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Based on review of hospital policy, medical record review and staff interviews, the nursing staff failed to monitor a patient receiving a blood transfusion per hospital policy for 1 of 3 patients receiving blood (Patient #11).

The findings include:

Review of the hospital's policy "Blood and Blood Product Administration" revised 11/20/2013 revealed, "...H. Blood Administration Monitoring 1. Monitor vital signs, patient tolerance, and obsreve for possible transfusion reaction. Monitor vital signs (at a minimum): a. Within 60 minutes prior to initiating transfusion. b. 15 minutes after the blood has reached the patient (5 - 15 minutes is an acceptable range). c. 1 hour after the transfusion is initiated (45 - 75 minutes is an acceptable range). d. Within 10 minutes of transfusion completion. e. 1 hour following completion of the infusion (45 - 75 minutes is an acceptable range). ..."

Open medical record review for Patient #11 revealed an 83 year-old male who was admitted on 05/09/2015 with chest pain and shortness of breath. Record review revealed a physician's order on 05/09/2015 at 1153 to transfuse patient with one unit of packed red blood cells and another order on 05/10/2015 at 1024 to transfuse another unit of blood. Record review revealed the first unit was started on 05/09/2015 at 1609. Record review revealed no documentation that Patient #11's temperature, respiratory rate, pulse and blood pressure were checked until 1649 (40 minutes after the transfusion was started). Review revealed the blood was completed at 1926. Review of the record revealed the patient's vital signs were assessed at 1926 when completed, with the next vital signs recorded at 2225 (2 hours and 59 minutes after the blood ended). Record review revealed the second unit of blood was started on 05/10/2015 at 1447 and ended at 1736. Review revealed vital signs were assessed and recorded at 1600, with the next vital signs recorded at 1854. Record review revealed no documentation that Patient #11's temperature, pulse, respiratory rate and blood pressure were checked at the time the blood was completed (1736).

Interview on 05/13/2015 at 1550 with Administrative Nursing Staff confirmed the nurse did not assess vital signs (temperature, pulse, respirations and blood pressure) while administering blood to Patient #11 per the hospital's policy.

Based on hospital policy review, observations, medical record review and patient and staff interviews, the hospital's staff failed to maintain equipment in an manner to ensure an acceptable level of safety and quality for 1 of 3 inpatient units toured (medical surgical unit).

The findings include:

Review of the hosptial's policy "Medical Equipment Management Plan" revised March 2014 revealed "...II. The Medical Equipment Management Plan (MEMP) defines the mechanism for interaction and oversite of the medical equipment used in the diagnosis, treatment and monitoring of patients. (Name of health system) Clinical Equipment Management Program (CEMP) has established and maintains a documented program to ensure that our patients. guests and co-workers will be provided with equipment that is reliable, safe for use and maintained in proper working order. ..."

Observation on 05/12/2015 at 1510 during tour of the 3rd floor Medical Surgical unit with administrative staff #1 and #2 revealed patient room #313 was empty. Interview with staff present revealed the patient room was clean and ready for patient use. Observation of room #313 revealed an area on the right upper, inside portion of the side rail on a patient bed that was missing a piece (broken) resulting in exposed jagged, sharp plastic edges. Observation during tour revealed administrative staff #1 touched the area and stated there was a piece broken off or missing.

Observation on 05/13/2015 at 1400 of room #313 revealed a female patient (#12) was located in the bed. Observation revealed the same bed with exposed jagged, sharp plastic edges on the upper inside of the side rail. Interview during the observation with Patient #12 revealed the patient was blind. Interview during the observation with administrative staff #1 revealed she was not aware of the broken side rail. The staff member stated the unit had extra beds and bed currently in room #313 would be replaced.

Observation on 05/14/2015 at 1100 of room #313 revealed a different patient located in the bed. Observation revealed the same bed with exposed jagged, sharp plastic edges on the upper inside of the side rail. Interview with administrative staff #2 revealed the staff member had verbally requested Engineering staff to check the bed in room #313 earlier on 05/14/2015. The staff member stated that Engineering staff did not find a problem with the bed.

Interview on 05/14/2015 at 1315 with Engineering staff #3 revealed all patient beds are evaluated for proper functioning semi-annually. Interivew revealed if there is a problem with a bed, a unit staff member should initiate a work order and remove the bed from use until it can be checked. The staff member stated he had been notified the morning of 05/14/2015 from administrative staff #2 that there was an issue with the bed in room #313. Interview revealed when he arrived on the unit to evaluate the bed, he was told by nursing staff there was no problem with the bed. The staff member stated he did not evaluate the bed at that time. Interview revealed he was called again while a surveyor was on the unit to evaluate the bed. The staff member stated there was a "safety issue" due to a plastic guard piece that was missing from the side rail. The staff member stated he removed the bed from service to be fixed. The staff member stated he relied on unit staff to notify him of safty risks on equipment.

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