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Based on record review and interview, the hospital failed to ensure administered medications were properly documented. The deficient practice is evidenced by failure of the nursing staff to properly document the administration of medication in the Medication Administration Record (MAR) in 1 (#3) of 3 (#1-#3) reviewed medical records.

Findings:

Review of the nurse's note on 01/20/2023 at 2:00 a.m. revealed "'S9MD' at bedside. Pt boggy and massaged to firm. Large amount of rubra lochia present. 'S10MD' at bedside. Vaginal sweep done. Bakri attempted and unsuccessful. MTP initiated. Meds given per protocol. Will continue to monitor vaginal bleeding."

Review of the physician's notes on 01/20/2023 at 3:00 a.m. (documented as a late entry) for Patient #3 revealed IM Methergine twice, IM Hemabate, and tranexamic acid (TXA) were administered.

Review of the Medication Administration Record (MAR) for Patient #3 revealed there was no documentation the Hemobate, Methergine or tranexamic acid was administered. Further review of the MAR did reveal five overrides of the automated medication dispense system for Methergine.

In interview on 10/25/2023 at 3:38 p.m., S2DQ verified the documentation of the MAR did not show administration of any of the above listed medications. S2DQ verified the nurses notation of "Meds given per protocol" was not adequate and was not standard of care.

Based on record review and interview, the facility failed to ensure medical records contained documentation of all procedures performed. The deficient practice is evidenced by 1) failure to document the entire Code Blue event for 1 (#3) of 1 reviewed record of a patient who experienced cardiopulmonary arrest; 2) failure to accurately document the transfusion of blood products for 1(#3) of 3 (#1-#3) reviewed records of patients who received blood products;
Findings:

1) Failure to document the Code Blue event for 1 (#3) of 1 reviewed record of a patient who experienced cardiopulmonary arrest.

Review of the policy "Code Blue Management" revealed in part, "B. The Lead Physician will assign tasks to the team members as needed. . . The Code Blue event will be documented in EPIC under Code Documentation Flowsheet. . .The Code Blue committee will review Code Blue documentation and summarize data into ongoing process monitors that will be shared with the Critical Care Committee and other committees as warranted".

Review of the Exploratory Laparotomy Operative Report for Patient #3 revealed, "While moving pt to the OR table, there was concern for loss of consciousness with loss of pulse. A Code Blue was called and CPR was initiated. Given suspected EBL of >2L and pt status, massive transfusion protocol was initiated. ROSC was noted within seconds and the remainder of care was completed by the Code Team, who remained in the OR for the entirety of the case due to acuity of case and critical status of the patient. Of note, pt was noted to be in V Tach during their initial evaluation and required to be shocked several times with ROSC achieved."

Review of the Code Documentation Flowsheet for Patient #3 for the code in the operating room revealed most of the code was missing including documentation of the ventricular tachycardia and the use of the defibrillator.
In interview on 10/26/2023 at 11:01 a.m., S2DQ verified the Code Documentation Flowsheet for the Code Blue event in the operating room was incomplete.

2) Failure to accurately document the transfusion of blood products for 1(#3) of 3 (#1-#3) reviewed records of patients who received blood products.

Review of the policy "Massive Transfusion Protocol" revealed in part, "D.6.e. The Blood Checker is the CRNA. Responsibilities include: i. Prepare and manage fluid management system/rapid infuser ii. Check and administer blood products upon arrival from Blood Bank iii. Keep track of products administered via TOURO INFIRMARY MTP TRANSFUSION FLOWSHEET."

Review of the Exploratory Laporotomy/ Supracervical Hysterectomy Operative Report for Patient #3 revealed the patient received 8 units PRBC's, 5 units FFP, 2 units cryoprecipitate, and 1 pack of platelets.

Review of the medical record of Patient #3 revealed the transfusion of blood was not documented on the Touro Infirmary MTP Transfusion Flowsheet and the transfusion was not documented in intraoperative anesthesia record. Further review of the intraoperative anesthesia record failed to reveal the total fluids administered for the procedure and in the "Notable Events" section under "Blood Products" it listed "none."

In interview on 10/25/2023 between 2:58 p.m. and 4:45 p.m., S2DQ verified the transfusions of blood products in the operating room were not documented on the Touro Infirmary MTP Transfusion Flowsheet or the intraoperative anesthesia record.

Based on record review and interview, the Utilization Management (UM) Committee failed to review professional services provided to determine medical necessity and promote efficient use of available health facilities and services. The deficient practice is evidenced by failure to perform a review of the performance of physicians involved in the death of a healthy pregnant patient admitted for a routine delivery that was complicated by: 1)incomplete documentation of the use of uterotonic medications used as early intervention for post-partum hemorrhage in a patient experiencing uterine atony; 2) missing documentation of a code blue and evidence hospital policy and ACLS protocol was not followed for the two episodes of cardiopulmonary arrest; 3) failure of the medical staff to properly initiate the Mass Transfusion Protocol; 4) failure to document the blood products transfused; and 5) the failed placement of a cardiovascular catheter.

Findings:

Review of the Touro Infirmary Utilization Management Plan revealed in part, "utilization review is the process of making sure healthcare services are being used appropriately and effectively, which is a key component of a value-based approach to paying for health care. The goal of utilization review is to make sure patients get the care they need, that is administered via proven methods, provided by an appropriate healthcare provider, and delivered in an appropriate (missing the end)," and "The UM committee has the authority to carry out the utilization management function; perform prospective, concurrent and retrospective review of medical records for medical necessity, resource utilization, and provider performance."

Review of the provided Root Cause Analysis (RCA) revealed a review of the care provide to Patient #3 was performed. The RCA failed to evaluate the performance of the medical staff related to the following:

1) Incomplete documentation of the use of uterotonic medications as early intervention for post-partum hemorrhage in a patient experiencing uterine atony after delivery.

Review of the Caesarian Section Operative Report for Patient #3 revealed the patient was given IU Pitocin and IM Methergine after uterine closure. There was no dose for the 2 medications and the site of the IM injection was not documented.

Review of the Medication Administration Record (MAR) revealed the only uterotonic documented as administered during this surgery was 30 units Pictocin given IV twice by the CRNA.

Review of the physician's notes for Patient #3 on 01/20/2023 at 3:00 a.m. (documented as a late entry) revealed IM Methergine twice, IM Hemabate, and tranexamic acid (TXA) were administered.

Review of the anesthesia notes for Patient #3 on 01/20/2023, which were not timed, revealed documentation in the anesthesia plan prior to the exploratory laparotomy by the anesthesiologist that read, "Bring back to OR for PPH/uterine atony. S/p Jaeda ballon, Hemobate and Methergine with continued bleeding."

Review of the nurse's note on 01/20/2023 at 2:00 a.m. revealed "'S9MD' at bedside. Pt boggy and massaged to firm. Large amount of rubra lochia present. 'S10RMD' at bedside. Vaginal sweep done. Bakri attempted and unsuccessful. MTP initiated. Meds given per protocol. Will continue to monitor vaginal bleeding."

Review of the Medication Administration Record (MAR) for Patient #3 revealed there was no documentation the Hemobate, Methergine, or tranexamic acid was administered. Further review of the MAR did reveal five overrides of the automated medication dispense system for Methergine.

In interview on 10/25/2023 at 3:38 p.m., S2DQ verified the documentation of the MAR did not show administration of any of the above listed medications. S2DQ verified the RCA did not investigate if the utertonics were administered and did not review the care provided by medical staff including the provision of appropriate early intervention.

2) Missing documentation of a code blue that occurred in the operating room and evidence hospital policy and ACLS protocol was not followed for the two episodes of cardiopulmonary arrest.

Review of the policy "Code Blue Management" revealed in part, "The Code Blue Team will adhere to American Heart Association Advanced Cardiac Life Support Guidelines, Pediatric Advanced Life Support Guidelines, and the Guidelines of NRP . . . . II. The Primary Code Blue Team Composition, in part: H. Clinical pharmacist will attend during the hours of 8:30 a.m. to 5:00 p.m. Monday through Friday, excluding holidays. Pharmacist will be available for consultation by phone after hours, weekends, and holidays. IIIA. The lead Physician will identify his/her leadership role to the other team members. Lead Physician will direct the process of care per American heart Association (ASA) guidelines. B. The Lead Physician will assign tasks to the team members as needed. . . The Code Blue event will be documented in EPIC under Code Documentation Flowsheet. . .The Code Blue committee will review Code Blue documentation and summarize data into ongoing process monitors that will be shared with the Critical Care Committee and other committees as warranted".

Review of the Exploratory Laparotomy Operative report for Patient #3 revealed, "While moving pt to the OR table, there was concern for loss of consciousness with loss of pulse. A Code Blue was called and CPR was initiated. Given suspected EBL of >2L and pt status, massive transfusion protocol was initiated. ROSC was noted within seconds and the remainder of care was completed by the Code Team, who remained in the OR for the entirety of the case due to acuity of case and critical status of the patient. Of note, pt was noted to be in V Tach during their initial evaluation and required to be shocked several times with ROSC achieved."

Review of the Code Documentation Flowsheet for Patient #3 for the code in the operating room revealed:
01/20/2023 at 2:59 a.m. Documented patient asystole and compressions initiated
01/20/2023 at 3:00 a.m. Epinephrine 1mg IV administered
01/20/2023 at 3:03 a.m. Amiodarone 300 mg IV administered
01/20/2023 at 4:00 a.m. documented Sinus Tachycardia
01/20/2023 at 5:15 a.m. Patient transferred to ICU intubated

Review of the Code Documentation Flowsheet for Patient #3 for the code in ICU revealed:
01/20/2023 at 11:30 a.m. pulse 39 PEA with respirations 9
01/20/2023 at 11:33 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:35 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:37 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:40 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:42 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:44 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:46 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:48 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:50 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:52 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:54 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 11:56 a.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:00 p.m. pulse 205 and respirations 102.
01/20/2023 at 12:04 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:08 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:20 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:22 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:26 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:28 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:30 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:32 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:34 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:36 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:38 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:40 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:42 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:44 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:46 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:48 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:50 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:52 p.m. Interventions: pulse checks and compressions resumed.
01/20/2023 at 12:54 p.m. Interventions: none. Survival: No. Pronounced: S13MD
01/20/2023 at 1:00 p.m. Interventions: none. Pulse 11 and respirations 3.

Continued review of Code Blue Documentation failed to reveal either a Clinical pharmacist attended during the hours of 8:30 a.m. to 5:00 p.m. Monday through Friday or that a clinical pharmacist was available for consultation by phone after hours as per hospital policy.

In an interview on 10/25/2023 at 1:00 p.m., S12CPM reported not knowing whether the clinical pharmacist was part of the Code Blue Team during a Code Blue in the operating room as per hospital policy.

In an interview on 10/25/2023 at 3:32 p.m., S7CPM stated that the clinical pharmacist does not respond to codes in the operating room.

In interview on 10/26/2023 between 10:00 and 11:45 a.m. S2DQ verified documentation of the first Code Blue event was incomplete. S2DQ verified the root cause analysis did not address issues related to the lack of documentation of the Code Blue. S2DQ verified that ACLS protocol was not followed for Patient #3's first Code Blue event which her cardiac rhythm was asystole and the second Code Blue event which her cardiac rhythm was PEA protocol. When the cardiac rhythm for Patient #3 was asystole the only medication administered was Epinephrine 1mg IVP and Amiodarone 300mg IVP which is not ACLS protocol for asystole. When the cardiac rhythm was PEA no medications were administeredz, only chest compressions were performed which is not ACLS protocol. S2DQ verified the RCA did not identify problems with the management of the cardiopulmonary arrest and did not perform a peer review of the physicians who managed the codes. Education related to cardiopulmonary arrest and ACLS for the physicians was not documented.

3) Failure of the medical staff to properly initiate the Mass Transfusion Protocol (MTP).

Review of the policy "Massive Transfusion Protocol" revealed in part, "Massive Transfusion Protocol (MTP) is required when a patient loses ?30% of their total blood volume acutely or has ongoing massive blood loss. This guideline will address indications for MTP, what products will be provided, the transition to non-ratio-based resuscitation, and termination of the MTP. . . . B.1.ii. order for MTP by attending physician must be documented in the medical record. Blood Bank will notify attending physician if there is no order for MTP at deactivation of the protocol. . . Massive Transfusion Protocol (MTP) for Obstetric Hemorrhage may be activated by the attending physician when the patient is experiencing a Stage 3 hemorrhage with a blood loss of > 1500 cc. . . . D.3. The Labor and Delivery Charge RN/designee will notify the following when MTP is activated. This group constitutes the OB Hemorrhage Response Team: a. Director of MTP- Staff Obstetrician; b. Blood Bank; c. Lab; d. Anesthesia (CRNA and Anesthesiologist); e. House Supervisor. . . . D.5. Use of empiric fixed ratios should be followed until bleeding is controlled and/or specific lab data are available. . . . 6.d.i. Draw ABGs and MTP panel upon activation and every 30 minutes until MTP is deactivate. . . . 7. Upon activation of MTP, draw the following labs: a. Type and screen if still needed; b. CBC with diff; PT/INR and PTT; d. Fibrinogen; e. CMP; f. ABG."

Review of the provided RCA revealed the committee did not address why the MTP was never correctly activated.

Review of the nurse's note on 01/20/2023 at 2:00 a.m. revealed "'S9MD' at bedside. Pt boggy and massaged to firm. Large amount of rubra lochia present. 'S10RMD' at bedside. Vaginal sweep done. Bakri attempted and unsuccessful. MTP initiated. Meds given per protocol. Will continue to monitor vaginal bleeding."

Review of the operative report from 01/20/2023 for the exploratory laparotomy revealed, "Given suspected EBL of >2L and patient status, massive transfusion protocol was initiated."

Review of the orders for Patient #3 revealed the MTP activation or deactivation orders were never placed.

Further review of the medical record for Patient #3 revealed coagulation studies were not performed prior to initiation of the transfusions and labs were not drawn every 30 minutes once the transfusions were started. None of the blood products transfused were documented.

In interview on 10/25/2023 between 3:40 p.m. and 4:05 p.m., S2DQ verified the MTP was never correctly initiated and the blood bank was never notified. S2DQ verified if the protocol had been activated, the blood would have been sent to the operating room in sets as outlined in the policy and the physician would not have ordered the blood components individually. S2DQ verified if the physician had been familiar with the protocol, she would have known the purpose was to provide access to large amounts of pre-defined blood products in an expeditious manner, sets of blood would have been ordered rather than individual blood components. S2DQ verified Blood Bank attempted to contact someone in the operating room to clarify if a MTP had been activated because the Blood Band was never notified.

In interview on 10/26/2023 between 10:00 a.m. and 11:45 a.m., S2DQ also verified there was no peer review to establish if the provided care was appropriate, resources were efficiently used, and to establish the licensed providers' knowledge of the hospital's policies, especially those for blood transfusion and massive transfusion protocol. S2DQ verified there was no documentation the licensed providers received education related to the policies.

4) Failure of medical staff to document the blood products transfused.

Review of the policy "Massive Transfusion Protocol" revealed in part, "D.6.e. The Blood Checker is the CRNA. Responsibilities include: i. Prepare and manage fluid management system/rapid infuser ii. Check and administer blood products upon arrival from Blood Bank iii. Keep track of products administered via TOURO INFIRMARY MTP TRANSFUSION FLOWSHEET."

Review of the RCA revealed the patient received 8 units PRBC's, 5 units FFP, 2 units cryoprecipitate, and 1 dose of platelets.

Review of the medical record of Patient #3 revealed the transfusion of blood was not documented on the Touro Infirmary MTP Transfusion Flowsheet and not documented in intraoperative anesthesia record. Further review of the intraoperative anesthesia record failed to reveal the total fluids administered for the procedure and in the "Notable Events" section under "Blood Products" it listed "none."

On 10/25/2023 between 3:40 p.m. and 4:05 p.m. a review of the documentation of blood products released from the Blood Bank was performed twice by S2DQ and the surveyors. The review revealed Patient #3 actually received 9 units of RBC's, 6 units FFP, 10 units of cryoprecipitate and 0 units of platelets.

In interview on 10/25/2023 between 2:58 p.m. and 4:45 p.m., S2DQ verified the documented count of transfused blood products in the RCA was wrong. S2DQ verified the transfusions of blood products in the operating room were not documented on the Touro Infirmary MTP Transfusion Flowsheet or the intraoperative anesthesia record.

In interview on 10/26/2023 at 9:25 a.m., S2DQ verified the intraoperative anesthesia record did not contain the total fluids administered during the procedure.

In interview on 10/26/2023 between 10:00 a.m. and 11:45 a.m., S2DQ verified the facility did not perform a peer review on any of the licensed providers involved in the care of Patient #3 and there was no documentation the providers received education related to the hospital transfusion and MTP policies.

5) The failed placement of a cardiovascular catheter.

Review of hospital policy dated 02/2020, titled "Insertion of Central Line Catheter" revealed, in part: "3. Monitoring and Documentation, in part: All patients must be monitored during the procedure ...continuously until chest X-ray confirms line placement and the patient does not have pneumothorax present. 4. Central Line Catheter Procedure, in part: a) The patient is placed in the Trendelenburg position. i) A CXR is ordered to insure proper position of the central line. A CXR is also ordered for failed line placement."

Review of the "Anesthesia Procedure Notes" for Patient #3 revealed revealed an attempt at central venous catheter (CVC) placement in Patient #3's right internal jugular on 01/20/2023 at 3:47 a.m. The procedure was performed by S11AMD. Patient #3's location was in operating room and the position was documented as "no Trendelenburg." The procedure note contained no explaination as to why the patient was not in Trendelenburg position as required by hospital policy.

Further review of "Anesthesia Procedure Note" revealed the initial CVC placement procedure was aborted at 4:13 a.m. due to hematoma and coagulopathy. The "XR Chest" was ordered at 6:37 a.m. The "XR Chest" was ordered 2 hours and 24 minutes following the failed CVC placement attempt.

A review of hospital's root cause analysis failed to reveal a peer review was completed to analyze the services provided by the medical staff involved in the failed attempt at CVC placement in Patient #3. The RCA did look at ways reduce the time for an intraoperative x-ray, but did not address the delay in ordering the x-ray for the failed CVC placement.

In an interview on 10/26/2023 at 1:30 p.m., S2DQ verified a peer review was not performed to analyze the services provided by the licensed providers involved in the failed CVC placement procedure that occured on 01/20/2023 at 3:47 a.m.


47397

Based on record review and interview, the facility failed to develop policies to reduce documentation errors and ensure patient safety in the operating room. The deficient practice is evidenced by 1) failure to provide guidelines in the blood administration policy for documentation of two person verification of blood administered in the operating room by anesthesia staff; and 2) failure to specify who responds to a Code Blue event in the operating room or other restricted areas.

Findings:

1) Failure to provide guidelines in the blood administration policy for documentation of two person verification of blood administered in the operating room by anesthesia staff.

Review of the policy "Transfusion of Blood and Blood Components" revealed in part, "Two person verification of blood products are done with the blood navigator/blood admin flowsheet in the EHR."

Review of the medical record for Patient #1 revealed the administration of blood products was documented by anesthesia staff on the intraoperative anesthesia record. There was no documentation of two person verification of the blood prior to administration.

In interview on 10/26/2023 at 1:22 p.m., S9CRNA verified there is no place in the intraoperative anesthesia record to document a two person verification. S9CRNA verified he was told that scanning the bar code on the blood was the equivalent of the two person verification, but he was not aware of a policy that verified the practice.

2) Failure to specify who responds to a Code Blue event in the operating room or other restricted areas.

A review of hospital policy titled "Code Blue management" revealed, in part: "Purpose: The purpose of the Code Blue team is to ensure the prompt and skilled cardiovascular and cerebral resuscitation of persons who suffer a cardiopulmonary arrest. The purpose of this policy is to outline the role and responsibilities of the Code Blue Team members. I. Procedure, in part: B. The Code Blue Team will adhere to American Heart Association Advanced Cardiac Life Support Guidelines ...II. The Primary Code Blue Team Composition, in part: H. Clinical pharmacist will attend during the hours of 8:30 a.m. to 5:00 p.m. Monday through Friday, excluding holidays. Pharmacist will be available for consultation by phone after hours, weekends, and holidays. V. Documentation of Code Event: A. Code Blue Documentation will be completed throughout event by charge nurse of the unit where code event occurred. Charge nurse may delegate documentation to another nurse of same department. B. The Code Blue event will be documented in EPIC under Code Documentation Flowsheet."

On 01/20/2023 Patient #3 had two Code Blue events. Only the end of the first code which occurred at 2:59 a.m. was documented. Review of the documentation failed to reveal if the pharmacist was available for consultation.

Review of Code Blue Documentation for the second code event for Patient #3, which occured about 11:30 a.m., failed to reveal that a clinical pharmacist was present or available for consultation during the code as per hospital policy.

In an interview on 10/25/2023 at 1:00 p.m., S12CPM reported not knowing whether the clinical pharmacist was part of the Code Blue Team during a Code Blue in the operating room as per hospital policy.

In an interview on 10/25/2023 at 3:32 p.m., S7CPM stated that the clinical pharmacist does not respond to codes in the operating room.


47397

Based on record review and interview, anesthesia services failed to document an updated and accurate pre-anesthesia evaluation. The deficient practice is evidenced by an inaccurate pre-anesthesia assessment in 1 (#3) of 2 (#1, #3) reviewed medical records with surgical procedures.

Findings:

Review of the anesthesia "Preprocedure Note" for Patient #3 prior to returning to the operating room for emergency laparotomy revealed, "Cardiovascular; negative ROS and normal exam.; Rhythm: regular; Rate: normal."

Review of the vital signs for Patient #3 revealed her pulse was 114 at 2:26 a.m. prior to returning to the operating room. The vital signs also indicated the patient had been hypotensive and tachycardic since the leaving the operating room after the cesarean section at 1:30 a.m..

In interview on 10/26/2023 at 9:36 a.m., S2DQ verified the documentation was inaccurate and was probably copied from a previous examination.

Based on record review and interview, anesthesia services failed to document all care provided during the course of anesthesia. The deficient practice is evidenced by 1) failure to document the transfusion of blood and failure to document the total IV fluids in 1 (#3) of 2 (#1, #3) reviewed medical records with surgical procedures; and 2) failure to document two signature verification of blood products before administration.

Findings:

Review of policy #ANES.1001, "Anesthesia Care Documentation," revised 01/2020, revealed in part, "Purpose: To provide a permanent record of all care during the patient's course of anesthesia care."

Review of the policy "Massive Transfusion Protocol" revealed in part, "D.6.e. The Blood Checker is the CRNA. Responsibilities include: i. Prepare and manage fluid management system/rapid infuser ii. Check and administer blood products upon arrival from Blood Bank iii. Keep track of products administered via TOURO INFIRMARY MTP TRANSFUSION FLOWSHEET."

1) Failure to document the transfusion of blood and failure to document the total IV fluids

Review of the Exploratory Laporotomy/ Supracervical Hysterectomy Operative Report for Patient #3 revealed the patient received 8 units PRBC's, 5 units FFP, 2 units cryoprecipitate, and 1 pack of platelets.

Review of the medical record of Patient #3 revealed the transfusion of blood was not documented on the Touro Infirmary MTP Transfusion Flowsheet and not documented in intraoperative anesthesia record. Further review of the intraoperative anesthesia record failed to reveal the total fluids administered for the procedure and in the "Notable Events" section under "Blood Products" it listed "none."

In interview on 10/26/2023 at 9:25 a.m., S2DQ verified the "MTP Transfusion Flowsheet" was not filled out and the intraoperative anesthesia record did not contain the total fluids administered during the procedure.

2) Failure of anesthesia staff to document two signature verification of blood products before administration.

Review of the policy "Transfusion of Blood and Blood Components" revealed in part, "Two person verification of blood products are done with the blood navigator/blood admin flowsheet in the EHR."

Review of the medical record for Patient #1 revealed the administration of blood products was documented by anesthesia staff on the intraoperative anesthesia record. There was no documentation of two person verification of the blood prior to administration.

In interview on 10/26/2023 at 1:22 p.m., S9CRNA verified there is no place in the intraoperative anesthesia record to document a two person verification. S9CRNA verified he was told that scanning the bar code on the blood was the equivalent of the two person verification, but he was not aware of a policy that verified the practice.