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Based on observation, interview, and record review, the facility failed to ensure there was an organized nursing service. The facility failed to ensure:

A. anti-coagulants were administered in accordance to the facility's policies and protocol in 2 of 3 sampled patients reviewed for intravenous Heparin therapy (Patient's 17 and 20).

B. nurses followed their policies and protocol on collecting lab timely to determine rate of administration of medications.


Refer to Tag A0405 for additional information.


C. nurses identified signs and symptoms of a possible blood/blood products transfusion reactions in Patient #'s 1 and 15.

D. nurses obtained post-transfusion vital signs per their policy in Patient #'s 1 and 15.

E. nurses obtained and followed physician orders for blood/blood product transfusion rates. in Patient #'s 15 and 21.

Refer to Tag A0410 for additional information.

Based on observation, interview, and record review, the facility failed to ensure anti-coagulants were administered per physician orders and their procedures in 2 of 3 sampled patients reviewed for intravenous Heparin therapy (Patient's 17 and 20).

This deficient practice had the likelihood to cause harm in all patients who were on Heparin therapy.

Findings include:

During an interview on 10/14/2024 after 12:42 p.m., Staff #16 (Registered nurse/RN) stated that the nurses were responsible for drawing their own blood on the Progressive care unit (PCU). If after two sticks, they completed a form and sent it to the lab so lab could send a phlebotomist up to the floor. Staff #16 (RN) stated the only thing that causes delays is that the lab labels print out in Intensive care unit (ICU). ICU sends the lab labels up to them, but they are old and past the due time. Staff #16 (RN) said the printer on their unit has never worked. There was push back from the night nurses because they got all the morning labs to draw.

After 1:09 p.m., Staff #16 (RN) showed the surveyor the printer in ICU. There were an approximate 4-foot strip of labels hanging from the printer that was touching the floor. Some of the following PCU patient's labels were found:

Patient #20 had a Heparin XA label that was to be drawn at 8:18 a.m.
Patient #17 had a Heparin XA label that was to be drawn at 10:45 a.m.
Heparin XA is a lab test to determine how much heparin is in the blood stream and used to adjust the rate of therapy.

During an interview on 10/14/2024 after 1:20 p.m., Staff #21 (lab director) stated the nurses had been drawing blood since November 2023. The nurses always late and the mornings are the worst. The morning lab results should be in the chart by 8:00 a.m... Timed labs should be around the time the lab is put into the computer and depending on the medication. Staff #21 (lab director) said she allows 15 before or 15 minutes after for timed labs.


Patient #20

Review of an emergency department (ED) record revealed that Patient #20 was a 66-year-old female who presented to the facility on 10/11/2024. Patient #20 had a chief complaint of chest pain.

Review of physician orders revealed Patient #20 was admitted to the PCU unit on 10/12/2024. Review of the orders revealed Patient #20 was started on the anti-coagulant Heparin in 0.45 percent sodium chloride, 25,000 units. It was written to start at 1:00 a.m. STAT (immediately), titrate (prn) and to follow hospital protocol.

According to the "Drips Titration Log" Patient #20's starting dose was 700 units per hour at 1:49 a.m. on 10/12/2024. There was documentation on the log that nurses were to dose every 6 hours per XA results. There was documentation that the next XA was due at 7:49 a.m. and that the order was placed in the system.

According to lab reports Patient #20 had a Heparin XA timed order for 7:50 a.m., collected 10:33 a.m. and received 10:43 a.m. and released at 11:05 a.m. (over 3 hours later after the time due). The results were .31 (reference ranges 0.30-0.70.

The next documentation on the "Drips Titration Log" was at 11:00 a.m. where nursing documented a XA lab result of 0.31 and that the next XA was due in 6 hours. Staff failed to document what the Heparin was running at 11:00 a.m...

According to lab the next Heparin XA timed was ordered for 5:00 p.m., collected 4:30 p.m. and received 4:35 p.m. and released at 4:56 p.m. The results were low at .20 (reference ranges 0.30-0.70).

The next documentation on the "Drips Titration Log" was at 5:00 p.m. when the Heparin was increased by 50 units.

According to the "Drips Titration Log" on 10/13/2014 there was documentation for 6:09 a.m. and 12:40 p.m.
At 12:40 p.m. there was no need for titration because the lab results were .33 and according to the Heparin protocol there was no rate change. There was documentation on the titration log that there would be an XA in 6 hours.

According to lab a Heparin XA timed was ordered for 6:30 p.m., collected 7:30 p.m. and received 7:38 p.m. and released at 7:59 p.m. The results were low at .26 (reference ranges 0.30-0.70). The intervention for this lab result was documented on the "Drips Titration Log" at 8:08 p.m. (over 1.5 hours late). At this time the Heparin was increased by 50 units.

Review of lab results dated 10/14/2024 revealed there were Heparin XA levels for 2:08 am and 8:18 a.m. The lab for 8:18 a.m. was ordered at this time, collected over an hour later at 9:20 a.m., received at 9:37 a.m. and released at 10:16 a.m.

Review of the ""Drips Titration Log" on 10/14/2024 after 3:00 p.m., revealed no documentation of what the rate of the drip, changes, or lab results for this day so far.

During an interview on 10/14/2024 after 3:00 p.m., Staff #17 (RN) confirmed the missing information on the forms.



Patient #17

Review of the emergency department (ED) record revealed that Patient #17 was a 60-year-old female who presented to the facility on 10/13/2024. Patient #17 had a chief complaint of chest pain.

Review of physician orders revealed Patient #17 was admitted to the PCU unit on 10/13/2024. Review of physician orders revealed Patient #17 was started on the anti-coagulant Heparin in 0.45 percent sodium chloride, 25,000 units. The order was written at 12:30 p.m. and staff were to titrate (prn) and follow the facility's acute coronary syndrome protocol 50 units per milliliters concentration.

According to the "Drips Titration Log" Patient #17's starting dose was 1000 units per hour at 2:00 p.m. on 10/13/2024. There was documentation on the log that staff would titrate every 6 hours per protocol.

On 10/13/2024 at 8:24 p.m., the Heparin was on standby because the Heparin XA was elevated at 1.11.
According to the facility's "Low Dose Acute Coronary Syndrome" Heparin protocol staff were to stop the dose for 6o minutes and decrease by 3 units per kilograms per hour and repeat the XA in 6 hours.

According to the "Drips Titration Log" Patient #17's Heparin was started back up on 10/13/2024 at 9:30 p.m. and the drip was decreased by 3 units.

The next Heparin XA was due on 10/14/2014 at 3:30 a.m.

On 10/14/2024 at 4:45 a.m. (1 hour and 15 minutes later) the Heparin was decreased because of a Heparin XA of .80.

The next Heparin XA and dose change was supposed to be 6 hours later according to the facility's "Low Dose Acute Coronary Syndrome" Heparin protocol. The next timed lab and dose monitoring should have been 10:45 a.m... There was nothing documented for 10:45 a.m. on the "Drips Titration Log."

According to lab results a Heparin XA timed was ordered for 10:45 a.m., collected 12:41 p.m. and received 12:59 p.m. and released at 1:46 p.m. The results were low at .24 (reference ranges 0.30-0.70) and the Heparin was increased. The intervention for this lab result was documented 2:15 p.m. on the "Drips Titration Log" which was over 9 hours since the 4:45 a.m. rate change.

Review of a facility's "Request for Phlebotomy Draw" form dated 10/14/2024 revealed documentation the reason for the late Heparin XA draw was a code at 12:00 p.m. Where nursing documented they asked lab staff to draw the lab for them.

During an interview on 10/14/2024 after 3:00 p.m., Staff #17 (RN) confirmed the missing information on the forms.

During an interview on 10/15/2024 after 10:01 a.m., Staff #21 (lab director) stated that nursing had not put in a request for her staff to come up before the code and draw the lab. One of her staff participated in the code and a nurse from the floor asked the lab staff member to draw the blood then. Staff #21 said the lab was due at 10:45 a.m. and it was not collected until 12:41 p.m... Staff #21 stated they were tracking the problems with late morning labs on the unit but did not have a performance improvement on it.


Review of a facility's policy named "Specimen Priority" reviewed 03/2024 revealed:

..." A test is ordered as TIMED when it needs to be drawn at a specified time due to medication, etc. ..."

Based on interview and record review, the facility failed to ensure blood transfusions were administered in accordance with their approved policies in 3 of 21 sampled patients reviewed for blood administration (Patient #'s 1, 15 and 21).

The facility failed to ensure:

A. Nurses identified signs and symptoms of possible blood/blood product transfusion reactions in Patient #'s 1 and 15.

B. Nurses obtained post transfusion vital signs per their policy in Patient #'s 1 and 15.

C. Nurses obtained and followed physician orders for blood/blood product transfusion rates in Patient #'s 15 and 21.



This deficient practice had the likelihood to cause harm in all patients receiving blood transfusions.


Findings include:

Review of a physician's consult note dated 03/26/2024 revealed that Patient #1 was a 36-year-old female who was admitted into the facility with shortness of breath, palpitation, and chest pain.

Review of the clinical record revealed Patient #1 had the following lab results on 03/27/2024 at 5:02 a.m.:

Low red blood cell counts 2.32 of (reference ranges 4.20-5.40).
Low hemoglobin 7.1 of (reference ranges 12-14).
Low hematocrit 20.5 of (reference ranges 37-47).
Low platelets count 18 of (reference range 130-400).

Physician progress notes dated 03/27/2024 revealed Patient #1 was diagnosed with TTP (Thrombotic Thrombocytopenia Purpura, a rare life-threatening clotting blood disorder). According to the progress notes Patient #1 was to receive 2 units of fresh-frozen plasma while waiting for transfer.

Review of a physician's order dated 03/27/2024 at 10:20 a.m., revealed Patient #1 was to receive one unit of fresh frozen plasma as soon as possible.

According to the "BLOOD TRANSFUSION RECORD" dated 03/27/2024 at 12:30 p.m., Patient #1 had a blood pressure of 123/81, pulse of 87, respirations 14 and a temperature of 98.4. At this same time nurses documented starting a unit of fresh frozen plasma. At 12:45 p.m., 15 minutes after the infusion Patient #1's blood pressure dropped to 91/58. The systolic dropped more than 30 mm of Hg (millimeters of mercury).

There was an adverse reaction category underneath the vital signs on the form. Nursing checked Patient #1 had no adverse reaction. One of the symptoms listed to determine a reaction was a decrease in blood pressure of greater than or equal to 30 mm Hg.

There was no documentation of the physician being notified of a possible adverse reaction or a directive as to if nursing was to continue with the transfusion.

According to the "BLOOD TRANSFUSION RECORD" the transfusion was completed at 2:30 p.m. There was a slot on the form for nursing to document a one-hour post transfusion set of vital signs. Post vital signs were not recorded.

During an interview on 10/14/2024 after 4:00 p.m., Staff #17 confirmed the missing physician notification and vital signs.


Patient #21

Review of a physician's history and physical revealed Patient #21 was a 66-year-old female who was admitted to the facility on 10/08/2024 with diagnoses which included congestive heart failure, hypertension, and anemia.

Review of the clinical record revealed Patient #21 had the following lab results on 10/08/2024 at 12:34 p.m.:

Low red blood cell counts of 1.97 (reference ranges 4.2-5.4)
Low hemoglobin of 4.3 (reference ranges 12-14)
Low hematocrit of 17.1 (reference ranges 37-47)
Low platelets count of 64 (reference range 130-400)

Review of a physician's order dated 10/08/2024 revealed Patient #21 was to receive four units of packed red blood cells. The transfusion rate was to run at 75 cc per hour for the first 15 minutes and then 100 cc per hour.

According to the "BLOOD TRANSFUSION RECORD" dated 10/08/2024 at 5:15 p.m., 10/08/2024 at 10:52 p.m.,10/09/2024 at 2:27 a.m., and 10/09/2024 at 6:15 a.m. nursing ran the transfusions at 75 cc per hour for the first 15 minutes but increased them up to 125cc per hour. The physician's order called for the transfusions to be increased to 100 cc per hour.

Review of a physician's order dated 10/09/2024 revealed Patient #21 was to receive two units of packed red blood cells. The transfusion rate was to be 75 cc per hour for the first 15 minutes. There was no rate written for the continuation of the transfusion.

According to the "BLOOD TRANSFUSION RECORD" dated 10/09/2024 at 11:08 p.m. and 10/10/2024 at 2:10 a.m., nursing ran the transfusions at 75 cc per hour for the first 15 minutes but increased them up to 125cc per hour. There was no physician's order for the transfusions to infuse at 125 per hour.

During an interview on 10/15/2024 after 9:00 a.m., Staff #17 confirmed the transfusion orders and rates.




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Patient #15

A review of the medical record for Patient #15 was completed on 10/15/2024 after 9:30 AM with RN Staff #4 and RN Staff #13.


Patient #15 was a 62-year-old male who presented to the Emergency Room (ER) on 10/05/2024 with complaints of chest pain and abdominal cramping with black tarry stools. (black tarry stools are an indication that the patient may be bleeding internally). He had a history of gastrointestinal bleeding. He was admitted to the Hospital on 10/05/2024 in critical condition.

An order was written on 10/06/2024 at 2:27 AM by Physician #22 that read, "Transfuse 2 units PRBCs (packed red blood cells)". There was no rate for the initiation of the blood transfusion in the physician's order.

A review of the transfusion record dated 10/06/2024 at 3:13 AM revealed Unit #1 was started by RN Staff #26 on 10/06/2024 at 3:13 AM. The initial rate of infusion was 75 milliliters (ml) per hour. The blood transfusion was completed on 10/06/2024 at 3:50 AM. Further review revealed the transfusion rate was increased to "999" and given as a rapid infusion on 10/06/2024. There was no time documented when the rate was increased. There was no physician order to increase the rate.

A review of the nurse's note documented by RN Staff #26 on 10/06/2024 at 3:38 AM was as follows: "Physician #22 is recommending that Patient #15's blood be changed to a rapid infusion. Infusion rate adjusted per his instruction".


A review of the transfusion record dated 10/06/2024 at 7:50 AM revealed Unit #2 was started on 10/06/2024 at 7:50 AM by RN Staff #23. The initial rate of infusion was 75 mls per hour. The rate of infusion was increased by RN Staff #23 at 8:50 AM to 125 ml's per hour. The transfusion was completed on 10/6/2024 at 10:15 AM. There was no order to increase the rate of the blood transfusion by a physician in the medical record.

Vital signs were taken at 7:45 AM, 8:00 AM, 8:50 AM, 9:50 AM, 10:00 AM, and 11:00 AM. There were no vital signs documented for 45 minutes after the blood transfusion was completed.

A review of the order dated 10/06/2024 at 5:08 PM by Physician #24 was as follows: "Fresh Frozen Plasma (FFP-a blood product) x 1".

A review of the Transfusion Record dated 10/06/2024 at 8:35 PM revealed the transfusion was started on 10/06/2024 at 8:35 PM by RN Staff #25 and the initial rate was documented as "free flowing". Physician #24 did not order a transfusion rate for the FFP. The transfusion was completed at 9:15 PM.

A review of the order dated 10/06/2024 at 3:28 PM by Physician #28 was as follows: "Fresh Frozen Plasma x 1".

A review of the Transfusion Record dated 10/06/2024 at 6:14 PM revealed the transfusion was started on 10/06/2024 at 6:14 PM by RN Staff #27 and the initial rate was documented as "free flowing". Physician #28 did not order a transfusion rate for the FFP. The transfusion was completed at 6:45 PM.


A review of the order dated 10/07/2024 at 7:39 AM by Physician #24 was as follows; "Transfuse 1 unit of PRBCs at 50 ml's per hour".

A review of the transfusion record dated 10/07/2024 documented by RN Staff #29 revealed the blood transfusion was started at 10:30 AM at 50 ml's per hour as ordered. Further review revealed RN Staff #29 increased the transfusion rate to 125 ml's per hour at 10:45 AM without a physician order.

In an interview on 10/15/2024 after 10:00 AM, RN Staff #4 confirmed there was no physician order to increase the rate of infusion.


An interview was conducted with RN Staff #13 on 10/15/2024 after 9:30 AM. RN Staff #13 was asked when the physician writes an order for a blood or blood product transfusion, was the physician supposed to order the rate of the infusion at the same time. RN Staff #13 stated, "Yes, they are supposed to. It is documented on the actual order for the blood transfusion. There is also a drop-down box for them to write an order for the nurse to increase the rate after 15 minutes". RN Staff #13 confirmed Physician #22 wrote an order to transfuse 2 units of PRBCs on 10/06/2024 at 2:27 AM but failed to include a rate for the transfusion. It was also confirmed by RN Staff #13, that Physician #24 failed to order the rate of infusion for the FFP that was administered to the patient on 10/06/2024 at 5:08 PM.


A review of the facility policy titled; "Transfusion of Blood Products" was as follows:

"Blood Products- Red blood cells, plasma, platelets, cryoprecipitate, albumin, intravenous immune globulin ...

POLICY

A. A provider order is required for the preparation and transfusion of blood products.

B. Informed consent for blood products should be obtained from the patient or legal guardian (unless emergent). Consent should be obtained prior to pre-transfusion testing ABO/Rh if possible. If patient refuses blood products a Release from Liability - Refusal of Blood and Blood Products must be completed ...

K. Transfusions should be administered per provider order, not to exceed the expiration date and time listed on the blood product ....

N. Pre transfusion vital signs should be obtained and documented within the 15 minutes prior to the initiation of the transfusion.

0. Once the transfusion has started, a full set of vital signs should be obtained and documented:
a. 15 minutes after the transfusion begins
b. One hour after the transfusion begins
c. Every hour thereafter during the transfusion
d. At the completion of the transfusion
e. One hour after completion of the transfusion ..."

During an interview on 10/15/2024 after 10:30 AM with RN Staff #4, RN Staff #13, and Physician #7 it was confirmed that all physicians ordering blood or blood products must document in their order the initial rate of infusion and any changes to the rate of the infusion before the blood or blood product administration begins. RN Staff #4 confirmed the order set for blood and blood products does allow the physician to order the rate at the time of the initiation and any changes to the rate of infusion for blood and blood products. RN Staff #13 confirmed the nursing staff failed to follow the facility policy and document the patient's vital signs according to facility policy.