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Based on record review, interview, and observation the facility failed to ensure that blood transfusions were administered according to the facility's policy and procedure for 2 of 6 patients reviewed (#6 and #24). The failure to ensure that policies and procedures are followed in the administration of blood products has the potential to cause the patient to receive mismatched blood.

Findings:

1. Review of the patient record for patient #24 reveals a Blood Bank Transfusion Record dated 10/20/2009 that revealed that the patient had received a transfusion of packed red blood cells that had not been crossmatched for that patient. Review of the medical record did not reveal that the patient or the patient's physician were notified. Review of the medical record did not reveal that the patient has suffered any adverse reactions related to the transfusion error.

Interview with the Chief Operating Officer, Chief Nursing Officer, Director of Quality Assurance, and Laboratory Director on 1/7/2009 at 09:20 AM revealed that patient #24 had received a unit of packed red blood cells that was of the same type as the patient however it had been crossmatched for another patient and not patient #24, who received the transfusion. It was also stated that the unit was properly labeled with a unit number and crossmatch label. It was verified that the crossmatch label included the name of the patient for whom the unit had been crossmatched. Further statements reveal that the nurse had signed out the unit from the blood bank and that the unit had been incorrectly verified by both the blood bank technologist and the nurse picking up the blood., and that the unit had been incorrectly verified again by the nurse at the bedside, as well as by a second nurse at the bedside. The unit was transfused without the error being identified.

2. Observation of the sign out process on 1/6/2009 at 9:30 AM revealed that nursing assistant #1 brought a blood product order sheet to the blood bank to sign out a unit of packed red blood cells for patient #6. The blood bank technologist then issued the crossmatched unit in the computer. The unit was then inspected by the technologist and the nursing assistant to verify a match.

3. Review of the hospital policy Blood Administration with a Reviewed/Revised date of 07/09 reveals that uncross matched blood is only used for emergency transfusions and requires an order for emergency release of a blood product indication the urgent nature of the transfusion. The policy also includes the following statements:

" C. Blood Issue and Return
1. When obtaining blood from the Blood Bank, a nurse will bring the Physician Blood/Blood Product Order Sheet (labeled with patient ID information), signed Blood Transfusion consent and armband number to the Blood Bank. A minimum of two unique identifiers and Blood Bank Number must be present on the Blood Product Order Sheet. NOTE: Blood Bank Armband number must be checked and verified as correct at the patient's bedside before obtaining blood.

2. The Blood Bank personal will match the Physician Blood/Blood Product Order Sheet information (brought by the nurse), Blood Bank Transfusion Record and unit label. All patient and information must match.

3. The Blood Bank Tech will complete the "issue" section of the Blood Bank Transfusion record. The Nurse's initials and nursing unit will be entered in the 'issued to.' field in the computer system. The nurse and Blood Bank Tech will inspect the unit and paperwork for accuracy and verify its identical match.

NOTE: If blood administration will be delayed more than 30 minutes, the unopened bag must be returned to Blood Bank refrigerator and reissued when the transfusion is to be initiated.

4. At the patient's bedside and prior to initiating the transfusion, two nurses (at least 1 RN) must verify and sign the Blood Bank Transfusion Record confirming the information on the donor blood component matches the recipient. At a minimum, two unique identifiers and the patient's Blood Bank Number will be verified."

Based on record review and interview, the facility failed to ensure that 8 of 38 (#10, #15, #37, #14, #17, #39, #19, and #7) sampled patients, failed to have all entries dated and signed. Failure to date and sign all entries has the potential for the entries not to be accurate and timely.

Findings:

Review of the medical record for patient #10 revealed physician progress notes written on 10/29/2009, 10/30/2009, 10/31/2009, and 11/2/2009 that did not include a time the note was written. Review of the medical record revealed a operative report dictated on 10/30/2009, but as of 01/6/2010 has not been signed by the physician.

Review of the medical record for patient #15 revealed a physician progress note written on 12/6/2009 that did not include the time the note was written. Review of the medical record revealed a cardiology consult written on 12/03/2009 that did not include a time the consult was written.

Review of the medical record for patient # 37 revealed a physician progress notes written on 12/09/2009 and 12/10/2009 that did not include the time the notes were written.

Review of the medical record for patient #14 revealed two physician progress notes written on 11/16/2009 that did not include the time the note was written.

Review of the medical record for patient #17 revealed a physician progress notes written on 12/30/2009, 12/31/2009 and 01/01/2010 that did not include the times the notes were written. Review of the medical record revealed a physical therapy note dated 01/01/2010 that did not include the time the note was written.

Review of the medical record for patient #39 revealed a physician progress note written on 12/02/2009 that did not include the time the note was written.

Review of the medical record for patient #19 revealed a cardiology consult dictated 11/17/2009, but as of 01/06/2010 the consultation was not signed by the physician. Review of the medical record revealed a history and physical dated 11/16/2009, but as of 01/06/2010 the history and physical was not signed by the physician. Review of the medical record revealed a discharge summary dated 11/23/2009, but as of 01/06/2010 the discharge summary has not be signed by the physician.

Review of the medical record for patient #7 revealed that the discharge summary dated 11/5/09 had not been signed by the physician.

Interview conducted with the Director of Nursing on 1/5/10 at 3:00 PM revealed that he/she was not aware of the missing documentation.








27676

Based on record review and interview, the facility failed to ensure that 8 of 38 (#1, #2, #6, #19, #20, #21, #22 and #23) sampled patients, had completed and signed physician's orders.
Failure to have completed and approved orders has the potential for patients to receive inappropriate care and services resulting in the patient's health decline.


Findings:

1. Review of the medical record for patient # 1 revealed a physician's order transferring the patient to another physician's care dated 11/5/09 at 1315. Further review of the patient's file revealed that as of 1/6/10, the physician had still not signed the order.

Interview conducted with the Quality Assurance Director on 1/6/10 at 2:00 PM revealed that he/she was not aware of the missing documentation.

2. Review of the medical record for patient #2 revealed a physician's order dated 11/5/09 and signed for post operative medications, but did not have documentation of the time the order was written.

Interview conducted with the Quality Assurance Director on 1/6/10 at 2:00 PM revealed that he/she was not aware of the missing documentation.

3. Review of the medical record for patient #6 revealed a telephone order from the physician for preoperative medications on 11/27/09 that as of the review on 1/5/10, remained unsigned by the physician.
No history and physical work up prior to the patient's surgery could be located in the patient's chart.
Interview conducted with the Director of Nursing on 1/5/10 at 3:00 PM revealed that he/she was not aware of the missing documentation.


27676

Review of the medical record for patient #19 has physician's orders that are dated and timed 11/23/2009 - 11:50 and 11/23/2009 - 22:05 revealed that they were not signed by the physician. Review of the medical for patient #19 and observation of the patient's Advanced Nurse Practitioner (ARNP) revealed that the ARNP wrote an order for a pain management consult that did not include the dated and time the order was written.

Review of the medical record for patient #20 revealed preoperative anesthesia standing orders that do not include a time or date. The patient also has physicians's orders with a date of 10/30/2009 that do not include a time and a page of physicians's orders that do not include a date or time.

Review of the medical record for patient #21 revealed preoperative orders with no date or time recorded.

Review of the medical record for patient #22 revealed preoperative anesthesia standing orders that do not include a date or time. The admission orders include a date of 12/304/2009 but no time. The post operative physicians's order sheet is dated 1/4/2010 but not timed.

Review of the medical record for patient #23 revealed physician's orders dated 1/4/2010 that do not include a time written.

Based on record review and interview the facility failed to ensure that all verbal orders were authenticated in a timely manor for 1 of 38 (#19) residents reviewed. The failure to ensure that verbal orders are authenticated in a timely manor has the potential to cause a patient to receive treatment that has not been prescribed by a healthcare practitioner.

Findings:

Review of the physician orders for resident #19 reveal a telephone order dated 11/23/2009 at 11:50 and another telephone order dated 11/23/2009 at 22:05 are unsigned.

Interview with the Chief Nursing Officer on 1/6/2009 around 10:00 AM reveals that the order remains unverified.

Based on record review and policy review the facility failed to ensure they properly executed consent for 4 of 7 (#15, #14, #10, and #1) records that the physician did not sign the blood transfusion consent form. The failure of the physician to sign the consent form may indicate that the patient was not informed of the risks and benefits of the blood transfusion.

Findings:

Review of the medical record for patient #15 revealed two consents forms dated 12/04/2009 and 12/09/2009 that were not signed by physician and review of the medial record did not revealed any documentation that the risks and benefits were explained to the patient by the physician.

Review of the medical record for patient #14 revealed a consent form dated 12/09/2009 that was not signed by physician and review of the medial record did not revealed any documentation that the risks and benefits were explained to the patient by the physician.

Review of the medical record for patient #10 revealed a consents form dated 10/30/2009 that was not signed by physician and review of the medial record did not revealed any documentation that the risks and benefits were explained to the patient by the physician.

Review of the medical record for patient #1 revealed a consent form dated 11/06/2009 that was not signed by physician and review of the medial record did not revealed any documentation that the risks and benefits were explained to the patient by the physician.

Review of the facility policy and procedure titled "Consents" dated as reviewed and revised 12/2009 revealed under Guidelines: B. "Treatments Requiring Consent under #1. Consent for Blood Administration." Review of the policy under Guidelines: F. Consent Form under #3. "Evidence of informed consent must be contained in the patient's medical record and documented either on forms designed for such purposes or by the practitioner's note."