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Based on facility policy review, medical record review, and interview, the facility failed to follow safe patient identification process when obtaining arterial blood gases (ABG's) for 3 of 8 specimen collections for Patient #2.

The findings include:

Review of a laboratory policy dated 4/7/2015, showed steps to properly identify the patient prior to a blood draw to include "...Check the marker board or for other notes for pertinent information and/or restrictions, such as 'no sticks in left arm'..."

Patient #2 was admitted to the facility on 9/13/2021 with diagnoses of Shortness of Breath and a recent diagnosis of COVID-19. Past medical history included Chronic Obstructive Pulmonary Disease, Pneumonia, Emphysema, History of Pulmonary Embolism, Coronary Artery Disease, Heart Attack, Hypertension, and Breast Cancer. Further review showed Patient #2's surgical history included a Left Mastectomy.

Review of Patient #2's ED (Emergency Department) Visit Data dated 9/13/2021, showed the ED physician documented "...Left Breast CA [Cancer]/Mastectomy involving lymph nodes-about 20 years ago... No needle sticks, BP's [blood pressures] in left arm..."

Review of a Nursing Admission Assessment dated 9/16/2021, showed Patient #2 was identified as having a history of breast cancer and a left mastectomy.

Review of Patient #2's orders dated 9/13/2021 - 10/14/2021 showed no order had been obtained for blood draws from the left arm.

Review of the Respiratory Therapy Interventions /Assessments documentation dated 9/26/2021 - 10/14/2021, showed ABG's were drawn 8 times during Patient #2's hospital stay. On 10/3/2021 at 5:20 AM and 10/7/2021 at 11:43 AM, the blood gas location was documented as "Left Brachial" and on 10/10/2021 at 5:09 AM, the blood gas location was documented as "Left Radial". Continued review revealed during the 3 ABG blood draws, no swelling, bleeding, pain, numbness, or tingling was identified at the site.

During a telephone interview on 3/7/2022 at 7:26 PM, Patient #2's daughter stated her mother had a history of a left mastectomy and was to receive no blood pressures or sticks in the left arm. A sign had been placed above Patient #2's hospital bed stating these restrictions. She further stated she visited her mother (Patient #2) on 10/7/2021 and observed "band aids and cotton balls on her wrist and in the bend of her left arm where blood had been drawn."

During an interview on 3/8/2022 at 2:15 PM, Hospitalist #1 confirmed Patient #2 had a sign posted above her bed stating no sticks or blood pressures in the left arm. Hospitalist #1 recalled the difficulty in obtaining blood from Patient #2, but would expect an order be obtained prior to using the left arm for blood draws. During continued interview Hospitalist #1 stated Patient #2 suffered no negative outcomes from the ABG's drawn from left arm.

During an interview on 3/8/2022 at 3:35 PM, the Quality Manager confirmed Patient #2 had been identified as having a history of a left mastectomy with no blood pressures or sticks to be performed in the left arm. The Quality Manager further confirmed the Respiratory Therapy Interventions /Assessments documentation showed 3 ABG's were drawn from Patient #2's left arm.