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Based on policy review, document review, and interview, the hospital failed to ensure the National Practitioner Data Bank (NPDB) was queried during the reappointment process for one (Physician [Phys]2) of three physician credentialing files reviewed for appointment/reappointment. This deficient practice had the potential to affect all patients receiving services of Phys2 while hospitalized.

Findings include:

A review of the hospital policy titled "Medical Staff Credentials Policy," approved 08/11/22, indicated ". . . Procedure For Initial Appointment and Privileges . . . Steps to Be Followed for Initial Applicants . . . The National Practitioner Data Bank will be queried . . . Procedure For Reappointment All terms, conditions, requirements, and procedures relating to initial appointment will, as applicable, apply to continued appointment and clinical Privileges and to reappointment. . ."

A review of Phys2's credentialing file with the Medical Staff Coordinator (MedStCoor) and Medical Staff Manager (MedStMgr) presenting the file documents for review indicated Phys2's reappointment date was 05/19/23 to 05/19/25. A review of the credentialing documents presented by MedStCoor and MedStMgr indicated there was no documentation of a NPDB query conducted at the time of the reappointment of Phys2.

During an interview on 05/16/24 at 8:54 AM, MedStMgr stated he/she could not find the NPDB query for this appointment that was done by the previous coordinator. MedStMgr stated the NPDB query was required for every physician's appointment and reappointment.

Based on policy review, document review, personnel file reviews, and interview, the hospital failed to ensure the nursing staff had documented competency evaluation for administering blood and blood products for five (Registered Nurse [RN] 2, RN3, RN4, RN5, RN6) of five RN personnel files reviewed for documented blood administration competency. This deficiency had the potential to affect all patients receiving blood and blood products while hospitalized.

Findings include:

A review of the hospital policy titled "New Employee Orientation Procedure - WH," approved 01/03/22, indicated ". . . The department manager or supervisor should: . . . Prepare a plan of action for training and orientation to their new role, covering the new employee's schedule depending upon the nature of the position. . . Coordinate clinical onboarding and documented competency relative to position requirements. . ."

A review of the undated "[name of hospital system] Department Specific Orientation - Contract Staff" indicated ". . . Blood Administration Verbalize location of blood bank Verbalize process for administration: Verify order Obtain/verify consent for blood administration Verify blood product is ready under "Blood product Status Tracking" in Epic [hospital's electronic computer documentation system] Print blood release form from EPIC, take blood release form to blood bank Two RN's [sic] required for verification at bedside Utilize EPIC transfusion tab for product scanning and documentation Vital signs as follows: Within 15 minutes prior to transfusion, 15 minutes after product start time, then every hour until complete, then within 20 minutes of Document blood volume, answer transfusion reaction questions, document transfusion completed . . ."

1. Review of RN2's personnel file indicated RN2 was a travel nurse from 08/28/23 - 11/25/23. A review of RN2's "[name of hospital] Contracted Travel Nurse Unit-Based Orientation" indicated the section relative to blood administration had the preceptor/evaluator's initials with the date 09/02/23 documented. There was no documentation of an observation of the evaluation of RN2's competency to administer blood and blood products.

2. Review of RN3's personnel file indicated RN3 was a travel nurse from 09/25/23 - 02/05/24. A review of RN3's "[name of hospital] Contracted Travel Nurse Unit-Based Orientation" indicated the section relative to blood administration had the preceptor/evaluator's initials with the date 09/28/23 documented. There was no documentation of an observation of the evaluation of RN3's competency to administer blood and blood products.

3. Review of RN4's personnel file indicated RN4's date of hire was 11/20/17, and RN4 became a RN on 12/30/23. Review of RN4's "Competency Statement" indicated ". . . DIRECTIONS: RN Position should review and complete the Core Competency Based Orientation with their
preceptor. For each of the competency statements listed below, the preceptor will review orientee's self assessment, verify the method used for validation, determines competency, and may use Performance Skills Checklist. Department Directors must work with preceptors and new employees to ensure the individual is progressing in the completion of these competencies. . ." The review indicated blood administration was not listed as one of the areas to be observed. There was no documentation of an observation of the evaluation of RN4's competency to administer blood and blood products.

4. Review of RN5's personnel file indicated RN5's date of hire was 04/17/23. A review of the personnel file indicated there was no documentation of an observation of the evaluation of RN5's competency to administer blood and blood products.

5. Review of RN6's personnel file indicated RN6 was a travel nurse from 06/19/23 to 02/24/24. A review of RN6's "[name of hospital] Contracted Travel Nurse Unit-Based Orientation" indicated the section relative to blood administration had the preceptor/evaluator's initials with the date 06/21/23 documented. There was no documentation of an observation of the evaluation of RN6's competency to administer blood and blood products.

During an interview on 05/16/24 at 11:14 AM, the Human Resource Director (HR Dir) and Chief Nursing Officer (CNO) both confirmed there was no documentation of observed competencies in administering blood and blood products for the above-listed nursing staff.

Based on record review, policy review, and interviews, the facility failed to ensure blood products were transfused per the facility's policy for two of six patients (P) (P1 and P2). Specifically, for P1 the hospital failed to ensure the initial infusion rate was according to hospital policy and for P2 the hospital failed to include complete documentation of a blood transfusion in the electronic medical record (EMR). This deficient practice had the potential to affect the quality and safety of care provided to all patients who received transfusions in the hospital.

Findings include:

A review of the hospital policy titled, "Blood, Blood Products Administration- NS- Patient Care," revised on 09/16/22, indicated, " ...Documentation in EMR: All IV [intravenous]or central line sites, verifications, start/stop times and vitals should be documented in the EMR ...and document vital signs up to 20 minutes' post transfusion ...Observe for signs and symptom of transfusion reaction by remaining with the patient during the first 15 minutes of the transfusion. Life threatening reactions can occur after the infusion of only a small volume of blood ...All blood products should be infused at a rate of 2 ml [milliliters]/min [minute] or less during the initial 15 minutes of a non-emergent transfusion while an RN [Registered Nurse] monitors the patient for signs of transfusion reaction. An elevation in temperature or heart rate may be one of the first signs that a person is having an adverse reaction to a transfusion. The rate may be increased if no adverse reaction is noted after first 15 minutes ...."

1. Review of the "Face Sheet" located in the EMR under the "Details" tab indicated P1 was admitted to the hospital on 11/09/23 for induction of labor for pre-eclampsia (type of high blood pressure during pregnancy) without severe features.

A review of the "Labor Summary and Delivery Note" dated 11/10/23 located in the EMR indicated, " ...Controlled delivery ...There was brisk bleeding with placenta separation ...Inspection of perineum revealed deep second degree laceration ...administered TXA [Tranexamic acid -a medicine that controls bleeding] and 600 mg [milligrams]of buccal [between mouth and cheek] misoprostol [medicine that increases uterine tone and decreases postpartum bleeding.] ...and single interrupted suture for hemostasis [cessation of bleeding from a blood vessel] ...2 [two] units of PRBCs [packed red blood cells] ordered. ..."

A review of the "Single Transfusion Record" located in the EMR indicated, " ...Transfusion of leuko-reduced [packed] RBC new bag administered at 250 ml per hour on 11/10/23 at 10:01 PM ...completed transfusion at 11:38 PM. ..."

A review of the "Single Transfusion Record" located in the EMR indicated, " ...Transfusion of leuko-reduced RBC new bag administered at 250 ml per hour on 11/10/23 at 11:41 PM ...completed transfusion at 12:44 AM. ..."

During an interview on 05/15/24 at 3:05 PM, the Director of Labor and Delivery (Dir L&D) stated per hospital policy, the flow rate for a blood transfusion is initially started at a slower rate to monitor the patient for any blood reaction. After about 15 minutes if there is no reaction, the flow rate can be increased. The Dir of L&D confirmed the documentation in P1's EMR revealed the flow rate for the two units of PRBC P1 received on 11/10/23 were initially started at 250 ml per hour and not a slower rate.

During an interview on 05/16/24 at 7:05 AM, RN1 stated he/she was the nurse who started both transfusions of PRBC for P1 on 11/10/23. RN1 stated when a blood product is started, hospital policy requires starting the blood transfusion at a slower rate, around 50-100 ml per hour to monitor for any transfusion reaction. RN1 was not sure what the initial flow rates were set at for the two units of PRBC P1 received on 11/10/23 but confirmed the initial flow rate should have been documented in the EMR.

2. Review of the "Face Sheet" located in the EMR under the "Details" tab indicated P2 was admitted to the hospital on 11/12/23 for induction of labor and resultant emergency cesarean section.

A review of "Physician Orders" dated 11/15/23 located in the EMR indicated to transfuse one unit of leuko-reduced RBC.

A review of the "Single Transfusion Record" dated 11/15/23 located in the EMR indicated, " ...transfuse leuko-reduced RBC completed ...220 ml volume ..." Review of the "Administration Detail" section revealed, " ...no administrations recorded."

During an interview on 05/15/24 at 2:10 PM, the Director of the Emergency Room/Intensive Care Unit (Dir ER/ICU) stated the "Single Transfusion Record" is used to document the administration of blood. The Single Transfusion Record includes the start time, stop time, flow rate, and dual verification by two nurses before the blood product is administered. The Dir ER/ICU stated P2 received a unit of PRBC on 11/15/23 and the "Single Transfusion Record" did not include the start time, stop time, flow rate, and the dual verification by two nurses. The Dir ER/ICU stated the nurse who administered the unit of PRBC on 11/15/23 no longer worked at the hospital. The Dir ER/ICU confirmed documentation of the start time, stop time, flow rate, and dual verification by two nurses of the unit of PRBC P2 received on 11/15/23 was not included in P2's EMR.