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Based on interview and record review, the facility's nursing staff failed to identify the site location of blood collection in 1 of 2 sampled patients. Patient #1



Findings:

Patient #1

Reviewed laboratory orders for Patient #1 on 05/06/2015 including CBC (Complete Blood Count). Order details stated "Blood, Stat Collect, Collection Date 05/06/2015 13:10 CDT, Nurse Collect." No further information about the location of blood collection.

Interview with the Assistant Chief Nursing Officer (2) on 09/10/2015 at 09:35 a.m., the Surveyor notified her that blood collection for Patient #1 has no specific location in the documentation; she said " We do not have it here, but the name of the nurse and time of collection is shown. "

Interview with the Director of Nurse Informatics (4) on 09/10/2015 at 09:45 a.m., the Surveyor notified her that blood collection for Patient #1 has no specific location in the documentation; she said " Our records cannot identify exactly how it was collected."


Facility Policy reviewed about Facility Policy was reviewed about Phlebotomy # 15.01 " Page 1 Objective: To safely obtain appropriate blood samples from a properly identified patient. Page 5 Documentation: On documentation tool, note specimen collection, date, time and date and time of collection. Note any specifics as to how and where the specimen was obtained."