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Based on interview and document review, the facility failed to clarify the current policy and procedures for blood or blood products administration to be consistent with the actual practice performed by the nurses when obtaining the blood or blood products. The deficient practice had the potential for the facility failing to establish a standard process in blood administration for the patients.

Findings include:

The facility's Blood Administration policy last revised in July 2021, documented when obtaining the blood component from the Transfusion Service Department, present two patient identifiers and the Blood Band Identification number. Facilities may have a site-specific blood dispensing form.

The site-specific blood dispensing form was not specified nor attached in the policy.

At the time of the inspection, the facility utilized two different Request for Blood or Blood Products forms. One form was dated October 2019 and used in all nursing units, except the Emergency Department (ED), and had a generic code to be used to access the pneumatic tube station (dispensing system used in obtaining blood or blood products from the blood bank) located in each nursing station.

Another form was revised on 07/26/2023 for temporary use in ED. The form documented the tube station secure code was the last four digits of the Blood Bank Armband Number which was patient specific.

On 08/18/2023, during the initial tour of the facility, a total of 26 Registered Nurses (RN) assigned in each nursing unit explained the process in blood transfusion which included obtaining the blood or blood products. The RNs indicated the facility utilized the pneumatic tube station in sending the request form to the laboratory/blood bank and obtaining the blood or blood products using the four-digit code.

On 08/23/2023 at 1:00 PM, the Quality Director confirmed the current Blood Administration policy did not mention the use of the pneumatic tube station or system in obtaining the blood or blood products. The Quality Director acknowledged there were inconsistencies with the policy, procedures, and the actual practice in obtaining the blood and blood products. The Quality Director revealed the Blood Administration policy was owned or originated from Risk Management while the Request for Blood or Blood Products forms were created by Laboratory Services.

The Quality Director confirmed the Quality Assurance and Performance Improvement (QAPI) Committee was responsible for making sure the forms, policy, procedures, and actual practices in blood and blood products administration were consistent. The Quality Director acknowledged it could have created confusion among the nurses in the provision of care such as blood transfusion if there were inconsistencies in the policy, procedures, and actual practices. There should have been a standard process in the provision of care. The Quality Director indicated QAPI and Risk Management should have reviewed and validated if the forms, policies, procedures, and practices in blood administration were consistent.

On 08/24/2023 at 10:00 AM, the Chief Nursing Officer (CNO) explained having reviewed and approved policies pertaining to nursing services. The CNO confirmed the current Blood Administration policy should have been clarified to include the details on the use of the pneumatic tube station for dispensing blood and blood products. The CNO revealed the policy should have indicated the specific blood dispensing form and documented as Annex A attached to the policy. The CNO acknowledged it was essentially important for the actual process or procedures to be aligned with the policy.

The CNO asked the Quality Director to verify with the Manager of Laboratory on when the facility started to use the pneumatic tube system. Upon verification, the Quality Director stated the system had been utilized since the facility opened in 2016.

Based on interview, record review and document review, the facility failed to ensure the nurses followed the required two-nurse verification of correct patient and correct blood product prior to blood transfusion, utilized the facility's blood transfusion safety application (software), and completed the facility's mandatory blood transfusion administration training.

The cumulative effect of these deficient practices resulted in the failure of the facility to deliver statutory-mandated care to the patient of concern. (See Tag A0410).

Complaint #NV00069223

Based on interview, record review and document review the facility failed to ensure the nurses employed a safe two-nurse verification for a blood transfusion for 1 of 30 sampled patients (Patient 1); used the facility's blood transfusion safety software for 4 of 30 sampled patients (Patient 1, 8, 15, and 26); and nurses completed the mandatory Bridge Blood Transfusion Administration policy for 6 of 28 sampled Registered Nurses (RN) (RN 1, RN 2, RN 11, RN 12, RN 19, and RN 20). The failure to follow the two-nurse verification process for blood transfusion and not using the blood transfusion safety software resulted in a transfusion of an incompatible blood product resulting in a blood transfusion reaction.

Findings include:

The facility policy titled Blood Administration Policy revised 07/2021, documented in Section D: Verification of Blood or Blood Component with the Crossmatch Tag.

1. At the patient's bedside, two licensed providers, including at least one RN, will:

a. Complete blood transfusion documentation in the electronic medical record (EHR). Follow the prompts to begin the transfusion process.
b. Have the patient verbally identify him or herself to the transfusionist, if possible.
c Compare the patient's name, birthdate, and medical record number on the patient identification band with name, birthdate, and medical record number on the blood bank identification band and on the crossmatch tag.

2. The blood bank identification band will be present on the patient and the numbers on the identification band will match the number on the crossmatch tag and on the blood/blood component.

The facility policy titled Transfusion Reaction Investigation revised 05/29/2023, documented the greatest risk of morbidity and mortality from transfusions is from adverse reactions that occur during or shortly after the infusion. In particular, the five most common causes of transfusion related fatality are from Transfusion related Acute Lung Injury (TRALI), Acute Hemolytic Transfusion Reaction (AHTR), sepsis and microbial infection also known as Transfusion Transmitted Infection (TTI), Transfusion Associated Circulatory Overload (TACO) and anaphylaxis.

Patient 1 (P1)

P1 was brought into the Emergency Department (ED) on 07/17/2023 at11:56 AM via ambulance, with a listed chief complaint: The patient was found at home by the son unconscious and unresponsive. An ambulance was called and was taken to the ED. P1 had a medical history of acute myeloblastic leukemia and had a do not resuscitate directive.

The physician documented in the ED notes: P1 will be admitted for intravenous antibiotics, blood, and platelet transfusion.

An ED physician's order dated 07/17/2023 at 1:28 PM, to transfuse two units of red blood cells.

The Discharge Summary dated 07/17/2023 at 9:18 PM, documented patient was started on blood transfusion and platelet transfusion as ordered by the ED physician. The patient had an incident where the patient was given somebody else's blood. The admitting physician documented witnessing P1 going into cardiac arrest. P1 death pronouncement was 07/17/2023 at 8:12 PM.

On 08/22/2023 at 1:30 PM, the Core Laboratory Transfusion Services System Manager and the Laboratory Medical Director explained as part of the post transfusion reaction laboratory work-up a pre and post transfusion blood sample would be tested for incompatibility. The laboratory results were consistent with a transfusion reaction. Based on the analysis the results were consistent with AHTR.

On 08/18/2023 at 3:10 PM, the RN discovering the wrong blood infusing to P1, the Quality Manager, the Director of ED and the ED Manager confirmed the transfusing RN, and the verifying RN did not practice safely by not properly identifying the correct blood to be transfused with the correct patient. The nurses did not employ basic nursing procedures for verification in blood transfusion practices.

On 08/22/2023 at 10:40 AM, the Quality Manager explained the facility utilized an electronic health record (EHR) with an additional software called "Bridge". Bridge software was designed for blood transfusion documentation which incorporates safety features to verify the correct patient, correlating the blood to be transfused with the current type and cross for the patient's blood type. Such software was incorporated into the EHR to prevent blood transfusion errors and promote patient safety. The Quality Manager indicated all nurses and transfusions should utilize the Bridge software by hospital policy.

P1's medical record lacked documented evidence that the Bridge verification software was utilized prior to the transfusion of the red blood cells.

P1's medical record documented the transfusing RN, and the verifying RN utilized a bypassed method wherein the transfusion information was entered manually bypassing the security features imbedded into the EHR.

An additional 29 sampled patient records who had received blood/blood products were reviewed and the following practices were identified:

Patient 8 (P8)

P8 was seen in the ED on 06/19/2023 at 9:05 AM, with an ED documented evaluation of possible ruptured aortic aneurism. A unit of blood was ordered and transfused as soon as possible.

P8's EHR documented a Transfusion Summary dated 06/19/2023 at 12:56 PM. P8's EHR lacked documented evidence the Bridge software was utilized. The Transfusing RN, and verifying RN manually entered transfusion data at 12:32 PM.

Patient 15 (P15)

P15 was seen in the ED on 05/30/2023 at 3:09 AM, with an ED documented evaluation of acute ascites, acute anemia, and cirrhosis. The patient was anemic and receiving a blood transfusion.

P15's EHR documented a Transfusion Summary dated 05/30/2023 at 8:18 AM. P15's EHR lacked documented evidence the Bridge software was utilized. The Transfusing RN, and verifying RN manually entered transfusion data at 8:05 AM.

Patient 26 (P26)

P26 was seen in the ED on 04/11/2023 at 3:26 PM, with an ED documented evaluation of forearm laceration and hypotension due to blood loss.

P26's EHR documented a Transfusion Summary dated 04/11/2023 at 5:01 PM. P26's EHR lacked documented evidence the Bridge software was utilized. The Transfusing RN, and verifying RN manually entered transfusion data at 4:45 PM.

On 08/24/2023 at 12:35 PM, the Quality Manager confirmed the three additional transfusion records did not utilize the use of the Bridge software and the nurses had manually entered transfusion data. The Manager acknowledged such practices were not specific to hospital standards.

On 08/18/2023 in the afternoon, based on interviews of 28 RNs, a consensus for two nurse verification process and the use of the Bridge software had to be utilized for all blood/blood products transfusions.

On 08/23/2023 at 2:43 PM, the Chief Nursing Officer (CNO) indicated the hospital expects all nurses to properly employ two nurses blood verification processes. The CNO acknowledged a properly executed two nurse verification would be vital as one the first line of defense for any blood transfusion error, The CNO expected all nurses would utilize the hospital EHR Bridge software for all blood/blood product transfusion infusions except for downtime (when staff must use paper documentation when the EHR is not operating).


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Mandatory Blood Transfusion Administration training

On 08/22/2023 at 8:30 AM, the Education Manager explained a mandatory training on blood transfusion administration was uploaded in the facility's online training system on 05/15/2023 with a deadline of completion date of 06/19/2023. The Education Manager revealed the training course was identified as not having been assigned annually in the online training system and would not have prompted the target participants such as the registered nurses (RN) to complete as scheduled. As a corrective measure, the Education Manager uploaded the training on 05/15/2023.

The Education Manager indicated the mandatory blood transfusion administration training included the utilization of the facility's blood transfusion safety application (software) and the required two-nurse verification of correct patient and correct blood product prior to blood transfusion. The Education Manager indicated all RNs had access to the online training system. The RNs would have received an electronic mail (email) when a mandatory training was uploaded in the system with the due date of the completion of the training. An email reminder would have been received by the RNs a week prior to the deadline.

A review of the training transcript report of 28 sampled RNs revealed the following RNs did not complete the mandatory blood transfusion administration training mentioned above:
- RN 1 (assigned in Emergency Department)
- RN 2 (assigned in Emergency Department)
- RN 11 (assigned in Neonatal Intensive Care Unit)
- RN 12 (assigned in Neonatal Intensive Care Unit)
- RN 19 (assigned in Outpatient Center)
- RN 20 (assigned in Post-Anesthesia Care Unit)

On 08/22/2023 at 10:23 AM, the Education Manager confirmed the findings and acknowledged the RNs should have completed the mandatory blood transfusion administration training on 06/19/2023. The Education Manager explained the Neonatal Intensive Care Unit, Outpatient Center, and Post-Anesthesia Care Unit were missed when the training was uploaded into the system on 05/15/2023, so the RNs in the three units were not prompted regarding the completion of the training. The Education Manager revealed the training was facility-wide and all nursing units should have been included when the training was uploaded into the system.

On 08/22/2023 at 12:35 PM, the Emergency Department (ED) Director confirmed having access to the online training system to verify compliance with the mandatory training for ED nurses. The ED Director indicated the ED nurses were expected to complete the mandatory training uploaded or assigned in the online training system.

On 08/23/2023 at 10:13 AM, an Intensive Care Unit (ICU) RN revealed having access to the online training system and had received an email reminder when a mandatory training was uploaded to the system with the deadline of the completion date. The ICU RN would have completed the online training as required.

On 08/23/2023 at 10:19 AM, another ICU RN confirmed having been reminded through an email when a mandatory training was posted in the online training system. The ICU RN would have logged on to the system and completed the training as mandated.

On 08/23/2023 at 10:24 AM, an ICU Clinical Manager indicated checking the ICU nurses' compliance with the mandatory training by logging in on the online training system regularly. The nurses would then be reminded of the deadline for completing the training.

On 08/23/2023 at 2:49 PM, the Chief Nursing Officer (CNO) explained the nurses were expected to complete the mandatory training in the online training system. A corrective action such as a disciplinary action should have been served if the nurses did not comply with the mandatory training. The CNO indicated the unit managers and directors should have been proactive and reminded the nurses for the completion of the mandatory training. The CNO acknowledged the unit managers and directors should have pulled out a report from the online training system at the end of each month and verified compliance of the nurses with the mandatory training.

The Course Overview of the mandatory blood transfusion administration training documented the learning objectives of the course. At the conclusion, participants should be able to:
- Start and complete a blood transfusion
- Chart Vital Signs during a blood transfusion
- Document a transfusion reaction
- Hold and resume a blood transfusion already in process
- Perform a Rapid Start for an emergent blood transfusion
- Handle a blood mismatch while starting a blood transfusion

The facility's policy titled Annual Mandatory Education and Employment Requirements dated November 2022, documented all employees and contract services staff were required to successfully complete the mandated education training annually via the facility's online training system. Timely completion was required annually. The manager would be responsible for ensuring their staff completed the annual mandatory education and monitoring for staff compliance for their department.

Complaint #NV00069223