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Based on observations, record review, and interviews, the hospital failed to ensure its system for controlling infections and communicable diseases of patients and personnel by maintaining a sanitary environment was implemented as evidenced by having employee food items stored in the refrigerator designated for patient nourishments.
Findings:

Observation on 11/14/17 at 9:45 a.m. with S1CEO and S2ICNO present revealed the patient refrigerator on the Medical/Surgical Unit had a note in the freezer indicating that patient care items are on the bottom shelf. Further observation revealed a 1/2 gallon of Blue Bell Ice cream, one Stouffer's Classics Lasagna with meat Sauce large size, and one Lean Cuisine Alfredo Pasta with Chicken and broccoli were stored on the top shelf of the freezer. Further observation revealed the patient refrigerator in the Intensive Care Unit had plastic containers of food on the bottom shelf.

Review of the policy titled "Care of Unit Kitchens", presented as a current policy by S1CEO, revealed that all non-patient items (such as employee foods) are to be labeled and placed in the designated employee refrigerator so as not to be confused with patient items.

In an interview on 11/14/17 at 9:45 a.m., S2ICNO indicated the above-listed items in the freezer on the Medical/Surgical Unit and in the refrigerator on the Intensive Care Unit were for employees and not patients.

In an interview on 11/14/17 at 10:15 a.m., S1CEO presented the hospital policy titled "Care of Unit Kitchens." She indicated that staff were not following hospital policy by having employee food items stored in the patient-designated refrigerators.

Based on record reviews and interview, the hospital failed to ensure a RN assigned the nursing care of each patient in accordance with the specialized qualifications and competence of the staff available as evidenced by having no documented evidence of an evaluation of competence in administering blood products for 1 (S7RN) of 3 (S4RN, S5RN, S7RN) RNs' personnel files reviewed for competency in blood administration.
Findings:

Review of S7RN's "Nursing Clinical Orientation 2014" revealed it included blood administration policies and procedures and a review of blood transfusion reactions and was signed by S7RN on 10/07/14. Further review of her personnel file revealed had an online training on blood transfusions between 04/17/17 and 06/30/17. Further review revealed no documented evidence that S7RN was evaluated for competence in blood administration.

In an interview on 11/15/17 at 9:45 a.m., S7RN indicated "we don't give blood that often." She further indicated that other than orientation and reviewing policies, she didn't recall if anyone had evaluated her for competency in blood administration.

In an interview on 11/15/17 at 3:40 p.m., S2ICNO indicated she had no documented evidence to present of S7RN having been evaluated for competence in administering blood products.

Based on record reviews and interviews, the hospital failed to ensure all drugs, biologicals, and intravenous medications were administered in accordance with written and signed orders, accepted standards of practice and hospital policy as evidenced by:
1) The RN failed to notify the physician of the assessment of signs/symptoms during the pre-administration evaluation, of a complication and/or adverse reaction to blood, and/or to complete an incident report as required by hospital policy for 4 (#2, #3, #4, #5) of 5 patient records reviewed for blood administration from a sample of 5 patients.
2) The RN failed to administer blood in accordance with physician orders and hospital policy for 4 (#1, #2, #3, #4) of 5 patient records reviewed for blood administration from a sample of 5 patients.
3) The hospital failed to include blood incompatibility as an adverse reaction in its blood administration policy.
Findings:

1) The RN failed to notify the physician of the assessment of signs/symptoms during the pre-administration evaluation, of a complication and/or adverse reaction to blood, and/or to complete an incident report as required by hospital policy:
Review of the policy titled "Blood & (and) Blood Products Administration", presented as a current policy by S2ICNO, revealed blood components are not administered to any patient without the order of a licensed physician and a signed informed consent for the transfusion of blood or blood components. Further review revealed any adverse symptom or physical sign during transfusion of blood or its components should be initially considered as a potential life-threatening reaction. Potential adverse reactions include fever with or without chills; shaking chills; pain at the infusion site or in the chest, abdomen, or flanks; a gradual rise in systolic blood pressure up to 50 mmHg is usually an indication of volume overload and is not by itself an indication to stop the transfusion, but the clinician should be notified as systolic blood pressure rises for orders to manage volume overload; a simultaneous drop of systolic or diastolic blood pressure of greater than or equal to 20 mmHG is alone an indication of possible blood transfusion reaction and the transfusion should be stopped and the physician notified; respiratory distress including dyspnea, tachypnea, wheezing, or hypoxemia; skin changes including urticaria, pruritis, flushing or localized edema; nausea with or without vomiting; darkened urine; oliguria/anuria; bleeding or other manifestations of a consumption coagulopathy. For a potential adverse reaction, the clinical personnel should do the following: stop the transfusion immediately; notify the nursing supervisor and physician of potential adverse reaction and follow orders received; if ordered by the physician, remove all lines and blood product, and if necessary hang a new bag of normal saline with new tubing; complete the Blood Transfusion Reaction worksheet and report to lab staff immediately; order and collect a post transfusion urine specimen for a urinalysis when a reaction is suspected. Reactions occurring after the completion of the transfusion must also be reported and investigated utilizing the same process as reactions occurring during the transfusion. Any transfusion reaction requires an incident report to be completed.

Review of the policy titled "Incident Reporting Policy", presented as a current policy by S2ICNO, revealed the incident report form should be utilized for reporting hemolytic transfusion reactions and any untoward or adverse occurrence.

Patient #2
Review of Patient #2's physician orders revealed an order on 09/26/17 at 1:24 a.m. to transfuse 4 units PRBCs with each to transfuse over 3 hours.

Review of Patient #2's "Blood Administration Form" documented by S6RN for the first unit of PRBCs revealed the blood was initiated on 09/26/17 at 3:15 a.m. and was completed at 6:25 a.m. Review of the "Transfusion Report" documented by S6RN revealed the question "did patient exhibit any of these symptoms during or after transfusion?" Further review revealed S6RN answered "yes" to "respiratory distress, including hypoxemia, wheezing, coughing, and dyspnea." Further review revealed instructions included the following: if any of the above are answered yes, stop the transfusion but keep the vein open with saline; notify nursing supervisor; report suspected reaction to lab; notify patient's physician. Review of S6RN's documentation revealed the patient tolerated the blood transfusion well without any signs/symptoms of reaction, and the patient experienced some anterior chest expiratory wheezing with a non-productive cough. There was no documented evidence that S6RN reported the possible transfusion reaction to the nursing supervisor, the lab, and the physician.

Review of Patient #2's fourth unit of PRBCs administration documented by S10RN revealed the blood was initiated on 09/26/17 at 4:10 p.m. and completed at 7:30 p.m. Review of the "Transfusion Report" documented by S10RN revealed S10RN answered "yes" to "respiratory distress, including hypoxemia, wheezing, coughing, and dyspnea." Further review revealed S10RN documented that the patient tolerated the PRBCs well without signs/symptoms of reactions. There was no documented evidence that S10RN reported the possible transfusion reaction to the nursing supervisor, the lab, and the physician.

In an interview on 11/15/17 at 11:30 a.m., S2ICNO indicated the above-listed documentation by S6RN and S10RN were potential adverse blood reactions according to hospital policy. She further indicated both RNs should have reported their assessments to the nursing supervisor, lab, and the physician.

Patient #3
Review of Patient #3's medical record revealed he presented to the ED on 09/26/17 at 7:47 a.m. with chief complaints of feeling weak and having passed blood in his stool this morning. Review of S11MD's documentation at 11:45 a.m. revealed Patient #3 had a witnessed syncopal episode in ED prior to transfer to the floor with a systolic blood pressure of 50. At 11:50 a.m. S11MD documented that Patient #3 was alert and responsive with a blood pressure of 93/56. Further documentation by S11MD revealed Patient #3 was to be transferred to the Intensive care Unit. Further documentation revealed that plans were made to transfer Patient #3 to another acute care hospital where he had seen a gastrointestinal specialist at the request of his family.

Review of Patient #3's physician orders revealed an order on 09/26/17 at 1:38 p.m. to transfuse 1 unit of PRBCs over 1 hour and an order at 1:07 p.m. to transfuse 1 unit of PRBCs over 1 hour.

Review of Patient #3's medical record revealed an "Emergency Transfusion Release" form signed by S11MD with no documented evidence of the date and time the form was signed. Further review revealed 1 unit of PRBCs was documented as cross match compatible. Further review revealed the 2nd unit was documented as "unit stopped, cross match incompatible, returned to lab, (initials of S8MT) 9/26/17, called to S7RN 09/26/17 by (initials) 1:25 p.m."

Review of Patient #3's documentation by S7RN of the first unit of PRBCs revealed the two units of blood were initiated on 09/26/17 at 1:02 p.m.. Further review revealed documentation by S7RN (no time documented) that units were released due to emergency; lab technologist notified "us" that the patient had antibodies; S7RN notified the physician who stated that blood will still be infused; S7RN notified lab. At 1:28 p.m. S7RN documented that she was notified that this unit of blood was not compatible with the antibodies in Patient #3's blood. The unit was stopped immediately; "unhooked IV and flushed line with NS." There was no documented evidence that the IV tubing was changed after administering incompatible blood prior to continuing the administration of the second unit of blood.

No documented evidence of an incident report was presented by the hospital for this adverse event with Patient #3.

In an interview on 11/15/17 at 3:50 p.m., S2ICNO confirmed that an incident report had not been completed for the adverse event of administering incompatible blood to Patient #3 on 09/26/17.

Patient #4
Review of documentation of Patient #4's unit of PRBCs documented by S10RN revealed it was initiated on 11/03/17 at 9:50 p.m. and completed at 12:00 a.m. on 11/04/17. Further review revealed the Hypotension was assessed during the pre-administration evaluation.

Review of Patient #4's medical record revealed her blood pressure was 130/64 at 7:47 p.m. on 11/03/17, 92/56 at 9:37 p.m., and 99/67 at 9:50 p.m. prior to the start of the transfusion. There was no documented evidence that S10RN notified the physician of the low pressure prior to administering PRBCs.

In an interview on 11/15/17 at 11:35 a.m., S2ICNO indicated S10RN should have notified the physician of the blood pressure of 92/56 prior to initiating the blood.

Patient #5
Review of Patient #5's physician orders revealed an order to transfuse 1 unit of PRBCs over 3 hours on 09/21/17 at 1:29 p.m.

Review of Patient #5's unit of PRBCs documented on 09/21/17 revealed it was initiated at 5:45 p.m. and completed at 9:25 p.m. (3 hours 40 minutes rather than 3 hours as ordered). The 1 hour post transfusion blood pressure was 90/60 (the baseline blood pressure at 5:40 p.m. was 141/82). Review of the "Transfusion Report" revealed the RN answered "yes" to Hypertension or Hypotension. Further review revealed the RN documented the nursing supervisor and lab were notified at 2:35 a.m. with patient's physician notified with a check with no documented evidence of a time of notification.

Review of Patient #5's "Patient Progress Notes" revealed no documented evidence of notification of the physician of the patient's low blood pressure and an assessment by the RN for a possible blood reaction.

In an interview on 11/15/17 at 1:15 p.m., S2ICNO confirmed Patient #5's medical record had no evidence that the physician was notified of Hypotension 1 hour after the PRBCs were transfused, and there was no evidence of an RN's assessment at that time.

In an interview on 11/15/17 at 3:50 p.m., S2ICNO confirmed an incident report was not completed for the above adverse event.

2) The RN failed to administer blood in accordance with physician orders and hospital policy:
Review of the policy titled "Blood & (and) Blood Products Administration", presented as a current policy by S2ICNO, revealed when an order is received from the patient's physician to administer blood or blood products, the order should contain the name of the blood component, the amount to be transfused, the duration of the transfusion, pre/post-transfusion medications if appropriate, and warming of blood and blood components. A pre-transfusion physical assessment and baseline VS should be obtained and documented before starting each transfusion. The transfusion should be started very slowly (100ml/hr or less for the first 15 minutes), then increase to desired rate if no reaction was noted. The patient is closely monitored for the first 15 minutes to observe for any possible transfusion reactions. VS are taken in 15 minutes and 1 hour after transfusion initiation, then every hour until the transfusion is completed, and 1 hour after the final unit is transfused. A set of VS is taken one hour after the final unit is completed and compared with the pre-transfusion baseline VS. The blood product administration is documented on the Blood Administration Form which is received with each unit of blood or blood products obtained from the blood bank. Further review revealed if a potential adverse reaction occurs, the the transfusion is to be stopped immediately. If ordered by the physician, remove all lines and blood product. If necessary, hand a new bag of normal saline with new tubing.

Review of the policy titled "Informed Consent", presented as a current policy by S2ICNO, revealed an informed consent must be obtained by the patient's attending physician, from the patient, or from a person authorized to grant consent for the patient before each medical or surgical procedure. It is the sole responsibility of the physician to provide appropriate information to a patient in a manner that will enable him/her to make an intelligent and informed decision about whether to accept treatment. The physician should sign the form certifying that he/she has in fact explained the information contained on the consent form to the patient.

Review of the "National Standards for Blood Transfusion Service 2013" revealed the standard requirement for volume of PRBCs was 250 ml plus or minus 30 ml , and the standard volume for platelet concentrate was 50 to 70 ml.

Patient #1
Review of S4RN's documentation of the administration of the first unit of PRBCs for Patient #1 revealed no documented evidence of an assessment of dyspnea as part of the pre-administration evaluation. Further review revealed the blood was initiated at 11:05 p.m., and the VS required prior to starting the transfusion were taken at the same time the blood was initiated at 11:05 p.m., rather than prior to initiating the transfusion. The blood was initiated at 11:05 p.m. and completed at 1:50 a.m. on 11/14/17 (2 hours 45 minutes rather than 3 hours as ordered).

Review of S4RN's documentation of the administration of the second unit of PRBCs for Patient #1 revealed the blood was initiated at 1:50 a.m. on 11/14/17 and completed at 4:30 a.m. (2 hours 40 minutes rather than 3 hours as ordered). Further review revealed the blood was initiated at 1:50 a.m., and the VS required prior to starting the transfusion were taken at the same time the blood was initiated at 1:50 a.m., rather than prior to initiating the transfusion.

Review of S4RN's documentation of the administration of the third unit of PRBCs for Patient #1 revealed the blood was initiated on 11/14/17 at 5:00 a.m. and completed at 7:25 a.m. (2 hours 25 minutes rather than 3 hours as ordered). Further review revealed VS was assessed prior to the start of the transfusion at 4:50 p.m. The VS taken 15 minutes after the start and 1 and 2 hours after the blood was initiated were based on the prior to start time VS rather than the blood initiation time. Therefore, the VS required 15 minutes after the start of the transfusion were taken 5 minutes after the blood was initiated, the VS required 1 hour after initiation were taken 50 minutes after the blood was initiated, and the VS required 2 hours after initiation were taken 1 hour and 50 minutes after the blood was initiated.

Review of S5RN's documentation of the administration of the fourth unit of PRBCs for Patient #1 revealed the blood was initiated on 11/14/17 at 8:38 a.m. and completed at 11:19 a.m. (2 hours 41 minutes rather than 3 hours as ordered). Further review revealed the blood was initiated at 8:38 a.m., and the VS required prior to starting the transfusion were taken at the same time the blood was initiated at 8:38 a.m., rather than prior to initiating the transfusion.

In an interview on 11/14/17 at 11:03 a.m., S2ICNO confirmed the physician's order did not include the specific number of units of PRBCs to be transfused for Patient #1. She indicated the volume used to be noted on the bag of blood, but now the nurses have to compute the rate based on an estimation of volume. She confirmed that without knowledge of the volume of blood in the bag, there isn't a way for the RN to compute the rate of administration to assure the physician's rate order is implemented. She indicated the VS documented prior to the start of the transfusion is taken before the blood reaches the patient, but it's documented as the same time as the initiation of blood.

In an interview on 11/15/17 at 9:10 a.m. with S4RN with S2ICNO present, S4RN indicated she should have clarified the physician's order, since it didn't have the specific number of units to be infused. She further indicated she didn't receive the verbal order, but she should have clarified the order. S4RN indicated she documented the VS prior to the start of the blood, but she should have had a set of VS about 20 minutes prior to the blood being administered. She further indicated not checking the assessment of dyspnea on the pre-administration assessment was an oversight. Regarding the second unit, S4RN confirmed the VS were taken based on the prior to start time and not the time of blood initiation. She indicated the CNA takes the VS and enters the results in the computer that appears on the record which she (S4RN) signs. She further indicated she didn't catch that VS were taken at the wrong time. When asked by the surveyor how she figures the rate at which the blood is to be transfused, S4RN indicated each bag has different volumes. She further indicated they used to weigh the bags but stopped that practice about a month ago. S4RN indicated she's estimating that there's 325 ml of blood in the bag to figure the flow rate. When informed by the surveyor that the national standards for volume of PRBCs was 250 ml plus or minus 30 ml, S4RN and S2ICNO indicated they weren't aware of this standard. S2ICNO indicated they "went by 300 to 350 ml."

Patient #2
Review of Patient #2's physician orders revealed an order on 09/26/17 at 1:24 a.m. to transfuse 4 units PRBCs with each to transfuse over 3 hours.

Review of Patient #2's "Blood Administration Form" documented by S6RN for the first unit of PRBCs revealed the blood was initiated on 09/26/17 at 3:15 a.m. and was completed at 6:25 a.m. Further review revealed the VS documented prior to the start of the blood was at 3:15 a.m., the same time the blood was initiated at 3:15 a.m., rather than prior to initiating the transfusion.

Review of Patient #2's second unit of PRBCs administration documented by S10RN revealed the blood was initiated at 7:30 a.m. on 09/26/17 and completed at 11:00 a.m. (3 hours 30 minutes rather than 3 hours as ordered). Further review revealed the VS required prior to starting the transfusion were taken at the same time the blood was initiated at 7:30 a.m., rather than prior to initiating the transfusion.

Review of Patient #2's third unit of PRBCs administration documented by S10RN revealed the blood was initiated at 11:10 a.m. on 09/26/17 and completed at 3:15 p.m. (4 hours 5 minutes rather than 3 hours as ordered). Further review revealed the VS prior to the start of the transfusion was documented at 11:25 a.m., 15 minutes after the transfusion was initiated. Further review revealed VS documented as 15 minutes after the start of the transfusion, 1 hour after the start of the transfusion, and 2 hours and 3 hours after the transfusion was started were timed from the prior to start time which resulted in the VS 15 minutes after the start of the transfusion being done 30 minutes after the start, the VS 1 hour after the start of the transfusion being 1 hour 15 minutes after the start, and the VS 1 hour, 2 hours, and 3 hours after the start being assessed 15 minutes late each time.

Review of Patient #2's fourth unit of PRBCs administration documented by S10RN revealed the blood was initiated on 09/26/17 at 4:10 p.m. and completed at 7:30 p.m. (3 hours 20 minutes rather than 3 hours as ordered). Further review revealed the VS documented prior to the start of the blood was at 4:10 p.m., the same time the blood was initiated at 4:10 p.m., rather than prior to initiating the transfusion.

In an interview on 11/15/17 at 11:30 a.m., S2ICNO confirmed the above findings and indicated the RN did not follow hospital policy for blood administration.

Patient #3
Review of Patient #3's physician orders revealed an order on 09/26/17 at 1:38 p.m. to transfuse 1 unit of PRBCs over 1 hour and an order at 1:07 p.m. to transfuse 1 unit of PRBCs over 1 hour.

Review of Patient #3's medical record revealed an "Emergency Transfusion Release" form signed by S11MD with no documented evidence of the date and time the form was signed. Further review revealed 1 unit of PRBCs was documented as cross match compatible. Further review revealed the 2nd unit was documented as "unit stopped, cross match incompatible, returned to lab, (initials of S8MT) 9/26/17, called to S7RN 09/26/17 by (initials) 1:25 p.m."

Review of Patient #3's documentation by S7RN of the first and second unit of PRBCs revealed the two units of blood were initiated on 09/26/17 at 1:02 p.m.. Further review revealed documentation by S7RN (no time documented) that units were released due to emergency; lab technologist notified "us" that the patient had antibodies; S7RN notified the physician who stated that blood will still be infused; S7RN notified lab. At 1:28 p.m. S7RN documented that she was notified that this unit of blood was not compatible with the antibodies in Patient #3's blood. The unit was stopped immediately; "unhooked IV and flushed line with NS." There was no documented evidence that the IV tubing was changed after administering incompatible blood prior to continuing the administration of the second unit of blood.

In an interview on 11/15/17 at 9:45 a.m., S7RN indicated she had both units of PRBCs on the same blood tubing and didn't have a bag of saline attached. She further indicated she flushed the IV line with saline after she stopped the unit of incompatible blood but didn't change the IV tubing. S7RN indicated she didn't know if not changing the tubing after administering incompatible blood before continuing blood through the same IV tubing was an acceptable standard of practice. S7RN indicated "we don't give blood that often." She further indicated that other than orientation and reviewing policies, she didn't recall if anyone had evaluated her for competency in blood administration.

In an interview on 11/15/17 at 3:40 p.m., S2ICNO indicated she could find no documentation that addressed whether the blood tubing should be changed after administering incompatible blood, but the hospital policy requires the tubing to be changed.

Patient #4
Review of Patient #4's consent for blood administration signed by his mother on 11/03/17 revealed no documented evidence that it had been signed by the physician as of the date of the record review on 11/15/17.

Review of Patient #4's physician orders revealed two orders on 11/03/17 at 6:41 a.m. for Platelet Pheresis with no documented evidence of the rate of infusion, and there was no clarification order requested by the RN. Further review revealed a physician's order on 11/03/17 at 8:22 a.m. for 3 units of PRBCs to transfuse over 2 hours each. Further review revealed an order to cross match 1 unit PRBCs on 11/03/17 at 8:39 p.m.

Review of documentation of Patient #4's first unit of platelets revealed the platelets were initiated at 10:45 a.m. on 11/03/17 and completed at 11:40 a.m. Further review revealed the VS required prior to starting the transfusion were taken at the same time the platelets were initiated at 10:45 a.m., rather than prior to initiating the transfusion.

Review of documentation of Patient #4's second unit of platelets revealed the platelets were initiated at 11:45 a.m. on 11/03/17 and completed at 12:37 p.m. Further review revealed the VS required prior to starting the transfusion were taken at the same time the platelets were initiated at 11:45 a.m., rather than prior to initiating the transfusion.

Review of documentation of Patient #4's first unit of PRBCs revealed the blood was initiated at 1:15 p.m. on 11/03/17 and completed at 2:50 p.m. (1 hour 35 minutes rather than 2 hours as ordered).

Review of documentation of Patient #4's second unit of PRBCs revealed the blood was initiated at 3:15 p.m. on 11/03/17 and completed at 4:45 p.m. (1 hour 30 minutes rather than 2 hours as ordered).

Review of documentation of Patient #4's third unit of PRBCs revealed the blood was initiated at 5:05 p.m. on 11/03/17 and completed at 7:35 p.m. (2 hours 20 minutes rather than 2 hours as ordered). There was no documented evidence that VS were assessed 1 hour after completion of the blood in accordance with hospital policy.

Review of documentation of Patient #4's unit of PRBCs documented by S10RN revealed it was initiated at 9:50 p.m. and completed at 12:00 a.m. on 11/04/17. Further review revealed the VS required prior to starting the transfusion were taken at the same time the blood was initiated at 9:50 p.m., rather than prior to initiating the transfusion.

In an interview on 11/15/17 at 11:35 a.m., S2ICNO confirmed the above findings.

3) The hospital failed to include blood incompatibility as an adverse reaction in its blood administration policy:
Review of the policy titled "Blood & (and) Blood Products Administration", presented as a current policy by S2ICNO, revealed no documented evidence that the policy identified the administration of incompatible blood as an adverse reaction.

In an interview on 11/15/17 at 10:50 a.m., S2ICNO confirmed the current blood administration policy did not include administration of incompatible blood as a potential adverse reaction.

Based on record reviews and interview, the hospital failed to maintain an effective QA program that evaluated the quality and appropriateness of the diagnosis and treatment furnished in the hospital that includes all patient care services affecting patient health and safety. The hospital had no documented evidence that lab data related to blood administration by the nursing staff had been collected, analyzed, tracked, and trended with action plans for improvement since March 2017. 34 opportunities for improvement were identified by the surveyor during the survey that had not been identified by the hospital.
Findings:

Review of the policy titled "Quality Improvement Plan", presented as the hospital current plan by S3DQ, revealed that the department director were responsible for promoting the development of standards of care and criteria to objectively measure the quality and safety of care/services rendered in their departments and for monitoring the care processes in their departments.

Review of the dashboard for the lab's QA data revealed a quality indicator was "blood transfusion forms completed correctly." Further review revealed no documented evidence that data had been collected and analyzed since March 2017.

Review of 5 medical records for blood administration revealed 34 opportunities for improvement that were identified by the surveyor that had not been identified by the hospital. This related to blood not being administered by the nursing staff in accordance with physician orders and hospital policy, RNs failing to notify the physician of the assessment of sign/symptoms identified during the pre-administration evaluation, RNs failing to recognize assessed complications after blood administration as an adverse event/reaction and reporting it to the physician, RNs failing to complete an incident report when an adverse event/blood reaction occurred, and not including the administration of incompatible blood as an adverse blood reaction.

In an interview on 11/15/17 at 2:30 p.m. with S3DQ, S2ICNO, and S1CEO present, S3DQ indicated each department develops their own quality indicators that they track, trend, and analyze. She further indicated the findings are brought to the QA Committee, Medical Executive Committee, and then to the Quality Board. She indicated blood administration is evaluated by the lab. S2DQ indicated no data had been collected by the lab since March 2017. She indicated some data was presented for April 2017 when she requested it the day the survey began on 11/14/17, but the there was no analysis of the data. S2DQ indicated the lab was in transition for lab management, and the hospital was without a lab manager from June 2017 to October 2017. She confirmed there was 6 months with no documented evidence of data collected by the lab which includes evaluation of blood administration by the nursing staff. She indicated the nursing director doesn't look at blood administration forms for QA. S2ICNO indicated the prior process prior to being without a lab manager was that the lab manager would review all blood administration forms, and he/she would forward any issues to the appropriate manager. She further indicated that process stopped once the lab manager left. S1CEO indicated the hospital's contracted pathology group provided management of the lab but was focused on the "lab perspective and not the quality function." No explanation was provided for the opportunities for improvement that were identified during the survey that the hospital had not identified prior to the survey.