HospitalInspections.org

36827

Based on observation, review of records, and interview, the Governing Body failed to:

A. provide complete and correct information to patients or patient representatives of their rights (including State required notices) prior to admission, at time of admission and prior to discharge.

Refer to Tag: A 0117


B. secure 2 of 2 areas where the acid concentrates are stored to prevent tampering.

C. ensure that medical record entries that were documented by the nursing staff were legible and if changes were made to the legal health record, the changes were made according to the facility policy. A review of legal records revealed 8 of 8 records were illegible or corrections were not made to the record per the facility policy. Also, the facility's policy was not followed for Changes to the Legal Health Record.


D. provide clean carts that carry the portable RO (Reverse osmosis for water purification) system to the patients' bedside in different nursing areas of the hospital and provide clean storage areas for the patient dialysis supplies, equipment, and the acid/bicarbonate products.


Refer to Tag: A 0144

E. provide a clear staffing plan or grid to ensure safe nurse to patient ration was provided in 6 (Medical/Surgical, Medical/ Telemetry, Intensive Care Unit, Emergency Department, Nursery, and Obstetrics) out of 6 patient units.

Refer to Tag A0392

F. ensure non-employee licensed nurses providing care in the emergency department to sexual assault victims were properly contracted, credentialed and supervised.

Refer to Tag A0398

G. follow policy and procedures to ensure blood and blood products, were administered to the patients in a safe manner, in 3 (#55, 22, and 19) out of 3 patient charts and 17 out of 20 transfusion records reviewed.

Refer to Tag A0409

36827

Based on observation, review of records and interview, the facility failed to:

1. provide complete and correct information to patients or patient representatives of their rights (including State required notices) prior to admission, at time of admission and prior to discharge as follows:

A. An Important Message From Medicare About Your Rights for 3 patients (Patient #s 31, 33, and 34) of 4 patients (Patient #s 31, 32, 33, and 34) was not delivered at admission and/or discharge. The facility failed to follow its own policy.

B. State required posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at 3 of 3 entrances/waiting areas (Entrance/Main Lobby Gaslight Boulevard, Entrance/Lobby Loop 287, and Ambulance Entrance/Emergency Room Waiting)

C. Provided the incorrect phone number to all patients for making a Health Facility Complaint at time of admission, creating a barrier to patients from exercising their right to make a complaint.

See Tag A0117

2.
A. secure 2 of 2 areas where the acid concentrates are stored to prevent tampering.

B. ensure that medical record entries that were documented by the nursing staff were legible and if changes were made to the legal health record, the changes were made according to the facility policy. A review of legal records revealed 8 of 8 records were illegible or corrections were not made to the record per the facility policy. Also, the facility's policy was not followed for Changes to the Legal Health Record.


C. provide clean carts that carry the portable RO (Reverse osmosis for water purification) system to the patients' bedside in different nursing areas of the hospital and provide clean storage areas for the patient dialysis supplies, equipment, and the acid/bicarbonate products.

These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate, providing legible documentation in the legal health record, and failure to provide clean dialysis equipment to the patients.

See Tag A0144

Based on observation, review of records and interview, the hospital failed to provide complete and correct information to patients or patient representatives of their rights (including State required notices) prior to admission, at time of admission and prior to discharge as follows:

A. An Important Message From Medicare About Your Rights for 3 patients (Patient #s 31, 33, and 34) of 4 patients (Patient #s 31, 32, 33, and 34) was not delivered at admission and/or discharge. The facility failed to follow its own policy.

B. State required posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at 3 of 3 entrances/waiting areas (Entrance/Main Lobby Gaslight Boulevard, Entrance/Lobby Loop 287, and Ambulance Entrance/Emergency Room Waiting)

C. Provided the incorrect phone number to all patients for making a Health Facility Complaint at time of admission, creating a barrier to patients from exercising their right to make a complaint.

Findings include:

A. Four patient charts (Patient #s 31, 32, 33, and 34) were selected from the Complaints and Grievances Log to be reviewed. Three of the patients (Patient #s 31, 33, and 34) did not receive proper notification.

Patient #31 was admitted on 8-11-2016. The patient was discharged to hospice on 8-12-2016. Review of records showed that the form, An Important Message From Medicare About Your Rights (IM) had notation in the "Signature of Patient or Representative" block "pt cannot sign". This was dated and time 8/11/16 1017 (10:17 A.M.). There was no signature of the person delivering the IM or explanation of why the patient could not sign. The chart did not contain documentation of follow-up action with a patient representative or the patient to provide them with the patient rights information. A second delivery of the IM was not necessary.

Patient #33 was admitted on 8-8-2016. The patient was discharged to home with home health on 8-29-2016. Review of records showed that the IM form had a patient representative's signature in the "Signature of Patient or Representative" block. It was not dated or timed. There was no IM form found in the chart with signature, date, or time of the second delivery of the IM prior to discharge.

Patient #34 was admitted on 6-13-2016. The patient left the hospital against medical advice on 6-19-2016. Review of the records showed that the IM form had a patient representative's signature in the "Signature of Patient or Representative" block. It was dated and timed "6 13 1900" (7:00 P.M.) There was no IM form with a signature, date, or time from the patient to show he had received a second delivery at time of discharge when he signed himself out of the hospital against medical advice.

Review of Community Health Systems Professional Services Corporation Policy Title: Important Message from Medicare Policy was completed. "Section II. Procedure" stated the following:

"Registration personnel are responsible for the following:

A. Delivery of the Important Message from Medicare (IM) at or near admission, but no later than 2 calendar days following the date of admission.

B. If the Medicare patient is admitted and/or transferred to a Distinct Part Unit within the hospital (e.g., Rehab or Psych unit), the IM specific to that Unit, which includes the DPU's Medicare provider number, should be delivered to the patient instead of the acute care IM.

C. When the IM is issued, obtain the signature of the patient or his/her representative on the IM to indicate that he/she received and understood the notice. This includes explaining the notice to the patient if necessary and providing an opportunity to ask questions ...

G. Regardless of the competency of a patient, if it is not possible to personally deliver a notice (initial IM or follow-up IM) to a representative, the attempts should be made to contact the representative by telephone to advise him or her of the patient's rights as a hospital patient, including the right to appeal a discharge decision ...

J. Place a dated copy of the notice in the patient's medical file, and document the telephone contact with the patient's representative (as in #8 above) on either the notice itself, or in a separate entry in the patient's fil or attachment to the notice...

L. If the patient refuses to sign the IM, indicate in writing on the IM the refusal. The date of refusal is considered the date of receipt of notice.

M. It is the ultimate responsibility of Registration personnel to ensure the initial IM is delivered to appropriate patients and/or their representatives, appropriate signature(s) is obtained, the original IM is given to the patient or his/her representative, and a signed and dated copy of the IM is placed in the medical record. A tracking system should be developed whereby there is certainty that the IM is delivered, as per Policy.

III. Delivery of the Follow-up IM Prior to Discharge
The Case Manager is responsible for the delivery and obtaining the patient's or the patient's representative's signature on the follow-up IM prior to discharge. When the CM is not available, the nurse manager, charge nurse or nurse assigned to patient is responsible for this process.

A. Provide the patient or his/her representative a new IM within 2 calendar days of the day of discharge. Obtain the patient's or patient's representative's signature and date on the new IM. Give the patient or the patient's representative the second signed and dated IM and place a copy of the second IM in the medical record."

Interview was conducted with Staff #51 on 9-21-2016. Staff #51 confirmed that it was the Case Management Department's responsibility along with nursing to ensure the second delivery of the IM. Staff #51 was unable to find the second delivery of the IM for Patient #33 and Patient #34.

Interview was conducted with Staff #54 on 9-22-2016. Staff #54 confirmed that registration staff was responsible for the initial delivery of the IM. Staff #54 stated the errors on the initial delivery of the IM on Patient #s 31, 33, and 34 had all been processed by the same person. Staff #54 stated the staff member that had made the mistakes was new and was to be re-educated on the process.

B. Tour of the facility was conducted on 9-19-2016 with Staff #7. State required posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at 3 of 3 entrances/waiting areas (Entrance/Main Lobby Gaslight Boulevard, Entrance/Lobby Loop 287, and Ambulance Entrance/Emergency Room Waiting). Staff #7 confirmed that the postings were missing.

C. Review of Patient Admission Forms was conducted. The "Patient Rights and Responsibilities ADM-1901 GHMS-TX" on page 2 of 2 stated:

"You also have the right to:

Lodge a concern with the state, whether you have used the hospital's grievance process or not. If you have concerns regarding the quality of your care, coverage decisions or want to appeal a premature discharge, contact the State Quality Improvement Organization (QIO) ....

If you have a Medicare complaint you may contact

Texas Department of State Health Services

Phone: (512) 834-6700"

Review of the Patient Guide, given to patients upon admission, contained the following information on page 24:
"Regarding Problem Resolution, You Have the Right To:

Express your concerns about patient care and safety to hospital personnel and/or management without being subject to coercion, discrimination, reprisal or unreasonable interruption of care; and to be informed of the resolution process for your concerns. If your concerns and questions cannot be resolved at this level, contact the accrediting agencies indicated below:"

This also lists the phone number for the Texas Department of State Health Services as (512) 834-6700.

An attempt to call the number provider was made with Staff #3 present. The phone number provided was for the Emergency Medical Services (EMS) group. There was an automated response that provided different options to contact various EMS related services. The only option for filing a complaint was for EMS services and not hospital provided care. Staff #3 confirmed this.

36827


Based observation, record review, and interview, the facility failed to:

A. secure 2 of 2 areas where the acid concentrates are stored to prevent tampering.

B. ensure that medical record entries that were documented by the nursing staff were legible and if changes were made to the legal health record, the changes were made according to the facility policy. A review of legal records revealed 8 of 8 records were illegible or corrections were not made to the record per the facility policy. Also, the facility's policy was not followed for Changes to the Legal Health Record.


C. provide clean carts that carry the portable RO (Reverse osmosis for water purification) system to the patients' bedside in different nursing areas of the hospital and provide clean storage areas for the patient dialysis supplies, equipment, and the acid/bicarbonate products.

These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to unsafe dialysate, providing legible documentation in the legal health record, and failure to provide clean dialysis equipment to the patients.


Findings included:


A. During a tour of the dialysis storage areas where acid concentrates are stored noted the door was a key-code. The unit manager was asked what personnel have access to the key-code. The unit manager stated, "That managers of different departments, housekeeping, and certain nursing staff have the key-code." Also, observed in one of the storage areas was a rack of six 5 gallon water containers. Staff #8 was asked does this mean the water supply company has access to the storage area too. Staff #8 stated, "I don't know."

An interview with the Unit Manager and Staff #8 confirmed that multiple hospital staff have access to the dialysis storage areas.

B. A review of water treatment log for the months of April through August of 2016 revealed numerous mark overs of dates, times, results of total chlorine test performed, drain lines secured, and time RO system was turned off.


A review of Machine/Infection log for the months of April through August of 2016 revealed numerous mark overs of dates, Hepatitis antigen results, and results of residual peracetic acid, residual bleach check, and time machine disinfected.


A review of Patient #1's record revealed 9 write overs and one of the sentences documented in the legal record was completely obliterated by a solid black line. There was no way to know what was to be documented in the legal record. The write overs consisted of vital signs, lot numbers of dialyzes and tubing, dialysis machine rates, and condition of the patient during intradialytic monitoring of the patient.

A review of Patient #2's record revealed 3 write overs and one the times was highlighted in yellow. Staff #8 was asked why the time was highlighted in yellow. Staff #8 stated, "I have no idea, unless it was to remind him to document his time."

A review of the policy titled, "Changes to the Legal Health Record" revealed the following:

"PURPOSE: The purpose of the health record is to provide a basis for planning patient care and for the continuity of such care. Each record should provide documentary evidence of the patient's medical evaluation, treatment, and change in condition as appropriate. The purpose of this policy is to provide guidance on the instances in which a correction, amendment, addendum, deletion or retraction of information is necessary to support the integrity of the health record.

II. DEFINITIONS:
A. Correction - a change to the information meant to clarify inaccuracies after the original document has been signed or rendered complete.
B. Amendment - a document or entry meant to clarify health information within the legal health record. An amendment is made after the original documentation has been completed and signed by the provider.
C. Addendum - a new document or entry used to add information to an original entry.
An addendum is made after the original documentation has been completed and signed by the provider.
D. Deletion - eliminating information from previously signed and closed documentation without substituting new information.
E. Retraction - correcting information that was incorrect, invalid or made in error by preventing display or hiding the entry or documentation from future general view.
F. Late Entry - documentation that is entered after the point of care.

III. POLICY: Providers documenting on paper and within the EHR must avoid indiscriminate use of correction, amendment, addendum, deletion, and retraction functionality as a means of documentation. All attempts to correctly identify patients and their medical conditions should be made prior to documenting within the record.

IV PROCEDURE: Note - please consult applicable state law for further guidance
A. Correction -
a. Electronic records- depending on the system certain administrative members may have access to "unlock" the signed document for the provider to make the correction. If this functionality is not available, an amendment or addendum will need to be utilized.
b. Paper records- draw a single line through the error, initial date and time the entry..."

An interview with Staff #8 on 09/19/2016 at 3:00 PM confirmed the above findings of changes to the legal record and not following the facility policy.

C. During a tour of the dialysis 2 store rooms on 09/19/2016 at 11:00 AM with Staff #8 and Staff #39 the following infection control issues were observed:

First Dialysis Storage Room:

1. In the first dialysis room observed "Four Monks" cleaning Vinegar x 12 jugs stored on a pallet underneath the dirty medical hopper sink. The hopper sink had dirty ring around the water line. The hopper sink had very unclean appearance. The cleaning vinegar was being used to rinse the dialysis machines after bleaching process.

2. The molding around the floor of the dialysis room was missing and tubing of some sort was lying on the dirty floor.

3. The cabinets in the first dialysis room would not close because the cabinets were full of supplies and plastic containers. There were numerous used blood pressures cuffs lying on the bottom shelf and falling out of the cabinet on to the dirty floor. There was stack of extra plastic lids lying on the counter. The counter had missing strips of molding, which caused exposed porous particle board wood to be showing and unable to clean. The bottom shelf of the cabinet was porous wood and patient supplies were being stored on the exposed wood.

4. The floor had dirty and discolored appearance with dust and trash particles.

Second Dialysis Storage Room:

1. The second storage room had eight 5 gallon water containers being stored with the dialysis supplies and equipment giving access to the acid concentrate and patient dialysis sterile supplies from the water company that delivers water to the facility.

2. The carts that held the portable RO systems #2, #5, and #6 were dirty, rusted, and had trash particles on the bottom shelf beside the tanks. The carts holding the RO system were used to dialyze patients at the bedside in different nursing areas of the hospital.


An interview with the Unit Manager (Staff #39) and Staff #8 confirmed that multiple hospital staff have access to the dialysis storage areas.

36827

Based on review and interviews nursing failed to;


Based on review and interviews nursing failed to;


A.) to provide a clear staffing plan or grid to ensure safe nurse to patient ration was provided in 6 ( Medical/ Surgical, Medical/ Telemetry, Intensive Care Unit, Emergency Department, Nursery, and Obstetrics) out of 6 patient units.

Refer to Tag A0392

B.) ensure non-employee licensed nurses providing care in the emergency department to sexual assault victims were properly contracted, credentialed and supervised.

Refer to Tag A0398

C.) follow policy and procedures to ensure blood and blood products, were administered to the patients in a safe manner, in 3(#55, 22, and 19) out of 3 patient charts and 17 out of 20 transfusion records reviewed.

Refer to Tag A0409

Based on record review and interviews nursing failed to provide a clear staffing plan or grid to ensure safe nurse to patient ratio in 6 ( Medical/ Surgical, Medical/ Telemetry, Intensive Care Unit, Emergency Department, Nursery, and Obstetrics) out of 6 patient units.
Review of the nurse staffing revealed the facility uses a staffing grid with budgeted full-time equivalents (FTE) and Manhours/Stat. The grid only refers to FTE's and does not distinguish between licensed and unlicensed staff. There is no clarification of RN's and LVN's. Due to the staffing based on FTE's and not nurse/patient ratio it was unclear if staffing was adequate to meet patient care needs.
An interview was conducted with staff #37 and staff #3 on 9/22/16. Staff #37 reported that the staffing is done to the budget grid of FTE's. Review of the staffing grid revealed there was three shifts 7:00AM-3:00PM, 3:00PM-11:00PM, and 11:00PM-7:00AM. Staff #3 reported that they don't have three shifts. Staff #3 stated they have 2- 12 hour shifts 7:00AM-7:00PM and 7:00PM-7:00AM. The grid had not been updated to the 2-12 hour shifts. Staff #3 stated that have been on 2-12 hour shifts for several years now. Staff #37 was asked how she knows the staffing is at a safe level for nurse/pt. ratio, patient acuity, anticipated discharges, and admissions. Staff #37 stated, "I just know." Staff #37 was asked again where she got that information or was it just a guess. Staff #37 stated,"Well, I'm not sure, I just know. I guess you could say it looks like a guess but we just know."

Review of the policy and procedure "Plan for Patient Care: Telemetry Unit Staffing Plan" stated, "Budgeted Man Hours/Stat 10.23
2. Staffing is accomplished through coordinated scheduling by Nurse Manager with input from staff and charge nurses. Staffing may be adjusted by the house supervisor form staff input based on the patient care requirements and census."

Review of the policy and procedure "Plan for Patient Care: Women's Services" stated, "Staffing Plan: 1.) Standard 6.95 man hours/stat
2.) Shift Distribution: 7 a.m-7p.m 50%, 7p.m-7a.m 50% "

Review of the policy and procedure "Plan for Patient Care: Emergency Department" stated, "Staffing is planned to provide for an average daily census of 64 patients per day with 19.97 FTE's."

An interview with staff #34 on 9/21/16 revealed the ICU patient nurse ratio was usually 1 RN to two patients and on occasion 1 RN for three patients. Staff #34 stated, "If it looks like the acuity is changing on my patients or I'm getting a fresh heart patient, and I need more help, I just get on the phone and start calling people in." Staff #34 reported that he has been given the ability to adjust his schedule. Staff #34 stated they schedule to the FTE's but he just "knows" how many he will need.

Based on review of documents and interview, the director of nursing service failed to ensure non-employee licensed nurses providing care in the emergency department to sexual assault victims were properly contracted, credentialed and supervised.

Review of the Sexual Assault Nurse Examination (SANE) program revealed that no hospital nursing staff were certified as SANE nurses.

Interview was conducted with Staff #44 revealed that SANE examinations were provided by nurses employed with an outside provider. Sometimes the nurses came to the emergency department to complete the examination. Sometimes the nurses requested the patient be sent to outside provider location.

Interview with Staff # 7 was conducted. Staff #7 stated there was not a contract with the outside provider for these services. Staff #7 stated that there were no policies concerning SANE exams since the hospital did not conduct the exam. Staff #7 stated there were no credentialing files on the nurses who came in to the hospital to examine the sexual assault patients.

Based on chart review and interview nursing failed to follow policy and procedures to ensure blood and blood products were administered to the patients in a safe manner, in 3(#55, 22, and 19) out of 3 patient charts and 17 out of 20 transfusion records reviewed.

1.) Review of patient #55's chart revealed the following;
A.) blood was ordered on 9/19/16 at 2255 (10:55PM). Review of the transfusion record revealed the "Order Verified" box had not been checked. There was no evidence found on the transfusion form that the physician order was checked by the nurse.
B.) The transfusion form stated, "Transfusion MUST begin within 30 minutes of removal from Blood Bank"
The policy and procedure "Blood Component Transfusions" stated, "#6 Administration of blood or blood components should be initiated within 15 minutes after obtaining blood from the laboratory." The blood was picked up from the lab on 9/19/16 at 2255 (10:55PM), however, the blood was not started until 2315 (11:15PM) 20 minutes after received from the lab. According to the policy and procedure the blood administration was started 5 minutes late.

An interview with staff #7 on 9/22/16 revealed that all nursing procedures should follow the policy and procedures.

2.) Review of patient #22's chart revealed the patient had an order for a blood transfusion on 9/19/16. On the transfusion record in the vital signs section, the nurse marked over a previous time that was put down on the "one hour after start" time. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.

3.) Review of patient #19 revealed the following issues on the blood transfusion records:
C.) 9/8/16 at 1243 (12:43PM) and 9/18/16 at 1418 (2:18PM) the signatures of the person accepting the blood from the lab and both verifier signatures and disciplines (Registered Nurse RN or Licensed Vocational Nurse LVN) were illegible.
D.) 9/8/16 at 2224 (10:24PM) the nurse failed to initial, date, and time the "Transfusion Stopped:" section.
E.) 9/9/16 at 0616 (6:16AM) the 2nd verifiers signature and discipline was illegible.
F.) 9/10/16 at 0215 (2:15AM) the 2nd verifiers discipline was illegible. The nurse failed to date and time the "Transfusion Stopped:" section.
G.) 9/10/16 at 0100 (1:00AM) the initial pre-transfusion pulse was written over another number leaving the pulse number illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
H.) 9/10/16 at 1420 (2:20PM) On the transfusion record in the vital signs section, the nurse marked over a previous time that was put down on the "one hour after start" time.
I.) 9/10/16 at 1843 (6:43PM) the signatures of the person accepting the blood from the lab and both verifiers signatures and disciplines (RN or LVN) were illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
J.) 9/10/16 at 2301 (11:01PM) the blood was picked up from the lab on 9/10/16 at 2301 (11:01PM); the blood was not started until 2330 (11:30PM) 29 minutes after received from the lab. According to the policy and procedure the blood administration was started 14 minutes late. The 1st verifier signature and discipline was illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
K.) 9/11/16 at 2152 (9:52PM): the signatures of the person accepting the blood from the lab and 2nd verifier signature and discipline (RN or LVN) was illegible. The pre-transfusion vital sign time, 15 min after start and 1 hour after start times were marked over, leaving the times illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
L.) 9/11/16 at 2017 (8:17PM) the blood was picked up from the lab on 9/11/16 at 2017 (8:17PM). The blood was not started until 2040 (8:40PM), 19 minutes after it was received from the lab. According to the policy and procedure the blood administration was started 8 minutes late. The 1st verifier discipline was illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
M.) 9/12/16 at 2324 (11:24PM): discipline of the person accepting the blood from the lab and 2nd verifier discipline (RN or LVN) was illegible. The pre-transfusion vital sign time was marked over leaving the time illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
N.) 9/12/16 0842 (8:42AM): the nurse failed to have two signatures for verification of blood before transfusion. Only the second verifier was on the form. Administering blood products and failing to have two nurses verify the patient's name, medical record number, arm band, DOB, blood type, donor's number, and expiration dates and times could cause serious injury and possible death. The blood was received from the lab at 8:42 AM and not started till 9:00AM. The blood administration was 3 minutes late.
O.) 9/12/16 at 0316 (3:16AM): the 2nd verifier signature and discipline was illegible. There was no blood pressure documented on the pre transfusion section. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
P.) 9/13/16 at 0043 (12:43AM): The date the blood was picked up from the lab was marked over another date. The nurse failed to strike through the error, initial, and write the correct date. The 2nd verifier's signature and discipline was illegible. The nurse failed to initial, date, and time the "Transfusion Stopped:" section.
Review of the policy and procedure " Changes to the Legal Health Record" stated, "Paper records- draw a single line through the error, initial date and time the entry."
Q). 9/19/16 at 1325 (1:25PM): the nurse failed to have two signatures for verification of blood before transfusion. Only the second verifier was on the form. Administering blood products and failing to have two nurses verify the patient's name, medical record number, arm band, DOB, blood type, donor's number, and expiration dates and times could cause serious injury and possible death. The blood was received from the lab at 8:42 AM and not started till 9:00AM. The blood administration was 3 minutes late.

Review of the policy and procedure "Blood Component Transfusions" stated, "Policy #5 All blood and blood products must be checked at patient's bedside by two nurses (one of which is an RN), CPP, or physician, also known as the transfusionist) before transfusing. Together they must check the patient's name, date of birth, hospital account number and/or medical record number, blood unit number, blood type, blood expiration date, individual key transfusion/BBID number, physician's original order, and patients arm band.
#6 Administration of blood or blood components should be initiated within 15 minutes after obtaining blood from the laboratory.
#8 Blood transfusions must be completed within 4 hours after it has been issued from the Blood Bank.
Procedure:
C. Check blood/blood component with a registered nurse at the bedside immediately prior to initiating the transfusion. Together they must check the patient's name, date of birth, medical record number, blood unit number, blood type, blood expiration date, key transfusion/BBID number on blood arm band, blood bad tag, and physician's original order. The blood bag tag attached to the unit with the patient's information, patient's blood type, compatibility results, and key transfusion/BBID number must remain attached to the unit and never removed outside of the blood bank. Both nurses must sign the transfusion form.
D. record vital signs and document on these on the transfusion requisition.
K. Stay with patient and monitor for signs of reaction for the first 15-30 minutes.
L. Monitor vital signs once the transfusing has begun, vital signs must be taken 15 minutes from the start time and recorded on the transfusion form in appropriate area.
P. Vital signs must be recorded in the post vital signs area of the transfusion requisition form taken 30 minutes to 1 hour post transfusion of the blood product.
T. Complete the data requested on the transfusion record and lab requisition."