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Based on a review of facility documentation, policies, and staff interviews (EMP), it was determined that Geisinger Lewistown Hospital failed to follow their Performance Improvement Plan by failing to ensure that a rapid response code, a patient transfer to a higher level of care, and a blood transfusion reaction was addressed as per their Plan for of one of six events reviewed.

Findings include:

Review of facilty policy Risk Management/Patient Safety Manual-System ... Policy 06.01 ... Section 6.0 Improving Organizational Performance ... Title Identification of Events and Patient Safety Reporting ... dated January 10, 2017, ... revealed, "... Policy: ... All employees and medical staff are required to report any event, condition, or situation that compromises patient safety or the quality of patient care to their immediate supervisor and the facility or system Patient Safety Officer. ... Responsibilities: ... In addition, all staff is responsible for reporting all incidents, infrastructure failures, patients safety/adverse/serious/sentinel events and near misses of which they are aware to the Risk Management/Patient Safety Department via the MIDAS reporting system. ... Reporting and Documentation of Incident/Event: All incidents/events and infrastructure failures shall be reported into the MIDAS System. ... ."

Review of Geisinger Policy 10.23 ... Rapid Response Team, reviewed June 8, 2016, was conducted. "... 12. RRT Documentation. Inpatient RRT: The responding Critical Care nurse should complete documentation in EHR using the Rapid Response Flow Sheet. ... At GLH, the RN providing care to the patient that the RRT was called on should complete the Rapid Response Flowsheet, with the assistance of the Critical Care nurse, if needed. The Charge Nurse will confirm the RRT form is completed. Outpatient or Non-Patient RRTs: (e.g. outpatient, visitor, volunteer or employee): The Nursing Supervisor should fill out a MIDAS report. ... ."

1. MR1 revealed, "... unresponsive to painful stimuli or verbal shout. Pt had peripheral pulse at that time and a RRT was called. ... ."

An interview conducted with EMP3 and EMP1 on February 23, 2017, at approximately 1:30 PM. EMP1 and EMP3 stated that it would be the facility's expectation for a MIDAS report to be completed on an inpatient RRT as well as on outpatient or non-patient.

An interview was conducted with EMP3 on February 22, 2017, at approximately 2:25 PM. EMP3 confirmed that there was no MIDAS report completed for this patient (MR1) ... ."

Review of Blood Bank Manual - GLH Geisinger, Policy glhadmin007. Section: Quality Control. Title: Investigation of Complaints, dated July 20, 2016, revealed, "Principle: The purpose of this policy is to assure the prompt investigations of complaints and/or problems which are the result of a breakdown in communication between the Laboratory and its users. ... Procedure: 1.0 Midas Incident Reporting Program are used to address concerns between departments and entities through the Geisinger Health System for both inpatients and outpatients. The individual generating the inquiry will enter all of the factual information into the Midas reporting program. The incident report is then sent to Risk Management and other involved departments. Risk Management will review and maintain a complete file of Midas inquires. Within the Departments of Laboratory Medicine, it is the responsibility of the Laboratory Manger to assure the timely investigation of QI inquires by appropriate Laboratory personnel. Significant trends or concerns are communicated to the Laboratory Chairman. ... ."

1. MR1 "... Progress Notes. Date of Service:12/17/16 1130 ... Progress Note - Hematology ... Subjective: Still sob, patient has Neutropenic fever post chemotherapy for SCLC. AS HD, CHF, post red packed cells transfusion, possible acute lung injury post transfusion ... ."

EMP2 on February 22, 2017, at 2:00 PM confirmed that a MIDAS report was not generated.

Based on a review of facilty documents, medical records (MR) and staff interviews(EMP), it was determined that Geisinger Lewistown failed to follow their adopted policy regarding administration of blood/blood products in nine of 19 medical records reviewed. (MR2, MR3, MR5, MR7, MR9, MR13, MR14, MR17 and MR18).

Findings include:

Review of Administration of Blood/Blood Products, dated April 2016, revealed, "... Prepare patient ... 5. Assess patient: 1. Include vital signs (TPR and BP) within 15 minutes prior to the start of the transfusion, after the first 15 minutes of transfusion and every hour. Also record vital signs after the transfusion has been discontinued. Staff is encouraged to stay with the patient for the first 15 minutes when started the transfusion. 2. I &O's will be done on all patients receiving blood ... ."

1. MR2 dated January 17, 2017, and January 19, 2017, revealed no documented evidence of vital signs upon completion of blood transfusion and on January 19, 2017, it was noted that one set of hourly vital signs were not documented.
MR3 undated, revealed no documented evidence of vital signs upon completion of blood transfusion.

MR5 dated January 20, 2017, revealed no documented evidence of 15 minute check of vital signs during blood transfusion.

MR7 dated February 14, 2017, revealed no documented evidence of one hourly set of vital signs during blood transfusion.

MR9 dated February 17, 2017, revealed no documented evidence of 15 minute set of vital signs after beginning and at the completion of blood transfusion.

MR13 dated February 2, 2017, revealed no documented evidence of a 15 minute set of vital signs prior to the beginning of blood transfusion.

MR14, dated February 2, 2017, revealed no documented evidence of hourly vital signs during transfusion.

MR17 dated February 3, 2017, revealed no documented evidence of a 15 minute set of vital signs prior to the beginning of blood transfusion and at the completion of the blood transfusion.

MR18 dated February 5, 2017, revealed no documented evidence of a 15 minute set of vital signs prior to the beginning of blood transfusion and at the completion of the blood transfusion.

An interview on February 24, 2017, EMP2 confirmed the above findings.