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Based on document review and staff interview, it was determined that the hospital failed to (a) respond to patient grievances in the time frame indicated in their policy and procedure and (b) address and investigate all allegations made by the complainants. This finding was evident in 15 of 20 grievance files reviewed.


Findings include:

The Hospital's policy and procedure titled, "Patient Complaints and Grievances," last revised November 2018, states that the written response to patient grievance would be within 7 days. However, if the grievance is complicated and requires extensive investigation the hospital shall inform the patient or the representative by day seven (7) that the hospital is still working on it.
Formal grievances, both written and verbal will be forwarded to Patient Experience for review and written response.

Review of the hospital Grievance File for January 2019 to June 2019 identified:

Patient #1: On 5/15/19, the Father of a patient sent a follow-up letter to one that he wrote on 4/30/19. In both letters he complained about the care his 2-year-old son received in the Emergency Room; the Social Work Department; not having a radiologist available to read the X-ray; and the patient not receiving pain medication in a timely manner.
On 5/23/19, the hospital wrote the father thanking him for sharing his concerns about his son's experience.
On 7/1/19, the hospital wrote another letter to the father acknowledging receipt of the two letters dated April 30, 2019 and May 15, 2019.

The hospital failed to respond to each written grievance in a timely manner and there is no documented evidence that all allegations made by the complainant were investigated.


Patient #2: On 5/15/19, patient's mother sent an email to the hospital complaining about the care her daughter received in the Emergency Room. She alleged that there was a delay in admitting the patient and that one of the ED Physician was "abusive and neglectful."
On 6/7/19, the hospital wrote a letter to the patient acknowledging receipt of the letter her mother wrote.
There was no documented evidence that the allegations were investigated.


Patient #3: On 2/4/19, the parents of a one-year old child filed a grievance with the hospital, complaining about the care received in the Emergency Room of the Children's hospital.
They stated that their son's heart rate dropped and that a code was called. The patient's mother stated, "the staff was not adequately prepared for the code and it gives them the feeling that the staff did not know what they were doing." The mother stated the delay in "recognizing and conducting" the code contributed to her son's brain damage.
The hospital's written response was dated 4/26/19.

Patient #4: The brother of a patient filed grievances on 5/3/19, 5/6/19 & 5/8/19, regarding his objection to the discharge plan.
On 5/23/2019, the hospital sent a letter to the patient's brother formally acknowledging receipt of the grievances.

Similar findings of untimely response to patient grievance and failure to investigate all allegations, were identified for Patient #5 through Patient #15.


During interview on 7/3/19 at 9:45AM, Staff J, Assistant Director of Patient Relation, stated that it is the hospital's policy to respond to patient's grievance with a written response within 7 days of it receipt. She acknowledged this was not always met.

Based on document review and staff interview, it was determined that the hospital's quality improvement process did not ensure monitoring and analysis of all collected data, specifically in the management of:
1. Blood Bank Events.
2. Patient Complaints/Grievances.


Findings include:

Review of the Blood Bank Events for June 2018 to June 2019 showed that the hospital collected and documented monthly incidents. The data showed no evidence of discussion or analysis of these incidents. For example: Incidents for "Blood-Delay in Testing/Product"
October 2018 - Total 19 incidents
November 2018 - Total 11 incidents
December 2018 - Total 4 incidents
There was no analysis or tracking of the data to determine how the blood delay incidents impacted patient care and there was no documented corrective actions.


Review of the hospital's "Quality and Safety Council" data for Complaint/Grievance, November 2018 to June 2019, showed the number of complaint/grievances for each month. There was no analysis of the data.
Example: The Department of Medicine had complaints as follows:
December 2018, 25 complaints
January 2019, 18 complaints
March 2019, 9 complaints
The hospital did not analyze and track the data and did not review the nature of the complaints.

Review of the "Grievance Issues by Category" for January 1, 2019 to April 30, 2019, showed:
Care/Treatment - 20.6%
Attitude/Courtesy - 13.0%
Communication - 11.5%
Accessibility - 10.7%
Financial - 9.2%
Discharge. 6.9%
There was no analysis or tracking of the data for each category. There was no evidence that the Quality Council evaluated the grievances to identify areas for improvement.

During interview on 7/3/19 at 9:45AM, Staff J, Assistant Director of Patient Relation, acknowledged the findings.

Based on medical record review, document review, observation and interview, it was determined that:
(a) The nursing staff failed to verify and ensure that the correct blood products were administered to patients, in accordance with its policies and procedures.
(b) The nursing staff failed to follow the corrective actions that were identified by the facility for blood transfusion.

Failure to verify the correct blood products for transfusion, resulted in harm to patients.

Findings include:

Review of the medical records identified:
Patient #1 was blood typed O negative and the patient received a unit of A negative red blood cells. His blood pressure deteriorated and attempts to stabilize the patient were unsuccessful. The patient expired.

Patient #2: Baby Boy B, (blood type A positive) was accidentally given O positive blood, for approximately 2 minutes.

Patient #3 received a blood transfusion. Half way through the transfusion, the staff became aware that the patient was getting the wrong unit of blood. The transfusion was stop, and it was calculated that the patient received approximately 200 milliliter of red blood cells of a wrong type.

Patient #9: The surveyor observed the nurse did not follow the process for blood verification prior to transfusion, in accordance with the facility's corrective action plan.


See Tag A 409.

Based on medical record review, document review, observation and interview, in four (4) of ten (10) medical records reviewed it was determined that:
(a) The nursing staff failed to verify and ensure that the correct blood products were administered to patients, in accordance with its policies and procedures.
(b) The nursing staff failed to follow the corrective actions that were identified by the facility for blood transfusion. (Patient #s 1, 2, 3 and 9).

This failure puts patients at risk for transfusion error and patient's harm.

Findings include:

The facility's Policy and Procedure titled " Blood Transfusion Procedures and Regulations. Manual Code: PC-27V " last reviewed 01/18 stated:

B. Verification
2. Blood components should be transfused as soon as possible after receipt of the product on the floor.......
4. Upon receiving the blood components:
Two (2) licensed practitioners (physician, registered nurse, nurse practitioner, physician assistant) one of whom must be the person administering the blood product must verify the following.
b. Patient name, date of birth and medical record number on the medical record matches the name, date of birth and medical record number on the transfusion form.
c. Valid order matching product to be transfused and identifies the length of the transfusion is present.
e. Confirmation that the ABO/Rh of the product being administered matches or is compatible with the patient's ABO/Rh (blood group and positive or negative antigens on the blood cells).

5. The verification process is to be continued at the patient's bedside.
a. Two (2) licensed practitioners, one of whom must be the person administering the blood product (same individual involved in the initial checking of the product) must verify independently the patient's identification. The independent verification process includes: Confirmation that the patient's name, date of birth and medical record number on the transfusion form matches the patient's name, date of birth and medical record number on the patient's ID (identification) band....


Review of the medical record for Patient #1 identified: A 57-year-old male who was transferred to Westchester Medical Center on 5/30/19 at 11:00 PM, for a liver transplant. The patient was admitted to the Intensive Care Unit (ICU) on mechanical ventilator support and treated with multiple blood transfusions. The patient remained in the ICU from 5/31/19 to 6/11/19 and was treated with 74 units of blood products.

The nursing progress note on 6/11/19, documented:

7:25 PM: A unit of Packed red blood cells was initiated, and the patient's blood pressure continue to drop. Medications were administered, and the blood pressure was stabilized.
7:45 PM: The blood transfusion was completed. The empty bag was assessed, and it was noted that the bag was labeled with another patient's identifier. The physician was notified immediately.
8:00 PM: The blood bank was notified, and the empty bag was returned. The patient was monitored, and blood work was done.
8:35 PM - 9:30 PM: The nurse noted the patient's blood pressure continued to drop. The patient received the maximum amount of blood pressure medication.
9: 41 PM: The patient's heart rate was 30 (normal is 60 - 100 beats per minute). An emergency code was called, chest compression was initiated, and defibrillation pads were applied. Medications were administered.
10:02 PM: The family requested to stop CPR. The patient was pronounced.

The documentation in the patient's medical record indicated that the patient's blood type was O negative. The patient received a unit of A- negative red blood cells.

During interview with Staff C, RN, Nurse Manager, and Staff H, VP of Quality and Safety, on 6/28/19 at 2:30 PM, the staff acknowledged that the patient with O negative blood type was given a unit of A negative red blood cells.

Review of the medical record for Patient #2 revealed: Baby Boy B, who was born on 5/19/19 at 9:22 PM and was admitted to the NICU for critical care. The baby's blood count remained low and blood transfusion was ordered.
On 6/19/19 at 8:55 PM, the nursing note documented, that Baby Boy B, (blood type A positive) was accidentally given O positive blood, for approximately 2 minutes. The charge nurse, Medical Director and Blood bank were informed. There was no change in the baby's medical status and no further treatment were ordered.

During interview with Staff I, Director of Quality on 7/1/19 at 11:00 AM, she acknowledged that Patient # 2, twin baby B, was given the incorrect blood transfusion.


Review of the medical record for Patient #3 revealed: On 9/28/19, a 53 y/o male with a history of anemia, iron deficiency, bleeding hemorrhoids, diabetic mellitus and depression, presented to the Outpatient Clinic for a scheduled outpatient blood transfusion. The patient received the first unit of blood without incident. The nursing staff started the second unit of blood and half way through the transfusion, the staff became aware that the patient was getting the wrong unit of blood. The transfusion was stop, and it was calculated that the patient received approximately 200 milliliters of red blood cells of a wrong type. The patient developed nausea, sweating and vomiting several hours later and was admitted to the hospital for observation.
The documentation in the medical record noted the patient's blood type was B negative and the transfusion was B positive that was crossed matched for a different patient.

There was no documented evidence that blood was verified by 2 practitioners before administration.

During staff interview on 7/5/19 at 11:15 AM, Staff A, Quality Manager for the Blood Bank, and Staff Y, M.D., Chief of the Blood Bank and Transfusion, acknowledged that Patient # 3, was given the incorrect blood transfusion at the clinic and there is no documented evidence that 2 (two) nurses verified the blood before administration.


During tour on 6/28/19 at 11:00 AM,to observe the administration of blood transfusion, Staff W, Nurse Manager/ Clinical Nurse Specialist, informed the Surveyor of the facility's corrective actions for blood transfusion.
Staff W stated, the facility's corrective actions for blood transfusion documented that the identification process is a process that involves participation by the patient.

During observation of a blood transfusion on the 7 South/West Unit at 11:00 AM on 06/28/19, Staff V, RN/Registered Nurse, identified Patient #9 by comparing the patient's name, date of birth and Medical Record number from his identification (ID) wrist band to the form attached to the blood component. Staff V, failed to actively involve Patient #9 in the verification process.

Staff W, Nurse Manager/ Clinical Nurse Specialist, who was present at the time of observation, acknowledged that the identification process is a process that involves participation by the patient, and this was done by the nurse.

Staff Z, Nurse Educator, who was also present, acknowledged that the facility's corrective actions for blood transfusion, documented that the identification process is a process that involves participation by the patient. She stated, that staff were trained regarding the process. This process was started 6/20/19. The Surveyor was presented with a document titled, "Patient Identification Attestation," which stated: "The identification process is an active process that involves participation by the patient. The RN ask the patient to state his/her full name and date of birth and compares stated information with name and date of birth on the ID band and with documentation from the patient's chart, label or computerized Physician order entry screen."

The facility did not consistently implement their corrective actions regarding independent patient and blood component verification.