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Based on observation, interview, and record review, the hospital failed to maintain the adequate blood product inventory levels in accordance with its P&P. This failure could potentially lead to the critical blood products being unavailable during the emergency situations, posing the risk to patient safety.

Findings:

Review of the hospital's P&P titled Blood Product Inventory Management dated 7/2/2019, showed in part:

* Purpose/Principle:

- it is the responsibility of the Blood Bank Technologist on all shifts to maintain adequate blood product inventory levels to meet the needs of our patients. To provide adequate supplies of blood for routine and emergency use while minimizing outdating.

* Procedure:

- LifeStream Blood Bank is the primary supplier and is a contracted service for mobile blood drive.

- All orders for stock are to be placed by phone before 0800 am to be delivered between 1100 to 1200 noon; and before 05:00 pm to be delivered between 8:00 - 9:00 pm daily (Monday - Sunday).

- Inventory Levels:

O Pos: Minimum 50 units, Critical 20 units
O Neg: Minimum 20 units, Critical 10 units
A Pos: Minimum 45 units, Critical 20 units
A Neg: Minimum 20 units, Critical 8 units
B Pos: Minimum 15 units, Critical 5 units
B Neg: Minimum 2 units,
Platelets: Aim to keep 6 units available at all times.

- Inventory must be done, every morning, to determine ordering needs.

- Log in must be done, every morning, to determine ordering needs.

On 8/21/24 at 0900 hours, a tour to the hospital's blood bank was conducted and accompanied by the Blood Bank Supervisor.

Review of the blood bank log titled Daily Blood Product Inventory Management dated 8/21/24, showed the following:
* O Pos: available 28 units (out of 50 units; 22 units below minimum inventory level)
* O Neg: available nine units (out of 25 units; 14 units below minimum inventory level)
* A Pos: available 28 units (out of 45 units; 17 units below minimum inventory level)
* A Neg: available three units (out of 20 units; 17 units below minimum inventory level)
* B Pos: available 14 units (out of 15 units; 1 unit below minimum inventory level)
* B Neg: available 0 (out of 2 units; 2 units below minimum inventory level)
* Platelets: available four units (out of 6 units; 2 units below minimum inventory level)

On 8/21/24 at 0900 hours, an interview was conducted with the Blood Bank Supervisor. The Blood Bank Supervisor acknowledged the hospital's P&P for the minimum inventory levels of the blood products was not updated, and the efforts were underway to seek the corporate approval to decrease the minimum inventory levels of the blood products. The Blood Bank Supervisor stated the suppliers typically faced the shortages of the blood products, especially in the summer months.

On 9/21/24 at 0950 hours, an interview was conducted with the Regional Director, Laboratory Services. The Regional Director, Laboratory Services confirmed the blood bank had inadequate supply of the blood products. The Regional Director, Laboratory Services stated the adequate blood supply should have been maintained as per the hospital's P&P. The Regional Director, Laboratory Services stated the inventory of blood products should be attached to the blood products refrigerator door and updated daily. The Regional Director, Laboratory Services confirmed the Governing Body still needed to approve a new policy reducing the minimum inventory of blood products.

Based on interview and record review, the hospital failed to ensure the pharmaceutical services met the needs of the patients when a TPN was not available for one of six sampled patients (Patient 3) based on the physician's orders. This failure had the potential to increase the risk of adverse health outcomes such as malnutrition and glucose fluctuations to the patients.

Findings:

Review of Patient 3's closed medical record was initiated on 8/21/24. Patient 3's closed medical record showed Patient 3 was admitted to the hospital on 8/10/24, and discharged on 8/20/24.

Review of the Admission History and Physical dated 8/11/24 at 0755 hours, showed the consulted pharmacy for TPN, but there was a logistic issue with the TPN at the hospital; to continue with the IV fluid and follow up with the pharmacy in the morning.

Review of the Progress Notes dated 8/12/24 at 0753 hours, showed Patient 3 was admitted to the hospital with a GT leak. The Assessment & Plan section showed pending TPN to be started and to proceed with the PICC line placement.

Review of the physician's order dated 8/12/24 at 2000 hours, for the TPN, with an order frequency of every 24 hours, intravenous, continuous, with the start date of 8/12/24 at 20:00.

Review of the Procedure: PICC Line Insertion showed a right PICC line was inserted for the patient on 8/13/24.

Review of the Progress Note for Parenteral Monitoring, showed the following:

* On 8/12/24, Patient 3 was on NPO. The patient's GT was removed. The MD wanted TPN for bowel rest. There was no PICC line. PPN was started.

* On 8/13/24, Patient 3 was scheduled for PICC Line today and advanced to TPN.

* On 8/14/24, Patient 3 PICC Line was placed on 8/13/24. The TPN was started.

* On 8/15/24, the TPN was not available.

* On 8/16/24, the TPN was not available on 8/15/24. The MD ordered D5NS with 20 mEq KCL to be run at 75 ml/hr. The patient's blood sugar was stable.

On 8/21/24 at 0900 hours, during an interview with Quality Manager 1, Quality Manager 1 confirmed the physician's order for TPN.

On 8/21/24 at 0900 hours, a concurrent interview and review of Patient 3's medical records was conducted with the Director of Pharmacy. The Director of Pharmacy stated the hospital's pharmacy could premix certain drugs for infusion, but TPN should be obtained from an outsourced supplier. The Director of Pharmacy stated the supplier withheld the TPN (did not deliver) due to an outstanding payment issue. The Director of Pharmacy stated he escalated the problem to the CEO and to the corporate account team to expedite the supplier payment. The Director of Pharmacy stated eventually Patient 3 received the TPN after a delay of 24 hours. The Director of Pharmacy stated he sometimes had to run to the sister facility to get medications when they run out of stock.