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Based on observation and document review, it was determined that the Governing Body failed to ensure that all hospital services were provided in a safe manner to meet the needs of all patients.


The hospital was notified of an Immediate Jeopardy situation by NYSDOH Laboratory Services on 5/12/16 and was given a directive to provide an immediate plan of correction to address the issues of delays in obtaining results for STAT blood type and screen.

See Tag 576
Although the Governing Body was aware that this was an ongoing issue, the facility failed to implement an effective plan to address the Immediate Jeopardy situation (see Tag 576) and had not addressed the ongoing issues related to the laboratory services.

See findings below.

These failures affected the effectiveness and safe delivery of care and may have placed patients at risk for potential harm.


Findings:

Review of documents identified that the Governing Body did not monitor, develop and implement corrective actions in response to ongoing issues identified with the delivery of laboratory services.


a. The Governing Body minutes for December 2015 did not reflect any information regarding the NYSDOH Laboratory Services visit to the facility in November 2015, or that they were aware of continuing issues related to the blood bank.

b. There was no evidence that the Governing Body provided adequate oversight to the Medical Executive Committee, regarding the serious issues identified in processing of blood and/or blood products in an acceptable turnaround time at either the facility or the contracted entity.

c. Minutes from the Transfusion Committee for March 16, 2016 identified that the staffing shortage at the contracted entity was affecting the timely processing of blood bank specimens. The report briefly noted that they had reached out to Department Chairs regarding the review of monthly transfusion indicators but there was no response.

d. Review of the Minutes of the Medical Executive Committee, dated April 18, 2016, noted that STAT orders for red blood cell (RBC) transfusions had achieved a 54% turnaround time (TAT) compliance of five hours. Type and Screen STAT orders were at 65% . The committee concluded that the goals for both STAT RBC orders and STAT Type and Screen testing were not met and that the delays were due to inadequate staff at the contracted entity.


During interview of Staff # K, Administrative Director of Blood Bank on 5/19/16 at 11:50 AM, the director stated the facility has relied on the contracted entity to perform its Type and Screen and cross matching services since 2013. The director confirmed the shortage of staff at the contracted entity and the challenge in hiring new staff persons. No other alternatives have been attempted by the facility.

There was no documented evidence that the Medical Executive Committee reported these findings to the hospital's Governing body.

Based on document review and staff interview, it was determined that the hospital failed to ensure corrective actions were developed and implemented for the indicators for Laboratory Services. Specifically, a quality improvement plan was not developed to address the facility's continued failure to meet the goal for acceptable turnaround times for blood bank testing.

This failure may have placed patients at risk for adverse blood transfusion outcomes.



Findings include:


Review of the minutes of the Transfusion Committee and Medical Executive Committee dated December 2015 through April 2016, found that the facility did not meet the goal for completing orders for STAT Red Blood Cell Count (RBC) and STAT Type and Screen within the acceptable turnaround time of within five (5) hours.

The unacceptable turnaround times were noted in the minutes as follows:

November 2015, STAT RBC orders turnaround time 54%; STAT Type and Cross orders 65%. The conclusion was noted as testing delay at the contracted entity.

December 2015, STAT RBC orders turnaround time 51%; STAT Type and Cross orders 61%.

January 2016, STAT RBC orders turnaround time were at 50%; STAT Type and Cross
orders 63%. No conclusion was noted.

February 2016, STAT RBC orders turnaround time 48.9%; STAT Type and Cross orders 66%. The conclusion was noted as testing delays staffing at the contracted entity.

April 2016, STAT RBC orders turnaround time 54%; STAT Type and Cross orders were at 65%. The conclusion was noted as delay due to short staffing at the contracted entity.


There was no evidence that a quality improvement plan was developed and implemented to address the ongoing failed outcomes with the blood bank testing which were reported in the hospital Quality Improvement Minutes.

During interview of Staff # K, Administrative Director of Blood Bank on 5/19/16 at 11:50 AM, the director stated the facility has relied on the contracted entity to perform its Type and Screen and cross matching services since 2013. The director confirmed the shortage of staff at the contracted entity and the challenge in hiring new staff persons. No other alternatives have been attempted by the facility.

Based on medical record review, document review, interview and deficiencies identified by the Clinical Laboratory Evaluation Program, the facility failed to ensure that the time frame for STAT blood testing was met.

This failure may have placed the health and safety of the patients at risk for adverse outcomes.


Findings include:

Review of the medical record for Patient #28 identified an order for routine blood transfusion was received on 5/12/16 by fax at 1:03 PM. At 1:11 PM a second order was received, this one was for a STAT transfusion. There is no evidence in the medical record that the STAT order for transfusion was implemented within the (5) five hour window.

During interview with the Administrative Director of Blood Bank on 5/19/16 at 11:50 AM, the director stated the staff noted the order, he did not act upon it or notify the prescribing physician. The staff did not seek clarification from the provider and this resulted in a delay in processing the STAT request.


The NYSDOH Laboratory Services identified serious concerns regarding the failures in turn around times in the blood bank and staff training. These concerns were brought to the facility's attention on 5/12/16. The facility has not implemented a plan of correction that addresses delays in the provision of services.

At interview on 5/13/16 at 11:30 AM, the Medical Director of the Blood Bank admitted that they were still experiencing delays in processing times. The new Administrator of the Blood Bank also verified this and stated that attempts are currently being made to procure additional staff.