HospitalInspections.org

Based on policy and procedure review, medical record reviews, staff and physician interviews, the facility failed to complete documentation of informed consent for a patient receiving blood in one of three patients' medical records reviewed requiring an informed consent for blood.

Findings included:

Review of the policy titled "Blood Administration" revised 04/04/2017, revealed "...Procedure B: ..3. ...This consent is an informed consent and the physician must explain the benefits and risks to the patient ..."

Closed medical record review on 04/13/2022 of Patient #7 revealed a 67 years old female patient was admitted for shortness of breath, and found to have a low blood count, that resulted in a blood transfusion during hospitalization. Review revealed a physician order for one unit of blood on 04/04/2022 at 0937. Review revealed the consent for administration of blood/blood products was signed by Patient #7 and RN (Registered Nurse) #1 on 04/04/2022 at 0737. The consent included "I, Dr._______ have explained the procedure, including the risks, benefits, and alternatives to the above patient or responsible person regarding the planned procedure. _______________ Signature of Physician." Review revealed no name or signature of the physician on the consent form signed by Patient #7 and RN #1. Review revealed the one unit of blood was initiated on 04/04/2022 at 1312 and completed at 1642.

Interview on 04/13/2022 at 1140 with RN #1 revealed she was the primary nurse during the blood administration for Patient #7. Interview revealed "a lot of education" was provided to the patient from the prior shift and during her shift. Interview revealed she had requested the physician talk with the patient regarding concerns with the blood transfusion and after that occurred the patient accepted the transfusion and signed the consent. Interview revealed at times it was "difficult to get the consents for blood transfusions signed" by the physicians. Interview revealed the benefits and risks were to be explained to the patients by the physicians prior to nurses administering blood products. Interview revealed "I felt the risks and benefits had been discussed" with Patient #7 by the physician. Interview revealed it was the nurse's responsibility to ensure the consent was completed prior to the blood administration.

Interview on 04/13/2022 at 0900 with Physician #2, primary physician for Pt # 7 on 04/04/2022, revealed she recalled explaining the risks and benefits to the patient in depth. Interview revealed "Sometimes I sign the consent. I don`t specifically write in my notes the risks and benefits were explained. As a provider discussing the blood transfusion with the patient is the expectation. I do not know the policy specifically."

Interview on 04/13/2022 at 1140 with the CNO, revealed confirmation of the requirement of the physician signature on the consent and nursing responsibilities of ensuring consents were completed prior to the blood administration. Interview revealed the policy was currently awaiting a new revised date. No changes to the current policy was provided.

Based on review of the procedure, observations during tour and staff interview, facility staff failed to date and label open containers of food and failed to remove expired food items from the refrigerator units in the dietary department in one of one dietary departments toured.

The findings include:

Review on 04/13/2022 of the "Sodexo's Food Safety Management System" with a revision date of 01/28/2022 revealed "Product Description" listed Mayonnaise: Opened 2 to 3 months....Horseradish : 4 to 6 months."

Observation during tour of kitchen on 04/13/2022 at 0850 revealed a one gallon plastic jug labeled Mayonnaise with less than one half of Mayonnaise remaining. Observation revealed no label with an open date or expiration date. Observation of a gallon plastic jug labeled Horseradish with one-fourth remaining with a label with an illegible opening and expiration date.

Interview on 04/13/2022 at 0915 with Dietary General Manager #3 (GM) revealed foods should be thrown out if unsure of date opened. Interview revealed dates were missing on the Mayonnaise. The interview revealed there were illegible dates on the label of the Horseradish. Interview revealed the food safety guidelines were not being followed.

NC00180254; NC00179491; NC00179441; NC00182266; NC00185590