HospitalInspections.org

Based on review of two (Patient #1 and Patient #6) of 11 sampled patients, the Hospital failed to: 1) follow Patient #1's informed decision that he/she was not to receive a blood transfusion and 2.) ensure that Patient #6 had a properly informed consent for transfusion of blood and blood products.

Findings include:

The Surveyor interviewed Nurse #1 at 9:50 A.M. on 3/21/16. Nurse #1 said she reported by telephone to the Hospitalist that Patient #1's blood count was low. Nurse #1 said the Hospitalist gave an order to administer blood to Patient #1. Nurse #1 said the Hospitalist asked about obtaining an informed consent from Patient #1. Nurse #1 said she told the Hospitalist that Patient #1 had surgery the day before and a surgical consent included the consent for blood administration.

The Surveyor interviewed the Hospitalist at 9:30 A.M. on 3/21/16. The Hospitalist said Patient #1 was blind and hard of hearing and because he/she had a low blood count he wanted to transfuse Patient #1 with a unit of blood. The Hospitalist said he knew he had to get consent and discussed that with the nurse. The Hospitalist said he was told by the nurse that the surgical consent contains consent for blood transfusions. The Hospitalist said he attempted to reach family members by telephone to discuss the plan for the blood transfusion and had three unsuccessful attempts trying to reach family members. The Hospitalist said he did not review Patient #1's informed Surgical Consent.

Patient #1's Surgical Consent, dated 12/22/15, indicated consent for a surgical procedure; however, item #10 on the Informed Surgical Consent Form indicated that Patient #1 imposes no specific limitations or prohibitions regarding treatment other than Patient #1 was a Jehovah Witness and no blood transfusions were to be administered even if this results in death.

The Hospital's Surgical Consent for the surgical patient to receive blood after surgery was not time limited.

The Director of Quality Resources was interviewed at 8:30 A.M. on 3/21/16. The Director of Quality Resources said the intent for after surgery meant in the post anesthesia care unit, immediately after surgery. However, there was a belief or understanding by some of the hospital nurses that the time included any time after surgery.

The Surveyor interviewed Nurse #2 at 2:00 P.M. on 3/21/16. Nurse #2 said she was called by Nurse #1 and was informed Patient #1 was to have a blood transfusion and was asked if she could administer the transfusion during dialysis. Nurse #2 said that Nurse #1 reported that Patient #1 had been to the Operating Room the previous day, and had the signed consent. Nurse #2 said she looked at the consent but did not read Patient #1's surgical consent. Nurse #2 said she and Nurse #1 confirmed the blood type together and she then transfused Patient #1 with the blood. Nurse #2 said the Surgical Informed Consent for a blood transfusion was good for 3 days after surgery.

The Director of Quality Resources was interviewed at 8:30 A.M. on 3/21/16. The Director of Quality Resources said on review of the blood transfusion incident, it was discovered there were varying interpretations of what "after surgery" meant. All of the Hospital's procedures related to blood transfusions are in the the process of being reviewed. The Director of Quality Resources said that the nursing staff were informed by their nurse managers of the intent of "after surgery." However, on 3/21/16, the Surveyor observed that Patient #6, a surgical patient, had a blood transfusion on post operative day #1 and a surgical informed consent was used, not the consent for a blood transfusion as indicated.

For Patient #6, the surgical consent was signed on 3/11/16 and Patient #6 had surgery on 3/11/16. Patient #6 had a blood transfusion on 3/12/16 and 3/15/16 and there was no informed consent for a blood transfusion except for the surgical consent in the medical record.