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Based on interview and record review, the hospital failed to ensure all physician orders for antibiotics and insulin infusions were administered as prescribed for five (Patients 6, 7,11,13,16) of 32 sampled patients. Patients 11 and 13 did not receive their first doses of IV antibiotics timely, delaying treatment for their infections. Patients 6, 7, and 16 did not receive insulin infusion therapy as prescribed, resulting in increased risk for high or low blood glucose levels.


Findings:

1. Review of Patient 11's medical record on 3/29/10 indicated he was admitted to the hospital on 3/24/10 for IV antibiotic therapy and debridement of an infected open chest wound resulting from a prior cardiac surgery. On 3/24/10, Patient 11 underwent surgical debridement of his wound. On 3/24/10 at 1:40 p.m., Patient 11's physician wrote an order for an IV (intravenous) antifungal "Voriconazole 6 mg./kg. Q (every) 12 hours X 2 (two doses) then start 400 mg. PO (orally) Q 12 hours."

On 3/30/10, review of the computer medication documentation showed the first dose of Voriconazole was not administered until 3/25/10 at 3:13 a.m., more than 12 hours after the antibiotic was ordered. During an interview on 3/30/10 at 1:30 p.m., RPH (Registered Pharmacist) 2 stated the physician order was not scanned to pharmacy until 3/25/10 at 2:29 a.m. RPH 2 further stated the order should have been scanned to pharmacy at the time the order was written. Based on the time the order was received by pharmacy, RPH 2 stated, "We scheduled for 2 a.m. and 2 p.m. We sent both doses." Further review of the computer medication documentation showed the second dose of Voriconazole was not administered at 2 p.m. as scheduled. Review of the physician orders indicated the physician was aware that Voriconazole had not been administered as prescribed: on 3/25/10 at 7:30 p.m., the physician gave the telephone order, "Give missed dose of Voriconazole 600 mg. IV due at 1400 (2 p.m.) X 1 now. Start Voriconazole 400 mg. PO Q 12 hours in a.m." Review of computer medication documentation showed the missed dose was administered at 7:56 p.m.

2. Record review on 3/29/10 indicated Patient 13 was admitted to the hospital on 3/21/10 for gastro-intestinal bleeding. On 3/23/10 at 2:45 p.m., the physician wrote orders for blood and urine cultures, and after Patient 13 developed fever, orders for antibiotics: "Vancomycin 1 gm. IV Q 12 hours" and "Meropenum 1 gm IV Q 8 hours." Nursing staff documented on the Physician Orders after the Vancomycin order "scheduled for 1700 (5 p.m.) " During an interview on 3/30/10 at 11:25 a.m., RPH 2 stated pharmacy entered the orders for Vancomycin and Meropenum on 3/23/10 at 3:58 p.m.; the delay caused by the pharmacist's need to review Patient 13's lab results for his renal function to determine whether Patient 13 should receive lower doses of the antibiotics. Pharmacy had scheduled the Vancomycin for 1700 (5 p.m.)

Review of computer medication documentation showed Meropenum was administered at 5:08 p.m. on 3/23/10, but Vancomycin was not administered until 6:34 p.m., more than 3.5 hours after the order was written, more than 2.5 hours after pharmacy finalized the order, and 1.5 hours after was scheduled. The ICU manager was present during the medication documentation review. She stated "We give antibiotics as soon as they're received." The ICU manager reviewed the medication documentation and stated the nurse waited to give vancomycin because the meropenum was being administered. RPH 2 stated Meropenum should have taken no more than 30 minutes to infuse and the infusion rates were printed on the IV bags.

The Director of Pharmacy Services stated in interview on 3/30/10 at 3:08 p.m. "All antibiotics are treated as stat (latin expression directing to act now). The first dose is to be given upon receipt."

Review of the hospital's policy:" Medication, Times of Administration" indicated "All first doses shall be given upon receipt. The time given counts for the standard time that falls within the designated time group."

3. Review of Patient 16's medical record on 3/30/10, indicated she was admitted to the hospital on 3/26/10 for back pain and fever. Her medical history included end stage renal failure requiring dialysis (procedure for blood filtration to subsitute the kidneys' function). In the emergency department, Patient 16 exhibited signs of sepsis, a severe blood infection, so she was admitted to the ICU (Intensive Care Unit) under the hospital's "Sepsis Early Goal-Directed Therapy" protocol as well as "Critical Care IV (intervenous) Insulin Infusion Orders" ordered as "per sepsis protocol."

The computer record documenting the time, the blood glucose result, and the insulin infusion rate was reviewed with the ICU manager. The insulin infusion was started on 3/27/10 at 4:40 a.m. and Patient 16's blood glucose (BG) was 211.

3/27/10 4:40 a.m. BG 211, Insulin rate 5 units/hr
8:29 a.m. BG 258, Insulin rate 6 units/hr
11:07a.m BG 293, Insulin rate 8 units/hr
1:15 p.m. BG 193, Insulin rate 6 units/hr
2:40 p.m. BG 122, Insulin rate 4 units/hr
3:37 p.m. BG 137
5:35 p.m. BG 169, Insulin rate 5 units/hr
6:11 p.m. BG 137
8:13 p.m. BG 58
10:01 p.m. BG 173, Insulin rate 2 units/hr.

According to the ICU manager, the absence of a printed insulin rate meant the rate was unchanged.

According to the Critical Care IV Insulin Infusion Orders, the blood glucose should be checked hourly until the blood glucose goal range of 80-120 mg/dl was achieved. The frequency of testing should be decreased only when three consecutive readings were in the goal range. Highlighted by a box was the statement "It is crucial for titrating infusion & avoiding hypoglycemia (low blood sugar level) that the blood glucose be checked Q 1 hour until parameters for decreasing frequency are met."

According to the ICU Manager, laboratory results might have been used in lieu of blood glucose testing, but review of lab draw times could not explain the lack of testing between 8:29 a.m. and 11:07 a.m.

According to the Critical Care IV Insulin Infusion Orders, nursing staff should have increased the insulin rate at 8:29 a.m. to 7 units/hour, not to 6 units/ hour. The inadequate insulin rate coupled with no testing for over two hours yielded a high glucose level of 293, causing the insulin rate to be increased to 8 units/hour. Two hours again passed before the blood glucose was tested again. The blood glucose level of 193 represented a decrease of nearly 40% with a corresponding need to decrease the insulin rate by 25% to 6 units/hour. Tested at roughly one hour intervals, from 2:20 p.m. until 5:35 p.m. blood glucose levels were relatively stable, requiring only one unit insulin rate adjustment. At 5:35 p.m., the blood glucose was 169 and the insulin rate was 5 units/hour, remaining at 5 units/hour for a 6:11 p.m. blood glucose of 137. Two hours passed before another blood glucose was checked, increasing the risk that the blood glucose would drop too far with the relatively high insulin infusion rate. At 8:13 p.m., the blood glucose had fallen to 58, a very low blood glucose that required the infusion be stopped and nursing staff "follow Hypoglycemic Treatment orders" according to the Critical Care IV Insulin Infusion Orders.

Review of the record indicated nursing staff administered 1/2 amp of D50 (25 ml of dextrose, 50% concentration). There was no documentation that nursing staff notified the physician for this hypoglycemic episode, as outlined in the Bedside Glucose Monitoring PRN (as needed) for Symptoms of Hypoglycemia. A lab draw done at 8:38 p.m. indicated the blood glucose had increased to 118. Fifty minutes later, another lab draw indicated the blood glucose rose to 173 and the insulin infusion rate was resumed at 2 units/hour.

Review of the record showed that Patient 16's blood glucose dropped to hypoglycemic levels twice in 13 hours. Twice, nursing staff needed to administer rescue doses of Dextrose 50 to Patient 16 to increase her blood glucose values. For the first of these two hypoglycemic episodes, the following was noted: The insulin infusion rate was inexplicably increased twice when the blood glucose decreased:

3/27/10 10:38 p.m. BG 182 Insulin infusion rate 3 units/hour
11:09 p.m. BG 134 Insulin rate 4.5 units/hour
3/28/10 12:14 a.m. BG 177 Insulin rate 4 units/hour
1:26 a.m. BG 156
2:07 a.m. BG 134 Insulin rate 4.5 units/hour
3:02 a.m. BG 99 Insulin rate 3.5 units/hour
4:23 a.m. BG 80 Insulin rate 2 units/hour
5.49 a.m. BG 64

Following the Critical Care IV Insulin Infusion Orders, the drop of BG from 182 to 134 represented over a 25% drop, and the insulin infusion rate should have been dropped 25% as well, not increased 50% as it was documented. When the BG dropped again from 156 to 134, the insulin infusion rate should have been left unchanged, not increased. The raised insulin rate was too high given the now decreasing BGs. Nursing staff stopped the insulin infusion at 5:49 a.m. and administered 1/2 amp Dextrose 50% due to low blood sugar level.

The next hypoglycemic episode occurred when the insulin infusion rate was not decreased per policy and hourly glucose testing was not documented.

3/28/10 6:42 a.m., BG 136, Insulin rate 1 unit/hour
8:28 a.m., BG 145
10:26 a.m. BG , Insulin rate 4 units/hour
1:09 p.m. BG 165, Insulin rate 5 units/hour
2:45 p.m. BG 115
3:23 p.m. BG 87, Insulin rate 4 units/hour
4:42 p.m. BG 50

Following the Critical Care IV Insulin Infusion Orders for hourly monitoring might have yielded smaller BG variations and smaller insulin infusion rate changes. When the BG dropped from 165 to 115, over a 25% decrease, the insulin rate should have been correspondingly reduced 25%, not remain unchanged. The raised insulin rate was too high given the now dropping BGs. At 4:42 p.m., nursing staff stopped the insulin infusion and administered 1/2 amp Dextrose 50%.


26985


4. Record review on 3/29/10 at 1:20 p.m., in the company of the pharmacy manager (RPH 1), clinical pharmacy manager (RPH 2), the clinical pharmacy coordinator (RPH 3) and the inpatient diabetes educator nurse (RN 2) showed the hospital had admitted Patient 6 on 3/25/10 for cardiovascular surgery and treatment of a myocardial infarction (heart attack). Patient 6 was 64 years old and her medical history included high blood pressure, and a chronic lung disease. After emergency cardiac surgery, the hospital transferred Patient 6 to the critical care unit on 3/26/10.

Further record review showed that Patient 6 had physicians' orders dated 3/26/10 for insulin infusion, "Critical Care IV Insulin Infusion Orders". The orders indicated the following:
Goal range for blood glucose (BG) 80-120 MG/DL (milligrams per deciliter)
Bedside blood glucose now, check BG every 1 hour until within goal range
Every 1 hour until stable in goal range for 3 consecutive hours, then every 2 hours
for 2 hours, then every 4 hours.

Review of Patient 6's blood glucose record, insulin infusion and medication administration record showed the following on 3/26/10:

10:30 a.m. BG=194, Insulin Infusion Rate 8 units/ hour
11:30 a.m. BG=177, Insulin Infusion Rate 10 units/ hour

a. According to the orders, "if BG is 161-200, increase infusion rate by 1 units/hour."

When Patient 6's BG was 177 on 3/26/10 at 11:30 a.m., the insulin infusion rate should have been increased to 9 units/hour. The increase in the insulin infusion rate to 10 units/hour was not consistent with the Critical Care IV Insulin Infusion Orders.

Further review of Patient 6's blood glucose record, insulin infusion and medication administration record 3/26/10showed the following:

3/26/10 3:30 p.m. BG=144, Insulin Infusion Rate 11 units/hour
3/26/10 3:50 p.m. BG=258, Insulin Infusion Rate 7 units/hour
3/26/10 6:51 p.m. BG=112, Insulin Infusion Rate 7 units/hour
3/26/10 9:54 p.m. BG=59, Insulin Infusion off
3/26/10 11:09 p.m. BG=131, Insulin Infusion Rate 6 units/hour
3/27/10 1:04 a.m. BG=77, Insulin Infusion Rate 3 units/hour

b. According to the orders, "if BG is greater than 200, increase infusion rate by 2 units/hour".

When Patient 6's BG was 258 on 3/26/10 at 3:50 p.m., the insulin infusion rate should have been increased to 13 units/hour.

During interview on 3/29/10 at approximately 1:30 p.m., RPH 1, RPH 2, RPH 3 and RN 2 could not provide an explanation for decreasing the insulin infusion rate from 11 units / hour to 7 units/hour instead of increasing the rate to 13 units / hour in accordance with the Critical Care IV Insulin Infusion Orders. Review of Patient 6's medical record did not show any other insulin orders.

c. According to the orders, the hospital should have obtained Patient 6's blood glucose every hour until stable within goal range (BG 80-120) for three consecutive hours. Patient 6 reached goal range (BG 112) once on 3/26/10 at 6:51 p.m. The hospital did not check Patient 6's blood glucose for three hours. At 3/26/10 at 9:54 p.m., Patient 6 became hypoglycemic (low blood sugar, defined as BG less than 70), with a blood glucose of 59. Patient 6 required hypoglycemia treatment with Dextrose 50%.

d. According to the orders, "restart when BG is greater than 130, at 4 units below previous rate". On 3/26/10 at 11:09 p.m., the hospital resumed Patient 6's insulin infusion at 6 units/hr for a blood glucose of 131. According to the order, Patient 6's infusion rate should have been 2 units / hour.

e. According to the orders, "if BG is 70--79, decrease infusion rate by 2 units/hour".
When Patient 6's BG decreased from 131 (3/26/10 11:09 p.m.) to 77 (3/27/10 1:04 a.m.), the insulin infusion rate should have been decreased to 4 units/hour. The decrease in the insulin infusion rate to 3 units/hour was not consistent with the Critical Care IV Insulin Infusion Orders

Further review of Patient 6's blood glucose record, insulin infusion and medication administration record showed the following:

3/27/10 2:09 a.m. BG=75, Insulin Infusion Rate 1 units/hour
3/27/10 2:56 a.m. BG=95, Insulin Infusion Rate 0.5 units/hour
3/27/10 6:43 p.m. BG=148, Insulin Infusion Rate 0.5 units/hour
3/27/10 10:00 p.m. BG=153, Insulin Infusion Rate 2.5 units/hour

f. According to the orders, the hospital should have obtained Patient 6's blood glucose every hour until stable within goal range (BG 80-120) for three consecutive hours. Patient 6 reached goal range (BG 95) once on 3/27/10 at 2:56 a.m. The hospital staff did not check Patient 6's blood glucose on 3/27/10 for approximately 16 hours between 2:56 a.m. and 6:43 p.m. and again between 6:43 p.m. and 10:00 p.m. for other three hours.

g. According to the orders, "if BG is 131-160 and remains in this range for 3 consecutive BG checks, increase infusion rate by 0.5 units/hour."
When Patient 6's BG was 153 on 3/27/10 at 10:00 p.m., the infusion was increased to 2.5 units per hour. This infusion rate was not consistent with the Critical Care IV Insulin Infusion Orders.

Patient 6's medication administration record showed that all intravenous insulin adjustments were independently verified by two nurses.

5. Record review on 3/29/10 at approximately 2:15 p.m., in the company of the pharmacy manager (RPH 1), clinical pharmacy manager (RPH 2), the clinical pharmacy coordinator (RPH 3) and the inpatient diabetes educator nurse (RN 2) showed the hospital had admitted Patient 7 on 3/14/10 for the treatment of pneumonia. Patient 7 was 58 years old and her medical history included diabetes. Review of Patient 7's blood glucose record, insulin infusion and medication administration record showed that on 3/28/10 at 12:53 a.m., Patient 7 had a blood sugar of 50 (hypoglycemia). According to the medication administration record, the nurse noted, "patient asymptomatic, gave 120 ml grape juice will continue to monitor."

Review of the hospital's hypoglycemia treatment orders on 3/29/10, showed that following treatment for a hypoglycemic episode, the patient's blood sugar should be rechecked in 15 minutes. According to the medication administration record, Patient 7's blood sugar was not rechecked until 3/28/10 at 1:46 a.m. During interview, RN 2 stated that Patient 7's blood sugar should have been rechecked 15 minutes after consuming the grape juice. RN 2 could not provide an explanation for why Patient 7's blood sugar was not rechecked in 15 minutes in accordance with hospital policy.

Patient 7's record review on 3/30/10 at approximately 12:45 p.m. on the cardiovascular/telemetry unit (A2), in the company of the Director of Operations and Patient Care Services (RN 1) and RPH 3, showed the hospital had transferred Patient 7 to the cardiovascular/telemetry unit on 3/27/10 from the critical care unit. Patient 7's transfer orders dated 3/27/10, included Insulin Infusion using the transitional IV insulin orders. Review of Patient 7's medication administration record showed that she had been receiving the Critical Care Insulin Infusion orders on 3/27/10 and 3/28/10. RN 1 stated that upon transfer to the cardiovascular/the unit should have been using the A2 IV Insulin Infusion Transfer Orders and not continued The Critical Care Insulin Infusion Orders. Patient 7's medication administration record showed that all intravenous insulin adjustments were independently verified by two nurses.

Further reviewed showed that The Critical Insulin Infusion orders aimed toward tighter glycemic control with a goal range for blood glucose between 80-120; whereas the A2 IV Insulin Infusion Transfer Orders goal range for blood glucose was between 80-140. Tighter glycemic control exposes patient to a higher risk of hypoglycemia.

Review of the hospital's high alert medication policy on 3/30/10 at 3:00 p.m., showed that insulin as one of the hospitals high alert medications. The policy indicated the following:
"High alert medications have the highest risk of causing injury when misused.
The right patient, medication, dose, route and time shall be independently verified by two licensed caregivers.
For intravenous insulin drips, the nurse is to perform an independent verification of the correct pump settings with another licensed caregiver when a new bag is hung or with any change in dose or rate.
The nurse who performs the independent verification will cosign on the electronic medication administration record."

During interview on 3/30/10 at approximately 3:00 p.m., RN 1 could not provide an explanation for the multiple discrepancies in following Patient 6 and 7's insulin infusion orders despite of the independent verification process. RN 1 stated the discrepancies could possibly be related to training, education and / or inconsistencies in documentation.

3. Record review on 3/30/10 at approximately 11:00 a.m. in the company of the Pharmacy Clinical Coordinator (RPH 3) and the Director of Operations and Patient Care Services (RN 1) showed Patient 4 was admitted to the hospital on 3/18/10. Patient 4 was 42 years old with multiple diagnoses including diabetes and coronary artery disease. Patient 42 had end stage kidney disease and required dialysis (procedure that allows the blood to be filtrated artifically). On 3/26/10, Patient 42 receive a transfusion of two units of Packed Red Blood Cells (PRBC) during dialysis. The first transfusion started at 9:30 a.m. and ended at 10:00 a.m. The second transfusion started at 10:00 a.m. and ended at 10:40 a.m.

Review of Patient 4's Acute Hemodialysis Log dated 3/26/10, which contained blood transfusion records, showed that the hospital did not obtain vital signs as required per policy every 15 minutes:

9:30 a.m.: PRBC unit 1 started, vital signs: temperature 97.4, respirations 20, heart rate 99, blood pressure 104/63

9:45 a.m.: vital signs: blood pressure 100/50, heart rate 95 (no temperature, no respirations)

10:00 a.m.: PRBC unit 2 started, vital signs: temperate 97, respirations 18, heart rate 90, blood pressure 114/75

10:15 a.m.: vital signs: blood pressure 100/50; heart rate 90 (no temperature, no respirations)

10:30 a.m.: vital signs: blood pressure 100/50; heart rate 92 (no temperature, no respirations)

10:40 a.m.: blood transfusion completed, no vital signs obtained.

Review of the hospital's policy regarding blood administration/transfusion on 3/30/10 at 3:30 p.m., showed the following, "Vital signs (including temperature with each set of vital signs.) Obtain baseline vital signs, then every 15 minutes x 2, then every hour during the transfusion, and at the completion of each unit."
Vital signs would include: temperature, pulse, respiration, and blood pressure.

During interview on 3/30/10 at approximately 3:00 p.m., RN 1 stated the hospital should have obtained Patient 4's temperatures, during blood transfusion as required per policy.



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4. Record review on 3/29/10 indicated Patient 13 was admitted to the hospital on 3/21/10 for gastro-intestinal bleeding. Due to loss of blood, Patient 13 required blood transfusions. In addition, Patient 13 had a clotting disorder and required platelets and fresh frozen plasma (FFP) transfusions to help stabilize his condition. Review of the record indicated Patient 13 first received FFP and platelets in the emergency department on 3/21/10 at 5:58 p.m. and was transferred to the ICU at 6:20 p.m. where he received a unit of red blood cells at 6:45 p.m. followed by FFP at 8:20 p.m.

Review of the form "Transfusion Consent & Release From Liability" indicated the Spanish version was used for Patient 13. Patient 13's signature was present, as well as two signatures from the nursing staff, but no date and time information that could document when Patient 13 first gave consent for the transfusions. The ICU manager present during the record review confirmed ICU nurses had signed the consent form and the date and time should have been documented.

5. Record review on 3/30/10 indicated Patient 14 was admitted to the hospital on 3/25/10 with sepsis (overwhelming infection in the blood). Beginning on 3/27/10 at 7:55 a.m. Patient 14 received multiple transfusions of red blood cells and platelets. Review of the hospital's "Blood Administration/Transfusion Guidelines" indicated nursing staff should "Obtain baseline vital signs, then q (every) 15 min X 2, then q 1 hr during transfusion, and at completion of each unit. Record all vital signs in Meditech!" The Meditech vital sign record during each transfusion Patient 14 received was reviewed with the ICU manager. According to the Transfusion Record documentation, Patient 14 received a unit of platelets that started on 3/27/10 at 4:30 p.m. and was completed at 6 p.m. Review of Patient 14's vital signs on 3/27/10 for the transfusion of the platelets indicated baseline vital signs were documented at the start of the transfusion at 4:30 p.m. The next set of vital signs was documented at 4:56 p.m., 26 minutes after the start of the transfusion. The next set of vital signs were not documented until 6:07 p.m., more than one hour after the last set of vital signs. The ICU manager confirmed nursing staff did not perform the vital sign monitoring specified by the transfusion guidelines



25714

Based on interview and record review, the facility failed to ensure that blood/blood products transfusions were administered in accordance with hospital policy and procedure for five (Patients 4, 13, 14, 22, and 25) of 32 sampled patients.

For Patient 4, there was incomplete documentation of the vital signs (temperature, pulse, respiratory rate, and blood pressure) during the transfusion of packed red blood cells.

For Patient 13, the "Transfusion Consent & Release From Liability" was incomplete; there was no date or time documented as to when Patient 13 had consented to the blood/blood product transfusion.

For Patient 14, there was incomplete documentation of the vital signs during the transfusion of packed red blood cells.

For Patient 22, the "Transfusion Record/Unit Slip" dated 3/28/10 had no signature for the person who had transfused the packed red blood cells.

For Patient 25, the "Transfusion Consent & Release From Liability" was incomplete, packed red blood cell unit #20LE29733 was infused beyond the four hours limit after it had been retrieved from the blood bank, and there was incomplete documentation of the vital signs during and after the transfusions.

These failures placed the patients at risk for a delay in detecting potential side effects/negative reactions and lack of honoring patients' rights. The lack of a second signature on the transfusion slip put to questionthe fact that a second person verified the accuracy of the patient identification and blood product information. The failure to infuse packed red blood cells products within four hours after they had left the blood bank increased the possibility of infection.

Findings:

Review on 3/29/10 of the hospital's policy and procedure for "LAB - Blood Transfusion", last revised on 3/10/10, showed that:

Consents for transfusions "will be reviewed for completeness",

The person transfusing the blood/blood products, "...RN (registered nurse) or MD (medical doctor) and the second RN, LVN (licensed vocational nurse) or MD must sign the transfusion record indicating that the identification was correct including who started the transfusion, the date, time begun..."

The patient's vital signs and condition "must be monitored closely and documented in the patient's chart throughout the transfusion and up to an hour after completion". The vital signs were to be taken every 15 minutes times two for the first 30 minutes from the start of the ransfusion, every one hour during the transfusion, and at the completion of the transfusion.

1. Record review on 3/29/10 showed that Patient 22 had been admitted for a left hip fracture on 3/26/10. Patient 22 had left hip replacement surgery on 3/26/10.
On 3/28/10, Patient 22's hemoglobin (part of the red blood cell that transports oxygen from the lungs to the tissues of the body) was 9 (normal range 12-16) and had symptoms of impaired oxygen carrying capacity indicated by "tachycardia" (fast heart rate). One unit of packed red blood cells was ordered to be transfused. The "Transfusion Record/Unit Slip" dated 3/28/10 showed that a unit of packed red blood cells had been started at 4:50 p.m. and completed at 8:25 p.m. The transfusion record slip section for the two signatures had only one signature entered. The two signatures required were for verification that the physician order was verified, the transfusion consent was completed/signed, that patient identification was confirmed, and that the patient information matched with the information on the transfusion slip.

2. Record review on 3/30/10 in the company of Quality Management Coordinator showed that Patient 25 had been admitted to the facility on 3/28/10 for heart failure and gastrointestinal bleeding. On 3/29/10 Patient 25's hemoglobin was documented at 6.4 (normal range 12-16). Patient 25 had received a combination of eight blood/blood product transfusions since admission.

Review of the "Transfusion Consent & Release From Liability" dated 3/28/10 and timed at 7:30 p.m. showed that the consent was not filled out completely. The form did not have the patient's written name, type of transfusion, the physician's name who had ordered the transfusion and it also had no witness' signature to Patient 25's signature.

On 3/29/10 Patient 25 had a unit of packed red blood cell, number 20LE29739, started at 4:25 a.m. and completed at 7:30 a.m. Review of the electronic medical record vital signs documentation showed that the next vital signs were done at 4:45 a.m. and at 7:30 a.m. when the unit was completed.

A second unit of packed red blood cells, number 29LE29733, was started on 3/29/10 at 8:16 a.m. and completed at 1 p.m. The unit of packed red blood cell had been completed in four hours and 44 minutes; over the four maximum transfusion time. Review of the electronic medical record vital signs documentation showed vital signs at 8:21 a.m., followed by a 5:01 p.m. entry.

The transfusion vital sign monitoring was not done as per hospital policy and procedure; 15 minutes x two after the transfusion was started then every hour until transfusion was completed.

25714

Based on record review and interview, the facility failed to ensure verbal/telephone physician orders were timely authenticated by the ordering practitioners for three (Patients 21, 22, and 26) of 32 sampled patients, which resulted in orders not being verified for accuracy by the ordering physician. This failure increased the potential for adverse events for this patients.

Findings:

Review of the facility's policy and procedure, "Physician Order-Verbal/Telephone" showed that physician's orders "must be authenticated, signed and dated by the ordering, attending or covering physician within 48 hours of the order".

1. Record review on 3/29/10 showed Patient 21 was admitted to the hospital on 3/18/10. Thre were the following orders documented in the patient's record:
Order written Order authenticated
3/25/10 at 12:20 p.m. 3/29/10 at 9:50 a.m.
3/25/10 at 5 p.m. 3/29/10 at 9:50 a.m.
3/25/10 at 5:38 p.m. 3/28/10 at 8:09 p.m.


"for Patients 21 and 22, and record review on 3/30/10 for Patient 26 showed that the physician's telephone orders had not been timely authenticated by the physicians.

2. On 3/29/10, record review showed Patient 22 was admitted to the hospital on 3/26/10, and the follwoing physician orderes were documneted:
Order written Order authenticated
3/26/10 at 4:35 p.m. 3/29/10 at 9:04 a.m.
3/26/10 at 7:15 p.m. 3/29/10 at 9:04 a.m.

3. Patient 26 was admitted to the facility on 3/21/10 according to the record review on 3/30/10.The following physician orders were documneted in Patient 26's record:
Order written Order authenticated
3/21/10 at 4:45 p.m. 3/25/10 at 7:44 p.m.
3/22/10 at 12 noon 3/25/10 at 7:44 p.m.
3/22/10 at 10:20 p.m. not done
3/22/10 at 11:10 p.m. not done

On 3/30/10 at 1 p.m. the DAPS (Director of Accreditation/Patient Safety) stated that getting physicians to timely authenticate verbal/telephone orders was still a problem but there had been an improvement in the monthly trending.