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Based on a review of the medica records of 5 patients receiving transfusions of blood or blood products at the facility, it was determined that while the facility had blood and blood products available on a 24-hours a day basis, facility staff failed to follow facility transfusion policies in 4 of 5 patients (#27, 29, 30, and 34).

Finding are:

The facility had a policy titled "Blood Transfusion and Blood products that was last reviewed in December 2009 and stated under PROCEDURE (C) Transfusion: "RN/LPN/Paramedic 18. Document the time the transfusion is completed, include the amount infused and if there was a reaction or not on the transfusion slip....."

Patient # 27 received 4 units of packed red blood cells (PRBC) from 12/13/2010 at 2242 to 12/14/2010 at 0725. Units # 21LQ58118, 21LQ59833, and 21LQ56952 lacked any checkmark indicating "Yes" or "No" to the question "Suspected transfusion reaction No ------ Yes ------."

Patient #29 received three units of PRBC from 12/25/2010 at 1400 to 12/25/2010 at 2130. Unit # 21LY59079 lacked any checkmark indicating "Yes" or "No" to the question "Suspected transfusion reaction No ------ Yes ------."

Patient # 30 received two units of PRBC from 11/14/2010 at 1948 to 11/15/2010 at 0205. Units # 21FT87090 and 21FT87077 lacked any checkmark indicating "Yes" or "No" to the question "Suspected transfusion reaction No ------ Yes ------."

Patient # 34 received two units of PRBC from 11/13/2010 at 0330 to 11/13/2010 at 0700. Units # 21N35774 and 21KX23952 lacked any checkmark indicating "Yes" or "No" to the question "Suspected transfusion reaction No ------ Yes ------."

Based on review of medical records, staff interviews, and hospital policies and procedures, it was determined that in 6 of 11 records (#3, #4, #5, #7, #10 and #23) the hospital failed to ensure the implementation of policies and procedures for advanced directives.
The following policy was reviewed: Advance Directives policy # GR07, revision 11/1999. The policy directed the following guidelines. The patient will be provided the following: A copy of the Advance Directive form as set forth in OSB 286 ... " and " The hospital will document in a prominent place in the medical record whether or not the individual has executed an Advance Directive. A copy of the Advance Directive will be placed in the medical record. In the absence of the actual Advance Directive, the substance of the Directive is documented in the patient ' s medical record. "
The policy included an algorithm form entitled " Tillamook County General Hospital Advance Directive Status. " The form was a series of shapes, arrows, and yes/no questions. Each portion of the algorithm ended with either " end " or " Copy received and on Patient chart. "
During an interview conducted 1/11/11 at 1330 with the RN charge nurse for the medical surgical unit it was revealed that the document entitled " Advanced Directive Status " was the established procedure for the documentation of patient wishes regarding advanced directives. It was further revealed that each step in the algorithm should be circled as it is completed until " end " or " Copy received and on Patient chart " is reached.
1.) Review of record #3 " Advanced Directive Status " document revealed that the patient did not have an advanced directive on file in the medical records department of the hospital. The patient was provided written information regarding advanced directives and indicated the following wishes " If I am unable to make medical decisions for myself I would want my son ...to make decisions for me. " The record lacked documentation to indicate whether or not the patient had an advanced directive, was mentally competent to complete an advance directive and whether or not the patient or responsible person was offered assistance with advanced directives according to the direction of the algorithm.
2.) Review of record # 4 " Advanced Directive Status " document revealed that the patient had an advanced directive on file in the medical records department of the hospital; however the first question on the algorithm portion of the document indicated that the patient did not have an advanced directive. The record further reflected that the patient was provided information regarding advanced directives and that the patient ' s statement of advanced directives wishes was " Full Code " . The record reflected conflicting documentation regarding the patient ' s advanced directive status and failed to reflect whether or not the patient was offered assistance with advanced directives according to the algorithm.
3.) Review of record #5 " Advanced Directive Status " document revealed that the patient did not have an advanced directive on file in the hospital medical records department. The patient ' s statement of advanced directives wishes was " DNR " . The record lacked documentation reflecting whether or not the patient had an advanced directive, was mentally competent to complete advanced directives, had received written information regarding advanced directives, or whether or not the patient was offered assistance with advanced directives according to the algorithm.
4.) Review of record #7 " Advanced Directive Status " document revealed that the patient did not have an advanced directive on file in the hospital medical records department. The patient ' s statement of advanced directive wishes was " Full code Husband will make decisions " . The record lacked documentation regarding whether or not the patient had an advanced directive, was mentally competent to complete an advanced directive, was provided written information regarding advanced directives and whether or not the patient or responsible person was offered assistance with advanced directives.
5.) Review of record #10 " Advanced Directive Status " document revealed that the patient did not have an advanced directive on file in the hospital medical records department. The patient ' s statement of advanced directive wishes was " Polst on chart ' DNR ' " . The record lacked documentation regarding whether or not the patient had an advanced directive, was mentally competent to complete an advance directive, and whether or not the patient was offered written information regarding advance directives according to the algorithm.
6.) Review of record #23 and an interview with the Quality Resource Manager was conducted 1/12/11 at approximately 1500. The computer portion of the record indicated that an advanced directive had been filed in the medical record. Further review revealed that the record lacked the existence of an advanced directive however the " Advanced Directive Status " form had been filed in the record.
During an interview conducted 1/11/11 at 1630 with the Quality Resources Director it was verified that the "Advanced Directive Status" algorithms lacked consistent and complete documentation.

Based on interviews and policy review, it was determined that the hospital failed to identify who was competent to complete the assessment of health status of pregnant patients and Labor and Delivery nurses were conducting the initial health status assessments on pregnant patients as part of their normal activities. Findings include:
Upon careful review of the Medical Bylaws with the Director of Emergency Department/Quality Resources on 1/11/2011 at approximately 13:30 it was determined that the Medical Bylaws and facility policies did not identify who could perform the initial health status assessments other than physicians.
Upon further discussion with the Director regarding the current screening practice for pregnant patients who come to the hospital having labor pains, it was determined that the nurses from Labor and Delivery complete the initial health status assessment.