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Based on documents reviewed and interviews the Medical Staff failed to ensure the quality of care provided to patients for 4 (Patients #2, #3, #4, and #9) of 7 Neonatal Intensive Care Unit (NICU) patients in a total sample of 10 patients who had procedures, diagnostic studies or heart surgery performed at Hospital #2.

Findings included:

Hospital #1 policy titled, Use of Hospital Blood Products at Hospital B, dated 3/20/17, indicated staff administered blood products issued by Hospital #1 at Hospital #2. The policy indicated that a Blood Transfusion Record was available in Hospital #2's operating room for documentation. The policy indicated that operating room staff documented other information in Hospital #2's operating room notes. The policy indicated that Hospital #2's operating room Registered Nurses documented blood products issued by the Hospital #1 and administered in Hospital #2's operating room. The policy indicated that Hospital #2 reported to Hospital #1, blood product transfusion reactions of blood issued from Hospital #1 and administered at Hospital #2.

The reference book titled Standards for Blood Banks and Transfusion Services, 30th Edition, dated 4/21/16 page 45 and Standard # 5.29, indicated the patient's medical record included the date and time of transfusion, pre-transfusion and post-transfusion vital signs, the volume of blood transfused, the transfusionist and, if applicable, transfusion-related adverse events.

The Surveyor interviewed NICU Charge Nurse #1, at 9:15 A.M. on 5/8/17. NICU Charge Nurse #1 said that patients (NICU babies) had gastrointestinal procedures, imaging studies, and cardiac surgery for Patent Ductus Arteriosus (PDA, heart defect) conducted at Hospital #2 and the NICU babies returned to Hospital #1 after the procedure, diagnostic study or PDA heart surgery.

NICU Charge Nurse #1 said that Patients #2, #3 and #4 had a jejunostomy feeding tube (tube placed into the infant's intestine) procedure conducted at Hospital #2.

Medical records of Patients #2, #3 and #4 indicated the nurses fed babies by a jejunostomy feeding tube.

Medical records of Patients #2, #3 and #4 indicated no documentation by the providers at Hospital #2 of the jejunostomy feeding tube procedure placement or the response of Patients #2, #3 and #4 to the jejunostomy feeding tube placement.

The Physician Note, dated 5/28/17 at 10:25 A.M., indicated Patient #9 had heart surgery for a PDA ligation. The medical record did not indicate any documentation regarding the procedure performed by the surgeon, care provided, monitoring and medications administered by the anesthesiologist or operating room staff at Hospital #2, or documentation of blood product administration by staff caring for Patient #9 during surgery performed at Hospital #2.

Based on interviews and documentation review for one (Patient #9) for a total sample of ten patients, Hospital #1 failed to have in their Transfusion Medicine policies and procedures a procedure to ensure Hospital #2 reported to Hospital #1 a blood transfusion reaction, if one was to occur in Hospital #2.

Findings include:

The Surveyor interviewed the Neonatal Intensive Care Unit (NICU) Nurse Director on at 9:15 AM on 5/8/17. The NICU Nurse Director said when surgery was indicated for a NICU patient, blood from Hospital #1 would be brought over to Hospital #2 and if needed would be administered by staff at Hospital #2.

The Contract between Hospital #1 and Hospital #2, dated March 16, 2016 regarding laboratory medicine, indicated that both Hospital #1 and Hospital #2 will be compliant with regulatory standards. There was not an individual procedure requiring Hospital #2 to report and document a transfusion reaction (if one was to occur ) to Hospital #1 so that this information would be available for the care of patients at Hospital #1.

A Memo, dated 5/10/17, indicated Hospital #1's NICU patients do at times go to Hospital #2's operating room for certain cardiac procedures and then return immediately to Hospital #1. Hospital #1's NICU patients do travel with a unit of packed red blood cells released from Hospital #1's Blood Bank. If a transfusion reaction was to occur while at Hospital #2, Hospital #2's blood bank would investigate the reaction if one was to occur and then report the information back to Hospital #1.