HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to complete blood transfusion records for 3 patients (#19, #20, #21) of 4 patients reviewed for blood transfusion of 27 records reviewed.

The findings included:

Review of the facility policy "Blood and blood product transfusion", not dated revealed "...verify that the patient or his legally authorized representative has signed an informed consent form before transfusion therapy is initiated...recheck vital signs, including temperature, every 15 minutes for the first hour (four times) after beginning the infusion, and then every 30 minutes and prn [as needed]...recheck vital signs one hour after the infusion has stopped...date and time the transfusion was started and completed...total amount of the transfusion...patient's vital signs before and after the transfusion..."

Medical record review revealed Patient #19 was admitted to the facility on 2/1/17 and discharged from the facility on 2/1/17 with a diagnosis of Iron Deficiency Anemia Secondary to Blood Loss.

Medical record review of the Physician's Order dated 2/1/17 revealed "...4 u [units] PRBC's [packed red blood cells]...transfuse 2 units PRBC's...then transfuse 2 more units PRBC's..."

Medical record review of the Blood Administration report dated 2/1/17 revealed missing documentation of the date and time of completion of the first unit of blood. Continued review revealed missing documentation of the date and time of completion of the third unit of blood, total amount of the third unit of blood transfused, and the vital signs 1 hour after the transfusion was completed. Further review revealed missing documentation of the date and time of completion of the fourth unit of blood, total amount of the fourth unit of blood transfused, and the vital signs 1 hour after the transfusion was completed.

Medical record review revealed Patient #20 was admitted to the facility on 1/27/17 and was discharged from the facility on 2/3/17 with the following diagnoses Upper Gastrointestinal Bleed, Coronary Artery Disease, Peripheral Vascular Disease, and Hypertension.

Medical record review of the Physician's Order dated 1/30/17 revealed "...transfuse 2 units packed red blood cells..."

Medical record review of the Blood Administration report dated 1/30/17 revealed missing documentation of the vital signs 1 hour after the transfusion of the second unit of blood was completed.

Medical record review revealed Patient #21 was admitted to the facility on 2/4/17 and discharged from the facility on 2/4/17 with the following diagnoses Iron Deficiency Anemias.

Medical record review of the Physician's Order dated 2/2/17 revealed "...2 units of PRBC [Packed Red Blood Cells]..."

Medical record review of the Blood Administration report dated 2/4/17 revealed missing documentation of the vital signs 1 hour after the transfusion of the second unit of blood was completed.

Interview with the Director of Obstetrics and the Informatics Registered Nurse (RN) on 2/8/17 at 11:20 AM, in the conference room, confirmed the facility failed to follow their policy for Patient #19, 20, and #21.

Based on review of facility policy, medical record review, and interview, the facility failed to complete a history and physical (H&P) addendum within 24 hours prior to surgery for 1 patient (#1) of 12 surgery patients reviewed of 29 records sampled.

The findings included:

Review of the facility policy, History and Physicals, last updated on 11/3/16 revealed "...when the history and physical...is conducted within 30 days before admission...an updated examination [H&P addendum] of the patient, including any changes in the patient's condition, must be completed and documented within 24 hours after admission...but prior to surgery or a procedure requiring anesthesia services..."

Medical record review revealed Patient #1 was admitted to the facility on 2/6/17 for an Esophagogastroduodenoscopy (visualization of the esophagus and upper part of the stomach) and a Colonoscopy (visualization of the lower gastrointestinal tract). Continued review revealed the History and Physical was dated 1/24/17 (14 days prior). Further review revealed the H&P addendum was not completed, signed, or dated by the physician.

Interview with the Chief Nursing Officer (CNO) on 2/6/17 at 2:20 PM, in the Same Day Surgery nurses station, confirmed the H&P addendum was not complete and the facility failed to follow the facility policy.

.

Based on facility policy review, review of a manufacturer's label, observation, interview, the facility failed to ensure expired supplies were not available for patient use in 4 of 15 areas observed.

The findings included:

Review of the facility policy "Warming of IV [intravenous] Fluids & [and] Irrigation" dated 6/2015 revealed "...At the time the [intravenous] fluids are placed in the warmer, they should be dated & timed...expiration date from the warmer...After 14 days, the containers should be removed from the warmer..."

Review of a manufacturer's label for 0.9% Sodium Chloride IV solutions revealed "...DO NOT REMOVE UNITS FROM OVERWRAP UNTIL READY FOR USE...USE ALL UNITS PROMPTLY WHEN POUCH IS OPENED...the inner bag maintains the sterility of the product..."

Observation and interview with the Director of the Intensive Care Unit (ICU) on 2/6/17 at 1:06 PM, in the ICU, revealed the following expired supplies:
1) 95 retracting 25 gauge (G) needles expired on 1/2017
2) 5 retracting 25G needles expired on 8/2015
3) 2 trachea disposable inner cannulas (part of a breathing tube) size 7.6millimeters (mm) expired on 11/2016
4) 1 trachea disposable inner cannula 7.6 mm expired on 5/2015
5) 1 arterial blood sampling kit expired on 9/2014
Interview with the Director of the ICU confirmed the supplies were expired and were available for patient use.

Observation and interview with the Chief Nursing Officer (CNO) on 2/6/17 at 1:52 PM, of the Same Day Surgery Lab, revealed the following expired supplies:
1) 33 blue top blood specimen collection tubes expired on 12/2016
2) 8 green top blood specimen collection tubes expired on 1/2017
Interview with the CNO confirmed the supplies were expired and were available for patient use.

Observation and interview with the Director of Surgery on 2/7/17 at 9:00 AM, of the fluid warmer in the surgery hallway, revealed 3 bags of Lactated Ringers (LR) solution (intravenous fluid) 1,000 milliliters (ml) in the fluid warmer with no labeled date or time. Interview with the Director of Surgery confirmed the solution should be dated and timed and the facility failed to follow facility policy.

Observation and interview with the Director of Surgery on 2/7/17 at 9:56 AM, of the anesthesia cart in surgery room #4, revealed a prepackaged sterile 7.0 mm endotracheal tube (tube placed in the trachea to assist with breathing) with the package opened and a syringe attached. Interview with the Director of Surgery confirmed the endotracheal tube package was opened, was no longer sterile, and was was available for patient use.

Observation and interview with the Director of Medical/Surgical Services (Med/Surg) on 2/7/17 at 2:40 PM, in the Med/Surg medication room, revealed 2 vacutainer blood transfer devices with an expiration date of 5/2016. Interview with the Director of Med/Surg confirmed the 2 vacutainer blood transfer devices were expired and were available for patient use.

Observation and interview with Registered Nurse (RN) #1 on 2/8/17 at 12:54 PM, in the Newborn Nursery nurses station, revealed 2 bags of 0.9% Sodium Chloride IV solution with the overwrap removed. Interview with RN #1 confirmed the overwraps were removed, the solutions were not used promptly, and were available for patient use. Further interview confirmed the facility failed to follow manufacturer's recommendations.