - Double door storage cabinet opened to the emergency room (exposure to contaminants) and opened to the Central Sterile clean room, used to store sterile instruments. 8. During a telephone interview on 04/24/24 at 11:30 AM, Staff N, Central Sterile Technician, stated staff were to put in a maintenance ticket for repairs needed. 9. During an interview on 04/24/24 at 12:00 PM, Staff F, Infection Preventionist, stated they perform environmental rounds in the kitchen and Central Sterile quarterly. They also expected staff to complete a work request for repairs needed and contact them or the Chief Nursing Officer if instruments needed to be taken out of service. 10. Review of the hospital quarterly Environmental Round’s log, showed the last environmental round in the Central Sterile area was 02/2024. 11. Review of the Association for Professionals in Infection Control and Prevention (APIC), “Infection Preventionists Guide to the Operating Room,” dated 2018, showed the operating room environment (Central Sterile Area) required surfaces that were smooth, cleanable, non-absorptive, and capable of withstanding cleaners and disinfectant solutions with no cracks and crevices where dirt can become trapped. Other materials (e.g., vinyl) can rip or wear in ways that create environmental reservoirs for microorganisms. Shower Room KH12. Observation on 04/24/24 at 12:55 PM, in the patient shower room, showed: - Several broken corners on the ceiling tiles; - Rust on the ceiling tile frames, door frame, shower faucet, tub drain, and wall mounted sink; - Dirty shower chair with vinyl seat damage; - Floor tile missing from shower floor; - Grout and sealent missing from floor and wall tile joints; and - A five gallon bucket to collect water from leaking sink. KH13. During an interview on 04/24/24 at 12:55 PM, Staff F, Registered Nurse, stated expectations is for this area to be free from rust, the shower chair should be free from soil and defects, the floor tiles to be present and sealed/grouted, the ceiling tiles to be clean and free of holes, missing corners, and the sink would be free of rust and not leak.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (vi) Communication and collaboration with the antibiotic stewardship program. This Standard is not met as evidenced by: 36473 Based on interview, policy review, record review and Centers for Disease Control and Prevention (CDC) review, showed the hospital leadership failed to ensure antibiotic stewardship activities provided an indication for use on antibiotic orders. These failures had the potential of affecting the measurement of effectiveness of the medications as well as the transparency for staff to determine appropriateness for all patients that presented to the hospital and received medications.The hospital census was one Acute Care patient, two Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of four. Findings included: 1. During an interview on 04/23/24 at 10:30 AM, Staff E, Pharmacist, stated they did not have indications for use in the medication orders. 2. During an interview on 04/24/24 at 12:00 PM, Staff F, Infection Preventionist, stated they were starting a system for indication of antibiotic use, but it is not in place at this time. 3. Review of the hospital’s policy titled, “Antimicrobial Stewardship Program,” last reviewed on 05/26/22, showed the direction for providers to specify the dose, indication, likely duration and apply stop dates or number of doses of the antimicrobial medication. 4. Review of the hospital’s Antimicrobial Stewardship Program, approved on 10/05/23, showed the direction for staff to follow the Core Elements set forth by the CDC for Critical Access Hospitals. 5. Review of the CDC “Antibiotic Stewardship Statement for Antibiotic Guidelines - Recommendations of the Healthcare Infection Control Practices Advisory Committee,” dated 09/21/17, showed: - Antibiotic stewardship has become a critical responsibility for all healthcare institutions and antibiotic prescribers. Professional societies and other organizations developing guidelines for management of infectious diseases that include recommendations for antibiotic prescribing also have an important responsibility in incorporating antibiotic stewardship principles in their recommendations. - An antibiotic stewardship program that incorporates the CDC Core Elements (Hospital Leadership Commitment, Accountability, Pharmacy Expertise, Action, Tracking, Reporting and Education) as appropriate for the type of infection and treatment setting should be cited in guidelines as a valued resource for determining the optimal antibiotic selection, dose, route, and duration of treatment. - We recommend that guidelines for treatment of infectious diseases include explicit recommendations for antibiotic stewardship relevant to the infections addressed in the guidelines.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 18018 Based on policy review, record review and interview the facility failed to perform an activity assessment and develop a comprehensive activity care plan that provided specific individualized activity interest and interventions to stimulate the patient’s physical and mental well-being for two current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients (#1 and #6) and for two discharged Swing Bed patients (#7 and #8) reviewed for a comprehensive quality of life activity assessment and activity care plan. This failed practice had the potential to affect all Swing Bed patients by failing to stimulate their minds, body, and social interests. The facility census was one Acute Care patient, two Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or discharge the patient) patient for a total census of four. Findings included: 1. Review of the facility’s policy titled, “Swing Bed - Care Plan,” dated 05/10/22, showed staff directives: - All Swing Bed Residents have the right to participate in their care plan throughout their stay. - The care plan shall include: - Measurable objectives and timeframes to meet; - Services provided to attain or maintain physical, mental, and psychosocial well-being; and - The resident’s goals for admission and desired outcomes. - If there is a change in residents’ condition, the provider must complete a new comprehensive assessment and the care plan must be updated by the interdisciplinary team. 2. Review of Patients’ Electronic Medical Health Records (EMHR) showed: - Patient #1 was admitted to the facility’s Swing Bed program on 04/18/24, for new right below the knee amputation; - Patient #6 was admitted to the facility’s Swing Bed program on 03/22/24, for intravenous antibiotic therapy for right knee infection status post right knee replacement; - Patient #7 was admitted to the facility’s Swing Bed program on 11/10/23, for complaints of hypercalcemia (a condition in which the calcium level in a patient’s blood is too high), esophagitis (inflammation of the esophagus) and weakness; and - Patient #8 was admitted to the facility’s Swing Bed program on 11/21/23 for complaints of status post hip fracture. Patient #1’s, #6’s, #7’s and #8’s EMHR showed staff failed to perform an activity assessment and develop a comprehensive activity care plan for the patients during their stay in the facility’s Swing Bed program. 3. During an interview on 04/23/24 at 3:01 PM, Staff B, Registered Nurse, Swing Bed Coordinator, acknowledged the Swing Bed patients did not have an activity assessment or activity care plan included in the patients’ EMHR. During an interview on 04/24/24 at 9:55 AM, Staff A, Chief Nursing Officer, stated the patients admitted to the facility’s Swing Bed program did not have an activity assessment or activity care plan included in the patients’ EMHR. Staff A stated the facility received information from the Hospital Association during a webinar that the Swing Bed Program was no longer required to perform either an activity assessment or include activities in patients’ care plans because the activity requirement was no longer a regulatory requirement for a facility’s Swing Bed Program. Staff A stated the facility stopped performing activity assessments and including activities in patients’ care plan after receiving information activities were no longer a regulatory requirement for patients admitted to a facility’s Swing Bed Program.”