HospitalInspections.org

Based on document review, and interview, it was determined that for 2 of 2 ( Pt #1 and #2) clinical records reviewed of ED patients that were transferred to another Hospital, the Hospital failed to ensure transfer forms were completed and accompanied the patient on transfer.

Findings include:

1. The Hospital policy titled, "Transfer or Referral to Outside Facility or Agency" (effective 10/1/12) required, "F. A transfer form, completed by nursing and physician, must accompany the patient to the accepting facility or home care agency..."

2. The clinical record of Pt. #1 was reviewed on 1/7/14 at approximately 10:00 AM. Pt. #1 was an 18 year old male brought to the Hospital's Emergency Department (ED) via ambulance on 12/1/12 at 9:16 PM with a category 1 trauma from a motor vehicle accident. Nursing documentation (E #1) indicated being "in the care of life star at this time. On transport cart, out to the heli-pad...." At 12:53 AM physician notes indicated "ED disposition set to Transfer to Another Facility." The clinical record lacked transfer forms being completed and accompanying Pt. #1 to the accepting facility.

3. The clinical record for Pt. #2 was reviewed on 1/8/14. Pt. #2 was a 36 year old male admitted to the ED, via ambulance on 6/26/13, as a category 1 trauma from a self inflicted guns shot wound to the chin and neck. The clinical record indicated Pt. #2 was transferred to another facility via helicopter. The record lacked transfer forms being completed and accompanying the patient to the accepting facility.

4. The above finding was discussed with the Manager of ED (E #3) on 1/9/14 at approximately 10:30 AM who stated that transfer forms should be completed and accompany patient on transfer.

Based on documents review and interview, it was determined that for 2 of 2 (Pt. #1 & #10) records reviewed of patients that had received blood products, the Hospital failed to ensure staff followed the policy relative to documentation of blood verification and administration.

Findings include:

1. The Hospital policy titled, "Blood/Blood Components Administration" (approval date 9/19/12) required, "Uncrossed blood can be administered in an emergency situation if ordered by the attending or designee physician, Emergency transfusion request forms needs to be signed by physician....Administration: At the bedside, two(2) RN's must cross check the patient's name and number of the patient's wristband with those on the blood bag label: Blood bank identification number, the unit, the ABO blood group, and Rh compatibility, and the patient's blood type and unit expiration date...."

2. The clinical record of Pt. #1 was reviewed on 1/7/14 at approximately 10:00 AM. Pt. #1 was an 18 year old male brought to the Hospital's Emergency Department by ambulance on 12/1/12 at 9:16 PM with diagnosis of trauma, categorized as 1.
A physician order noted on 12/1/12 at 11:09 PM for, " Emergency Uncrossed O-negative RC type and/cross; transfuse RBC " and acknowledged by a registered nurse at 11:24 PM to " transfuse RBC." The clinical record included documentation of 2 units being given on 12/2/12 with the cross check of the patient's name and number to the blood bag label. However, two additional units(#3 and #4) documented as being started at 12:19 AM, and 12:31 AM, lacked the blood product identification forms documenting the cross check of the patient's name and number of the wristband with the blood bag label. The clinical record also lacked the physician signed emergency transfusion request forms.
3. The clinical record of Pt. #10 was reviewed on 1/9/14 at approximately 2:00 PM. Pt. #10 was a 33 year old female admitted to the ED on 10/7/13 with trauma from a motor vehicle accident, categorized as a level 1 trauma. The clinical record contained documentation of 5 units of packed red blood cells (PRBC) being administered. However there were no documentation of two RN's cross checking the patient's name and number with the blood label bag.
4. The above findings were discussed with the Trauma Nurse Coordinator (E #2) during an interview on 1/10/14 at approximately 2:00 PM. who stated two RN's should cross check the patient's name and number with the blood label bag and document in the clinical record.