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Based on medical records reviews, reviews of policies and procedures and staff interviews, it was determined the facility did not ensure that its nursing staff provided adequate and appropriate care for its patients. Specifically, (1) nursing assessments were not consistent with prevailing standards of practice; (2) a medication was not administered according to federal and state laws and; (3) the nursing staff did not follow the facility's policies. This was found in 5 of 10 medical records reviewed. This was found in medical record (MR) #1, MR #2, MR #5, MR #6 and MR #7.

Findings include:

1. Nursing staff did not conduct comprehensive assessments of patients who received blood transfusions in the ambulatory surgical unit (ASU). As a result, patients who received blood transfusions in the unit their physical and mental status deteriorated as medical and nursing care were not initiated in a timely manner. See citation at A 395.


2. Nursing policies were not followed which resulted in delay in care. See citation at A 395.

3. The nursing staff did not administer drugs and blood products according to the facility's policies and procedures. See detailed findings at A 405, A 406 and A 409.

Based on medical record reviews, policies reviews and staff interviews, it was determined (1) the nursing staff did not adequately assess the patients as the patients' conditions warranted; (2) the nursing staff did not follow the facility's policies and procedures; and (3) did not formulate effective policies to ensure that patients received care in a safe environment. This was found in 5 of 8 patients that received blood transfusions or received care in the ASU. This was found in MR #1, MR#2, MR #5, MR#6 and MR #7.

Findings included:

1. Patients #1, #5, #6 and #7 who received blood transfusions in the ambulatory surgical unit (ASU) were not adequately assessed prior to, during, and after the blood transfusions were completed.

(a) The nursing staff did not follow its policy titled "Rapid Response Team" last revised 10/13. A review of this policy on July 14, 2014 revealed the goal is "to provide early and rapid intervention in order to promote better outcomes such as: reduced cardiac and/or respiratory arrests in the hospital; reduced or more timely transfers to the ICU or a higher level of care; reduced patient intubations and reduced number of hospital deaths."

A review of medical record # 1 on July 12, 2014 revealed the patient developed shortness of breath in the ASU on May 2, 2014, however based on staff interviews conducted on July 11, 2014 at 11:20 AM with Staff #12, who is the Assistant Nurse Manager of the ASU, stated the nursing staff in the unit seldom activates a rapid response notification if patients are having a problem. There was no documentation in the medical record that a rapid response team was requested. The patient was intubated and transferred to ICU where she subsequently expired that day. The nursing staff failed to follow this policy in the ASU.

(b) A review of patient #1's medical record on July 11, 2014 revealed this ninety-seven year old patient arrived at the facility on May 2, 2014 for transfusion of 2 units of packed red blood cells (PRBC). The patient had a previous medical history of Coronary Artery Disease (CAD), Hypertension, Dementia, Myocardial Infarction, Deep Vein Thrombosis, Pulmonary Embolism and Anemia of Chronic Disease. The patient's vital signs were taken (not timed) and the oxygen saturation was noted to be 90%. During a review of patient #1's medical record conducted on July 11, 2014 revealed there was no documentation from the nursing staff of the patient's arrival time and physical and mental status or if the low oxygen saturation was addressed.

According to the medical record the patient received 1 unit of packed red blood cells (PRBC) and during the second unit of blood went into severe respiratory distress and loss of consciousness. The patient was subsequently intubated in the ASU according to the intensive care unit (ICU) nurse's note. There was no documentation to indicate if the patient was assessed in the ASU. The only documentation to indicate the change in status was a note that stated "Blood stopped due to fluid overload/CHF/SOB/DVT/PE" (CHF = Congestive Heart Failure / SOB = Shortness Of Breath / DVT = Deep Vein Thrombosis / PE = Pulmonary Embolism).

A review of the physician's note on July 11, 2014 revealed he documented on May 2, 2014, after the patient's condition deteriorated, that "I just saw the patient 2 days ago and she was quite awake and alert and verbal". The nursing staff did not document the patient's mental and physical status in the facility throughout her hospitalization until her demise.

During an interview conducted on July 11, 2014 at 11:20 AM with Staff #12 , the Assistant Nurse Manager of the ASU, she stated that at approximately 11:30 AM on May 2, 2014 she observed Staff #4, the patient's RN, standing at the bedside while the patient was sitting up with her legs dangling off the bed. Staff #12 further stated that the patient was in severe respiratory distress, drooling and lethargic. There was no documentation to reflect the patient's status or that the patient was bagged and intubated in the ASU, as she also stated during this interview.

Further review of the medical record on July 11, 2014 revealed there was no documentation that the patient's physical and mental status was assessed upon arrival and monitored in the ICU when she was transferred to that unit.

During an interview conducted on July 14, 2014 at 11:10 AM, Staff #7, a registered nurse in the ICU, stated the patient was extubated as it was later learned she had a DNR/DNI (Do Not Resuscitate / Do Not Intubate) status. She expired at 2:06 PM that day.

The nursing staff did not follow the facility's policy titled "Assessment of Patients" which was last revised 3/14. The policy states that "The Ambulatory Care Unit assesses patients on arrival and post procedure as per guidelines and protocols".

(c) The policy titled "Blood Transfusion Guidelines" last revised 6/14 states blood transfusions should "begin at a rate of 50 cc/hour(hr.) per minute for first 30 minutes. If no apparent reaction increase flow rate to between 16 to 18 drops per minute depending on need and age of the patient. Pediatric and elderly patients may require a slower infusion time as per physician." Increasing the transfusion of PRBC by 16 - 18 drops per minute is not safe for an elective transfusion.

For patient #1, an elderly (ninety-seven years old) female, her vital signs were stable and there was no sign of acute or active bleeding. Based on an interviews conducted on July 11, 2014 at 11:20 AM, Staff #6, a registered nurse stated she observed that the pump was beeping and programmed to administer the blood at 200 cc/hr. According to the medical record reviewed on July 11, 2014 the patient received 350 cc of blood in 1 hour and 40 minutes. During administration of the second unit of blood the patient developed shortness of breath and subsequently expired at 2:06 PM that day. Staff #4, the patient's RN did not follow the facility's policy to administer the blood transfusion slowly because the patient was elderly. The policy was inappropriate because blood should not be increased by 16 - 18 drops per minute in non-emergent situations. Furthermore, Staff #2 did not ensure that Staff #4 administered the blood transfusion according to the facility's policy.

(d) A review of patient #5's medical record on July 15, 2014 revealed this is a seventy-six year old patient who presented to the facility on May 2, 2014 for transfusion of 2 units of blood. The patient's previous medical history included Hypertension, Cardiac problems, and Acute GI (gastrointestinal) Bleeding with Severe Anemia [hemoglobin /hematocrit (H/H) were 6.4/20.8]. The reference ranges for hemoglobin is 12.0 - 16.0 gm/dL and for hematocrit it is 36.0 - 46.0 %. The physician documented that the patient's complaint was weakness and dyspnea (difficulty breathing) on exertion. The nursing assessment indicated the patient's vital signs were taken and the B/P was 115/48 and an oxygen saturation of 90% on room air. The physical assessment conducted by the nursing staff only indicated the patient had a few scattered wheezes. The patient was placed on 2 L (liters) of oxygen via a nasal cannula.

Based on the nurse's notes in the medical record reviewed on July 15, 2014 it could not be determined the time of the patient's arrival and when she was placed on oxygen because there was no space on the form to document this information. It could not be determined if she continued to receive oxygen throughout the transfusion and what was her mental status upon arrival and throughout her stay in the unit. There was no documentation to indicate if a physician was notified of the low oxygen saturation. It could not be determined which member of the nursing staff conducted this assessment on admission. The transfusion began at 4:15 PM and ended at 7:40 PM. At 8:30 PM the patient signed a document that she was refusing the second unit of blood. It could not be determined what time she left the unit and if she was still wheezing during the transfusion and when she was discharged from the unit.

During staff interviews conducted on July 14, 2014 at 1:55 PM, with Staff # 9, who is the patient's primary physician, he stated that one of his patients had antibodies so there was a delay in administering the blood. This was not documented in the medical record by either a nurse or a physician. He also stated that he was going back and forth before between two patients, one of whom was having a delay in starting the transfusion because she had antibodies. Patient #1 and patient #5 were the only patients receiving blood transfusions in the ASU on May 2, 2014. Furthermore, there was no documented evidence that patient #5 was provided post transfusion discharge instructions.

Documentation in patient #5's medical record, which was reviewed on July 15, 2014, notes that patient #5 returned to the unit the following day for the second unit of blood. The assessment of the patient only consisted of the vital signs and the pain score. There was no assessment of the patient's lung during this visit even though the nursing staff noted wheezing during the previous visit on May 2, 2014. There was no documentation of the patient's oxygen saturation upon arrival. It could not be determined at what time the patient was discharged from the unit. The last oxygen saturation was 95%, but it could not be determined if this was on room air or on oxygen. There was also no documentation that the patient was given Lasix 20 milligrams (mg) after the transfusion of each unit of blood as prescribed, and there was no evidence in the medical record that post transfusion discharge instructions were provided. The nursing assessment of the patient was inadequate throughout both of her visits in the unit.

(e) A similar finding was noted in patient #2's medical record when it was reviewed on July 14, 2014. In this record, Staff #4, one of the patient's nurses did not accurately identify the patient's abdominal distention in the recovery unit (after the patient had undergone a 3 hour procedure of Kyphoplasty) which was due to retention of 1800 cubic centimeters (cc) of urine on May 1, 2014.

(f) A similar finding was also noted in patient #6's medical record when it was reviewed on July 15, 2014. The patient presented to the facility on May 2, 2014 for transfusion of 1 unit PRBC. The nursing staff did not ascertain who the health care proxy was, did not conduct an adequate physical and mental status evaluation prior to, during and after the blood transfusion as only the oxygen saturation, pain score and vital signs were documented. There was no physician order for the transfusion and there was no evidence in the medical record that the patient was assessed to determine if there was a transfusion reaction. In addition, discharge instructions were not provided. The volume of PRBC that was transfused was only documented as "full amount given". This information is important because Staff #10, the Laboratory Director stated in an interview on July 14, 2014 at 2:40 PM that the volume of blood in a unit of blood can be from 250 cc - 350 cc.

(g) A similar finding was noted in the patient #7's medical record when it was reviewed on July 18, 2014. The patient presented to the unit for a transfusion of blood on May 22, 2014. The evaluation of the patient's physical and mental status was missing and the informed consent for the blood transfusion form was not signed by a physician. The nursing staff failed to ensure that completed consent form was in the medical record prior to the transfusion.

2. (a) Staff #3, stated during an interview on July 11, 2014 at 11:20 AM that it's the facility's policy that a history and physical examination should be performed prior to a blood transfusion is administered in the ASU. This protocol was not followed for patient #1 on May 2, 2014 as the nursing staff did not ensure that a physical examination was conducted prior to starting the transfusion. The record contained a physician assessment documented at 2:00 PM on May 2, 2014, six hours after the blood transfusion started.

During an interview conducted on July 14, 2014 at 1:55 PM Staff #9, the patient's primary physician stated he was unaware that a history and physical examination must be performed prior to beginning a blood transfusion.

(b) The nursing staff did not follow the facility's "Do Not Resuscitate" policy. A review of patient #1's medical record on July 11, 2014 revealed the nursing staff did not ascertain that the patient had a DNR/DNI status. The patient developed shortness of breath and was intubated in the ASU. The policy was subsequently followed when the nursing staff obtained a copy of the health care proxy from the patient's nursing home.

During an interview conducted on July 14, 2014 at 1:55 PM Staff #9, the patient #1's primary physician stated that the patient had a DNR/DNI status.

(c) The nursing staff did not obtain an order to transfer the patient from the ASU to the ICU. A review of patient #1's medical record on July 11, 2014 revealed the patient was transferred to the ICU, however, there was no order to transfer the patient from the ASU on May 2, 2014.

(d) During a review of patient #1's medical record on July 11, 2014 revealed the nurse did not document the Identi- Match Blood Bank number on the medical record for each unit of PRBC that was transfused on May 2, 2014.

A review of the "Identi-Match ID Bands" policy states "the identi-match number will be recorded on the transfusion tag."

During an interview conducted with Staff #3, the Supervisor of Surgical Services, on July 11, 2014, revealed this information was not documented on this medical record as per the hospital's policy.

(e) The nursing staff did not follow the "Blood Transfusion Guidelines" policy, last revised 8/12, which states that the facility must report the transfusion reaction to the Laboratory Services. Patient #1 developed severe respiratory distress on May 2, 2014, but the events surrounding these transfusions were not investigated at that time because the Laboratory Services was not notified in timely fashion. The Laboratory Services conducted an investigation a month later, after the the events that occurred on May 2, 2014 in patient #1.

3 (a). The facility's policy for administering oxygen requires a physician's order before it can be administered. This policy/practice is not safe for emergency situations. Also, there was no form or designated area on any form to document the administration of fluids and medications.

During an interview conducted on July 11, 2014, at 11:20 AM with Staff #3, who is the Supervisor of the Surgical Services, she stated that patient #1 received oxygen on May 2, 2014, when patient #1 developed shortness of breath, in spite of the facility's policy which requires a physician's order before oxygen can be administered.

(b) A review of the forms that are used during blood transfusions in the ASU revealed the forms were inadequate because there was no area or section to document comprehensive nursing assessments of the patient upon arrival, during the transfusion, and when the treatment is rendered.

Based on medical record reviews, reviews of the policies and procedures and staff interviews, the nursing staff did not administer medications as prescribed. This was found in 1 of 10 medical records reviewed, MR #5.

Findings include:

There was no documentation in the medical record that a patient was given Lasix. A review of patient #5's medical record on July 15, 2014 revealed this is a seventy-six year old patient who presented to the facility for transfusion of 2 units of PRBC on May 2, 2014. The physician ordered 20 milligrams (mg) of Lasix intravenously (IV) after each unit of blood. The patient received the units of blood on May 2 and 3, 2014, but there was no documentation that the patient received any of the drug that was prescribed.

A review of the medication administration policy on July 15, 2014 revealed that medications shall be administered only by the registered nurses and licensed practical nurses.

This finding was explained to Staff #1, from Quality Systems on July 15, 2014.

Based on medical records reviewed, policy reviews and staff interviews, the nursing staff failed to obtain written orders for medications. This was found in 1 of 10 medical records reviewed. This was found in medical record #1.

Findings include:

A nurse failed to ensure that a physician documented and signed a telephone order. A review of medical record #1 on July 11, 2014 revealed the patient developed shortness of breath in the ASU on May 2, 2014. The medical record revealed there were orders for Lasix IV and Nitroglycerine. There was no documented evidence that any physician gave the order, how much of each drug was to be given, and when they were to be administered. In addition, it could not be determined if the nurse gave the medication.

During an interview conducted on July 11, 2014, Staff #12 stated that on May 2, 2014, Staff #4, a registered nurse, obtained an order for Lasix.

A review of the "Telephone & Verbal Orders" policy states the nurse must "record the date, time and physicians name" when an order is received. The policy also states "the prescribing practitioner shall authenticate such orders within twenty-four hours (24) hours. There was no evidence in the medical record that the nursing staff followed this policy.

Based on medical record reviews, policy reviews and staff interviews, it was determined the facility failed to ensure that a medication was ordered by a physician. This was found in 1 of 10 medical records reviewed in the medical record for patient #1.

Findings include:

A nurse administered Lasix intravenously without documenting who gave the order, the dose that was given and the time that it was administered. A review of MR #1 on July 11, 2014 revealed this ninety-seven year old patient presented to the hospital for transfusion of 2 units of PRBC on May 2, 2014. The patient developed shortness of breath and became unresponsive while the second unit of blood was being administered. According to documentation in the medical record by the intensive care unit (ICU) nurse, the patient was given Lasix IV in the ASU and the patient was intubated and transported to the ICU. There was no documentation in the medical record that a physician prescribed the medication. There was no documentation to indicate how much Lasix was given, which nurse gave the drug and the time that the drug was given. The patient subsequently expired at 2:06 PM that day.

During an interview conducted on July 15, 2014, at approximately 2:30 PM, Staff #1, from Quality Systems, stated that she did not know who gave the order to administer the Lasix.

A review of the policy titled "Medications-Administration Guidelines" which was last revised 6/14, states "A medication order shall consist of the following components: Name of drug; dosage; route of administration; administration schedule and physician's signature." Based on the above findings the hospital's nursing staff did not follow this policy.