HospitalInspections.org

Based on staff interview, review of medical records and policies and procedures, the hospital failed to ensure accurate and complete documentation for 4 of 4 patients (#15, #22, #23, #29) receiving transfusions. The hospital further failed to ensure staff followed written procedures for tracking pre-transfusion timelines for blood products as established in written policies. The findings were:

1. Medical records reviewed on 2/26/14 and 2/27/14 included 4 closed records selected specifically for inclusion based on blood transfusions. Of these 4 records, the following discrepancies were discovered on review:
a. Patient #15 received 2 packed red blood cells (pRBC) units on 9/1/13. A total of 55 minutes elapsed between retrieval from the blood bank and the transfusion for the first unit; the second unit experienced an elapsed time of 40 minutes from retrieval to transfusion. Documentation of the first transfusion event also included an inaccurate blood group and type for the patient: "A negative" was listed as the pRBC unit group/type by the administering RN, whereas the blood bank documentation showed the unit to be A positive.
b. Patient #22 received 2 units of pRBCs on 9/17/13. The elapsed time from blood bank retrieval to transfusion was 35 minutes for the first unit and 36 minutes for the second pRBC. Further, the temperature of the first unit was not documented as safe.
c. Patient #23 received a unit of pRBCs on 9/23/13 and a second unit on 9/24/13. A total of 2 hours and 25 minutes elapsed between the time the first pRBC unit was retrieved from the servicing blood bank and the transfusion was initiated. The second unit required 50 minutes from retrieval to transfusion. The record further lacked a temperature reading for the first pRBC on receipt in the facility.
d. Patient #29 received 4 units of pRBCs on 4/9/13 and 4/10/13. Subsequent documentation of these 4 transfusion events revealed missing blood group and type information (unit #1), unit group/type and unit number information missing or incorrectly listed (unit #2), missing documentation to show a visual inspection was completed prior to transfusion (unit #3 and #4), and lack of temperature checks, unit group/type, and unit number (unit #4).

2. The facility's policies and procedures for blood product transfusion were reviewed on 2/26/14 beginning at 2:10 PM. The facility required staff to initiate transfusion of all blood components within 30 minutes of the time the product was retrieved from the servicing blood bank. Interview with the director of nursing (DON) on 2/26/14 at 2:45 PM confirmed the existing standard of 30 minutes was the facility policy. The DON further stated her expectation that all information related to transfusion of blood products be documented in an accurate and complete fashion.

Based on observation and staff interview, the hospital failed to identify and correct safety hazards (sharp edges) on 3 of 3 patient hallways and in 1 of 1 physical therapy gymnasiums (PT gym). The findings were:

1. Tour of the facility on 2/25/14 beginning at 10:15 AM uncovered the facility's use of plastic scuff guards to protect the lower half of door frames leading into patient rooms on the 100, 200, and 300 hallways. The guards were constructed of rigid, formed plastic glued to the metal door frame and, when loose from the frame, presented an abrupt edge that felt sharp when rubbed by hand and with skin on the outside of the forearm. It was further observed that scuff guards on 4 of 9 rooms in the 300 hallways were also loose from the door frames. Subsequent observation and associated interview with the plant operations director on 2/26/14 at 10:25 AM confirmed the plastic scuff guards presented a potential hazard to patients.

2. The initial tour of the facility's PT gym was conducted on 2/25/14 beginning at 8:30 AM. A parallel bar apparatus was observed in the PT gym; the apparatus had a total of eight 1 inch by 1 inch square mounting adaptors at regularly spaced intervals along the length of the parallel bars, each presented at knee height to a 69 inch tall individual. Five of the adaptors were covered with a plastic cap to cover the abrupt edges; however, three of the mounts were open and uncovered, presenting a rough edge at knee-level to individuals using the apparatus. The director of plant operations was shown the uncapped mounting adaptors on 2/26/14 at 11:10 AM; he acknowledged the mounts were supposed to be covered with a plastic protective cap to shield users from the rough edges.