HospitalInspections.org

Based on policy and procedure review, medical record reviews and staff interviews; the hospital nursing staff failed to ensure vital signs were monitored according to hospital policy for 2 of 3 patients during blood administration (Patients #2 and #8) and failed to ensure total volume of blood infused was documented according to hospital policy for 2 of 3 patients during blood administration (Patients #2 and #7).
The findings include:
Review of the hospital policy, "Blood and Blood Product Administration-General Policy", with a revision date of April 27, 2015 revealed, "PURPOSE: ...DEFINITIONS: ... POLICY: ...INTRODUCTION ... EQUIPMENT...IMPLEMENTATION... Pre-Transfusion: For all blood and blood products ...Vital signs include Temperature, Blood Pressure, Heart Rate and Respiratory Rate and should be taken within 30 minutes before the start of the infusion. ...Post-transfusion Care-All Blood Products: Obtain vital signs within 30 minutes of the time the blood product infusion is completed. ...SPECIAL CONSIDERATIONS ...PATIENT TEACHING ...DOCUMENTATION included in documentation: All vital signs relating to the transfusion(s) ...Volume infused ..."
1. Closed medical record review conducted July 29, 2015 revealed Patient #2, a 76 year-old who was transferred from Hospital XXX and was admitted to the hospital on June 20, 2015. Review revealed the patient received an admitting diagnosis of Gastrointestinal (GI-digestive tract) Bleed. Review revealed on June 21, 2015 at 0000, the patient vital signs were monitored. Review revealed at 0017, the patient was ordered a type and screen (lab test for blood compatibility). Review revealed at 0040, the patient was ordered a Complete Blood Count (CBC-lab test). Further review revealed the CBC and the type and screen were collected at the same time of the CBC order. Review revealed at 0110, the CBC result revealed a hemoglobin (protein on the red blood cell that carries oxygen) of 7.7 (low). Review revealed at 0214, type and screen was performed and the patient was compatible with red blood cell (RBC) unit # [1234] and was "OK TO TRANSFUSE." Review revealed at 0324, the patient consented to the blood administration and at 0350, the blood transfusion was started. Further review revealed the temperature was the only vital sign monitored at the start of the blood. Review revealed complete set of vital signs were monitored at 0400, 0500 and at 0600. Review revealed at 0633, the blood transfusion was completed (2 hours and 23 minutes later). Review failed to reveal the total amount of blood transfused was documented and failed to reveal a complete set of vital signs were monitored within 30 minutes before the start of the blood transfusion for RBC unit # [1234].
Interview conducted July 31, 2015 at 1054 with Coordinator #1 revealed all the vital signs were not monitored within 30 minutes before the start of a blood transfusion. Interview revealed the total amount of blood transfused was not documented. Interview revealed no additional documentation was available for review.
2. Closed medical record review conducted July 30, 2015 revealed Patient #7, a 65 year-old who was admitted to the hospital on July 3, 2015. Review revealed the patient received an admitting diagnosis of Lower GI Bleed (lower digestive tract). Review revealed on July 3, 2015 at 2151, a GI consult was ordered. Further review revealed at 1951, the first CBC was ordered, and at 2022, the laboratory sample was collected and at 2040, the laboratory sample revealed a hemoglobin within normal limits. Review revealed on July 4, 2015 at 0037, the second CBC was ordered and at 0113, the laboratory sample was collected and at 0129, the laboratory sample revealed a hemoglobin of 8.0. Review revealed at 0130, the patient consented to blood/blood products transfusion. Review revealed at 0155, one (1) unit of Fresh Frozen Plasma (FFP-blood products) unit # [121314] was administered to the patient and at 0315, the transfusion was completed (1 hour and 20 minutes later). Review revealed a complete set of vital signs were monitored prior to the administration of the FFP. Further review revealed total volume of FFP infused was not documented at the completion of the transfusion. Review revealed at 0109, the third CBC and the second unit of FFP were ordered. Review revealed at 0330, FFP unit # [151617] was administered to the patient and at 0500, the transfusion was completed (1 hour and 30 minutes later). Review revealed a complete set of vital signs were monitored prior to administration. Further review revealed total volume of FFP infused was not documented at the completion of the transfusion. Review revealed at 0541, the third CBC was collected and at 0618, the laboratory sample revealed a hemoglobin level of 6.5 (low). Review revealed at 0624, the patient was ordered RBC transfusion for one (1) unit. Further review revealed at 0650, RBC unit # [252630] was administered to the patient and at 0915, the transfusion was completed (2 hours and 25 minutes later). Review revealed a complete set of vital signs were monitored prior to and at the completion of the transfusion with documentation of the total volume infused. Review revealed at 1043, the patient was ordered RBC transfusion for 1 unit. Further review revealed at 0930, RBC unit # [452132] was administered to the patient and at 1030, the transfusion was completed (1 hour later). Review revealed at 1122, the GI consult was performed and recommendations included to hold aspirin and blood thinner medication and an outpatient procedure was scheduled. Review failed to reveal the total amount of FFP was documented at the completion of transfusion for unit # [121314] and unit # [151617].
Interview conducted July 31, 2015 at 1054 with Coordinator #1 revealed the total amount of blood product transfused was not monitored. Interview revealed no additional documentation was available for review.
3. Closed medical record review conducted July 30, 2015 revealed Patient #8, a 78 year-old who was admitted to the hospital on June 19, 2015. Review revealed the patient received an admitting diagnosis of Hypothyroidism, unspecified (low thyroid function with unknown cause). Review revealed on June 20, 2015 at 0033, the patient was ordered a CBC. Further review revealed at 0819, the laboratory sample was collected and at 0836, the laboratory sample result revealed a hemoglobin level of 7.1 (low). Review revealed on June 21, 2015 at 0033, the patient was ordered a CBC. Further review revealed at 0500, the laboratory sample was collected and at 0603, the laboratory sample result revealed a hemoglobin level of 5.6 (low). Further review revealed at 0606, laboratory personnel notified Nurse #1 of the hemoglobin result and at 0650, Nurse #1 notified the physician. Further review revealed at 0738, the patient was ordered a type and crossmatch (blood transfusion) and to transfuse two (2) units of red blood cells. Review revealed a type and crossmatch was performed and the patient was compatible with RBC unit # [5678]. Review revealed at 0819, the patient consented to the blood transfusion. Review revealed at 1038, RBC unit # [5678] was administered to the patient and a complete set of vital signs were monitored at 1148 and at 1245, the transfusion was completed (57 minutes later). Review revealed the total amount of blood transfused was 335 milliliters (ml). Review failed to reveal a complete set of vital signs were monitored within 30 minutes before the start of the blood transfusion for RBC unit# [5678].
Review revealed a type and crossmatch was performed and the patient was compatible with RBC unit # [91011]. Review revealed at 1519, the patient blood pressure and temperature were monitored. Review revealed at 1545, RBC unit # [91011] was administered to the patient and at 1857, a complete set of vital signs were monitored. Review revealed at 1900, the blood transfusion was completed (3 hours and 41 minutes later) and the total amount of blood transfused was 350 ml. Review failed to reveal a complete set of vital signs were monitored within 30 minutes before the start of the blood transfusion for red blood cell unit # [91011].
Interview conducted July 31, 2015 at 1054 with Coordinator #1 revealed all the vital signs were not monitored within 30 minutes before the start of the blood transfusion for red blood cell units [5678] and [91011]. Interview revealed no additional documentation was available for review.

Based on hospital policy review, medical record reviews and staff interview; the hospital staff failed to ensure an informed consent for medical treatment was obtained for 1 of 5 patients. (Patient #3).
The findings include:
Review of the hospital policy, "Patient Admission" with an effective date of April 3, 2015 revealed, "PURPOSE: ...DEFINITIONS: 1. Emergency admission: ...2. ...3. ...4. Inpatient: Patients who are admitted to a hospital bed for inpatient hospital services with the expectation that they will remain overnight. Physicians should use a 24-hour period as a benchmark, i.e., they should order admission to inpatient for those expected to need hospital care for 24 hours or more. ...PHYSICIAN ORDER: Each patient who is admitted to a [hospital name] hospital bed must have an order signed by the responsible physician. The patient should be designated as follows: 1. Admit to Inpatient ...PROCEDURE: 1 ...2 ...3. At the time of admission, the Department of Admitting will obtain the necessary signatures for the assignment of benefits, the guarantee of payment, consent for medical treatment and release of medical information. ..."
Closed medical record review conducted July 29, 2015 revealed Patient #3, an 82 year-old was admitted to the named hospital on June 29, 2015. Review revealed the patient received an admitting diagnosis of Lower Gastrointestinal Bleed (GI-digestive tract). Review revealed at 2044, the patient was ordered a Complete Blood Count (CBC-lab test) and at 2107, the laboratory sample was collected and at 2121, the laboratory sample revealed a blood count within normal limits. Review revealed on June 30, 2015 at 0211, the patient was ordered a CBC and at 0725, the laboratory sample was collected and at 0751, the laboratory sample revealed a blood count within normal limits. Review revealed on July 1, 2015 at 1202, the patient was ordered a Hemoglobin/Hematocrit (blood levels) and on July 2, 2015 at 0330, the laboratory sample was collected and at 0420, the laboratory sample revealed blood levels within normal limits. Review revealed at 1305, the patient was discharged to home with home health (4 days later). Review failed to reveal the hospital staff obtained informed consent for medical treatment prior to patient discharge.
Interview conducted July 30, 2015 at 1155 with the Vice President of Nursing revealed the hospital staff failed to obtain an informed consent for medical treatment prior to patient discharge.

Based on medical record reviews and staff interviews, the hospital staff failed to ensure post-hospital arrangements were made to avoid delays in discharge for 1 of 5 patients. (Patient #2).
The findings include:
Closed medical record review conducted July 29, 2015 revealed Patient #2, a 76 year-old was transferred from Hospital XXX and was directly admitted (not seen in the Emergency Department) to the named hospital on June 20, 2015 at 2224. Review revealed upon admission, the patient was evaluated by Physician #1. Further review revealed the patient past medical history included asthma and Sarcoidosis (lung diseases), in which the patient had administered continuous supplemental oxygen at home. Further review revealed and based upon Physician #1 evaluation, the patient course of treatment included "chronic oxygen" treatment and a Gastrointestinal consult (GI-digestive tract). Review of the initial nursing assessment performed at 2232, revealed home equipment consisted of oxygen. Review revealed on June 21, 2015 (one day after admission) the patient was ordered discharge to home and discharge instructions included to continue home regimen of oxygen therapy. Review failed to reveal the hospital staff arranged for oxygen for discharge transportation to home to avoid delay in discharge.
Interview conducted July 30, 2015 at 1345 with Director #1 and Case Manager (CM) #1 revealed CM #1 works every weekend with some weekday responsibilities. Interview revealed CM was on duty during Patient #2 hospitalization. Interview revealed CM#1 did not remember any interaction with the patient and family. Interview revealed CM #1 possibly received a telephone call, but there was no documentation; therefore, CM #1 could not remember. Interview revealed Director #1 verbalized the hospital does not allow their oxygen tanks to leave the building. Interview failed to reveal the hospital staff arranged for oxygen for discharge transportation to home to avoid delay in discharge.
Interview conducted July 30, 2015 at 1520 with Director #1 and Assistant Director (AD) revealed Patient #2 was hospitalized for 20 hours over the weekend (Saturday and Sunday) which meant the patient would be seen by Case Management on Monday for the standard assessment. Interview revealed there was an on-call CM for emergent needs. Interview revealed no Case Management referral was ordered. Interview failed to reveal the hospital staff arranged for oxygen for discharge transportation to home to avoid delay in discharge.
Interview conducted July 30, 2015 at 1234 with Nurse #1 revealed this nurse works 12-hours on dayshift. Interview revealed on June 20-21, 2015, Patient #2 was in Nurse #1 patient care assignment. Interview revealed CM on-call (name unknown) spoke with patient and family related to oxygen. Further interview revealed the on-call CM stated the family member would have to drive to the patient home to get the patient oxygen tank. Further interview revealed the family member left the hospital {city/state #1} and traveled to the patient's home {city/state#2} and returned back to the hospital with an oxygen tank. Interview failed to reveal the hospital staff arranged for oxygen for discharge transportation to home to avoid delay in discharge.
Interview conducted July 31, 2015 at 1035 with Physician #2 revealed this physician saw Patient #2 on June 21, 2015 and discussed procedure and laboratory results. Interview revealed Physician #2 spoke with CM (name unknown) and was told unable to send oxygen from the hospital and the nurse (name unknown) recommended to the family to go home, get and bring the oxygen tank back to the hospital. Interview revealed Physician #2 was informed prior to the interview to contact [Home Health Company] for oxygen for discharge to home. Interview failed to reveal the hospital staff arranged for oxygen for discharge transportation to home to avoid delay in discharge.

Based on the medical record reviews and staff interviews, the hospital staff failed to ensure post-hospital arrangements for durable medical equipment were made for 1 of 5 discharged patients. (Patient #2).
The findings include:
Closed medical record review conducted July 29, 2015 revealed Patient #2, a 76 year-old was transferred from Hospital XXX and was directly admitted (not seen in the Emergency Department) to the named hospital on June 20, 2015 at 2224. Review revealed upon admission, the patient was evaluated by Physician #1. Further review revealed the patient past medical history included asthma and sarcoidosis (lung diseases), in which the patient had and administered continuous supplemental oxygen at home. Further review revealed and based upon Physician #1 evaluation, the patient course of treatment included "chronic oxygen" treatment and a Gastrointestinal consult (GI-digestive tract). Review of the initial nursing assessment performed at 2232 revealed the patient home equipment consisted of oxygen. Review revealed on June 21, 2015 (one day after admission) the patient was ordered discharge to home and discharge instructions included to continue home regimen of oxygen therapy. Review failed to reveal the hospital staff arranged for oxygen for discharge transportation to home.
Interview conducted July 30, 2015 at 1345 with Director #1 and Case Manager (CM) #1 revealed CM #1 works every weekend with some weekday responsibilities. Interview revealed CM was on duty during Patient #2 hospitalization. Interview revealed CM#1 did not remember any interaction with the patient and family. Interview revealed CM #1 possibly received a telephone call, but there was no documentation; therefore, CM #1 could not remember. Interview revealed Director #1 verbalized the hospital does not allow their oxygen tanks to leave the building. Interview failed to reveal the hospital staff arranged for oxygen for discharge transportation to home.
Interview conducted July 30, 2015 at 1520 with Director #1 and Assistant Director (AD) revealed Patient #2 was hospitalized for 20 hours over the weekend (Saturday and Sunday) which meant the patient would be seen by Case Management on Monday for the standard assessment. Interview revealed there was an on-call CM for emergent needs. Interview revealed no Case Management referral was ordered. Interview failed to reveal the hospital staff arranged for oxygen for discharge transportation to home.
Interview conducted July 30, 2015 at 1234 with Nurse #1 revealed this nurse works 12-hours on dayshift. Interview revealed on June 20-21, 2015, Patient #2 was in Nurse #1 patient care assignment. Interview revealed CM on-call (name unknown) spoke with patient and family related to oxygen. Further interview revealed the on-call CM stated the family member would have to drive to the patient home to get the patient oxygen tank. Further interview revealed the family member left the hospital {city/state#1} and traveled to the patient's home {city/state#2} and returned to the hospital with an oxygen tank. Interview failed to reveal the hospital staff arranged for oxygen for discharge transportation to home.
Interview conducted July 31, 2015 at 1035 with Physician #2 revealed this physician saw Patient #2 on June 21, 2015 and discussed procedure and laboratory results. Interview revealed Physician #2 spoke with CM (name unknown) and was told unable to send oxygen from the hospital and the nurse (name unknown) recommended to the family to go home, get and bring the oxygen tank back to the hospital. Interview failed to reveal the hospital staff arranged for oxygen for discharge transportation to home.
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