HospitalInspections.org

Based on medical record review and document review, it was determined the facility staff failed to update the patient's care plan based on the patient requiring a blood transfusion for three (3) of eight (8) patients sampled and failed to document patient education regarding blood transfusions for two (2) of the eight (8) patients.

Findings:

On 1/3/24, the surveyor reviewed eight (8) medical records for patients who received blood transfusions with SM8. For three (3) medical records, the surveyor could not find evidence that the care plan was updated to reflect the blood transfusion. Additionally, for two (2) medical records, the surveyor could not find evidence that patients received patient education regarding blood transfusions. SM8 was unable to locate an entry/update that referenced these missing items in the medical records for each patient. SM5 was present during the review and looked through the charts as well and was unable to locate the information. SM5 acknowledged that care plans should be updated to reflect the patient's needs and patient education should be documented.

SM5 provided the surveyor with the procedure document followed by the facility titled, Lippincott Procedures: Blood and blood product transfusion, that reads, in part: "... Implementation... Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation... Patient Teaching... When developing a teaching plan, set objectives based on the information you gathered during your assessment. Set criteria for evaluating whether your objectives were met... Documentation... teaching provided to the patient and family (if applicable), understanding of that teaching and follow-up teaching needed...".

During the exit conference, the surveyor reviewed the findings with SMs 1, 3, 5 and 17.

Based on medical record review, interviews and document review, it was determined the facility staff failed to ensure the correct administration of a vaccine for one (1) of eight (8) patients sampled.

Findings:

A review of P4's medical record evidenced that P4 received HRIG (human rabies immune globulin) and one dose of a rabies vaccine in the same anatomical site.

The following was documented in P4's record: "Most Recent Administration... 11/8/23 at 1:28 a.m. 1 mL IntraMUSCular. Deltoid Left, given by [SM12]... Most Recent Administration... 11/8/23 at 1:27 a.m. 1,740 Units IntraMUSCular left deltoid... comment: split between left & right deltoid given by [SM12]...".

The following information was available to staff at the time of HRIG medication administration: "Administration: IM... Do not administer rabies vaccine in the same syringe or at the same administration site as HRIG [human rabies immune globulin]...".

During a telephone interview on 1/3/24 at 11:20 a.m., SM9 said, "I think it's pretty well known that they [Ig and vaccine] are given in separate sites."

During a telephone interview on 1/3/24 at 11:40 a.m., SM12 said, "I knew they couldn't go in the same syringe [Ig and rabies vaccine], but I didn't know they couldn't go in the same site... I learned how to give it through my preceptor".

A facility policy titled, Medication Administration (with Barcoding) and IV Addendum, was reviewed and reads, in part: "... POLICY STATEMENT: [Name of facility[ is committed to safe medication administration by ensuring the right patient receives the right medication, by the right route, at the right time, and in the right dose... I. PERSONNEL AUTHORIZED TO ADMINISTER MEDICATIONS: A. Medications will be administered by a registered nurse (RN), licensed practical nurse (LPN),... after validation of competency... Medication safety is part of ongoing education and competencies... III. PROCEDURE: MEDICATION ADMINISTRATION:... 4. Before administering a medication, the authorized personnel are to: a. Verify the "5 Rights" of medication safety: right patient, drug, dose, time, and route...".