HospitalInspections.org

Based on record review and review of hospital policies, it has been determined that the hospital failed to meet the Condition of Participation of Patient's Rights relative to care in a safe setting for 4 of 5 sample patients (ID #'s 2, 3, 4 and 5).

Findings are as follows:

1. The hospital failed to adhere to the policy entitled "Restraints" for 3 of 5 patients relative to nursing assessment (ID #'s 2, 3 and 5). (refer to A-167)

2. The hospital failed to adhere to the policy entitled "Restraints" for 4 of 5 patients relative to Provider evaluation (ID #'s 2, 3, 4 and 5). (refer to A-167)

Based on surveyor record review, staff interview and review of hospital policy, it has been determined that the hospital failed to adhere to their own policy entitled "Restraints" for 3 of 5 patients relative to nursing assessment (ID #'s 2, 3 and 5) , and for 4 of 5 patients relative to Provider evaluation (ID #'s 2, 3, 4 and 5).

Findings are as follows:

The hospitals "Restraints" policy, last revised in 7/18, states in part,

A. "Standard of Care ...During restraint period: Patient care and monitoring provided every 2 hours while awake and every 4 hours while asleep, by a trained staff member ...". This monitoring includes "Safety checks, respiratory status, psychological behavior, alternative interventions being utilized, care delivery, circulation and sensation, skin integrity, range of motion and repositioning ..."

1. Review of the medical record for Patient ID # 2 revealed s/he was hospitalized in 9/2020 for confusion secondary to a bowel obstruction (blockage of the intestines) and a perforated diverticulum (a hole in part of the intestine) which required surgery. The patient was placed in non-violent restraints (right and left side soft wrist restraints) from 9/16/2020-9/24/2020. Nursing documentation reveals greater than 2 hours without evidence of restraint monitoring for Patient ID #2 on the following dates: 9/21/2020 from 11:58 AM- 2:53 PM, 9/23/2020 from 3:30 PM until 6:51 PM, and on 9/24/2020 from 4:42 AM until 8:00 AM.

2. Review of the medical record for Patient ID # 3 revealed s/he was hospitalized in 5/2020 for poor nutritional intake, placement of a nasogastric tube (a small tube that is passed through the nose, down through the throat and into the stomach) for medications, and chest congestion. Patient ID # 3 was placed in non-violent restraints from 5/21/2020-5/26/2020. Nursing documentation reveals greater than 2 hours without evidence of restraint monitoring for Patient ID #2 on the following dates: 5/21/2020 from 6:19 PM until 11:30 PM, 5/22/2020 from 3:38 AM until 8:20 AM and 2:23 PM until 6:28 PM, and on 5/25/2020 from 6:00 AM until 9:00 AM, 2:41 PM until 9:00 PM and 9:00 PM until 12:00 AM.

3. Review of the medical record for Patient ID # 5 revealed s/he was hospitalized in 6/2020 with a diagnosis of syncope (fainting). While inpatient, s/he was also diagnosed with delirium (a temporary mental state characterized by confusion, anxiety, incoherent speech, and hallucinations). Patient ID # 5 was placed in non-violent restraints (right and left side soft wrist restraints) from 6/30/2020-7/2/2020 at approximately 10:30 AM, when the non-violent restraints were discontinued. Nursing documentation reveals greater than 2 hours without evidence of non-violent restraint monitoring for Patient ID # 5 on the following dates: 6/30/2020 from 5:21 PM until 8:00 PM and on 7/1/2020 from 5:21 AM until 8:30 AM and 4:47 PM until 8:00 PM.

During an interview with the Telemetry Nurse Manager, Director of Risk Management and Vice President of Quality Improvement on 11/20/2020 at approximately 1:15 PM, they were unable to provide evidence that the hospital policy had been followed relative to nursing restraint monitoring for the above patients.

B. "Non-Violent/Non-Self-Destructive Restraint Orders ...The provider assessment is documented in the medical record including, but not limited to the following information: Patient's current status, Attempted less restrictive intervention, Patient's reaction to the intervention, Patient's medical and behavioral condition ...Rational for continuation or termination of the restraint ...

Violent/Self-Destructive Restraint Orders: A provider evaluated the patient in person within one hour of the initiation of restraint for violence or self-destructive behavior. The Provider's evaluation is documented in the medical record including, but not limited to the following information: Patient's current status, Attempted less restrictive intervention, Patient's reaction to the intervention, Patient's medical and behavioral condition ...Rational for continuation or termination of the restraint ...

1. Review of the medical record for Patient ID # 2 revealed s/he was placed in non-violent restraints from 9/16/2020-9/24/2020. The Provider evaluations on 9/16/2020, 9/17/2020, 9/18/2020, 9/19/2020, 9/20/2020, and 9/21/2020 failed to include evidence of an attempted less restrictive intervention and the patient's reaction to the intervention.

2. Review of the medical record for Patient ID # 3 revealed s/he was placed in non-violent restraints from 5/21/2020-5/26/2020. The Provider evaluations on 5/24/2020, 5/25/2020 and 5/26/2020 failed to include evidence of an attempted less restrictive intervention and the patient's reaction to the intervention.

3. Review of the medical record for Patient ID # 4 revealed s/he was placed in non-violent restraints from 10/18/2020-10/20/2020 and then from 10/25/2020 to 10/26/2020. The Provider evaluations on 10/19/2020 and 10/25/2020 failed to include evidence of an attempted less restrictive intervention and the patient's reaction to the intervention.

4. Review of the medical record for Patient ID # 5 revealed s/he was placed in non-violent restraints from 6/30/2020-7/2/2020 and violent restraints (right and left side wrist and ankle soft restraints) from 7/3/2020 at 3:53 AM until 7:40 AM and then again on 7/3/2020 at 11:22 PM until 7/4/2020 at approximately 6:15 AM. The Provider evaluations on 7/1/2020 and 7/2/2020 failed to include evidence of an attempted less restrictive intervention and the patient's reaction to the intervention.

On 11/17/2020 at approximately 3:20 PM, the Telemetry Nurse Manager and Director of Risk Management were unable to provide documentation that the Provider's included evidence of an attempted less restrictive intervention and the patients reaction to the intervention for Patient ID #'s 2, 3 4 and 5. Furthermore, they were unable to provide evidence that a Provider evaluated Patient ID # 5 in person within one hour of the initiation of the violent restraints, as per hospital policy.

Based on record review and staff interview, it has been determined that the hospital failed to meet the Condition of Participation relative to Nursing Services for patient ID #1 relative to the administration of blood products resulting in Immediate Jeopardy.

Findings are as follows:

1. The hospital failed to provide nursing care in accordance with the hospital policy for "Blood and Blood Component Administration" for Patient ID #1. (refer to A-0409)

2. The hospital failed to provide nursing care in alignment with the Joint Commission National Patient Safety Goal 1 from July 2020, which is to improve the accuracy of patient identification. The elements of performance of this goal includes, in part, to use at least two patient identifiers when administering blood or blood components. (refer to A-0409)

Based on surveyor policy review and staff interview, it has been determined that the hospital failed to follow its own policy relative to the administration of blood for 1 of 1 sample patients, patient ID #1.

Findings are as follows:

Patient ID #1 was admitted to the hospital in 11/2020 for rectal bleeding requiring the administration of blood transfusions. During one of the transfusions, blood prepared for another patient was incorrectly identified and verified for this patient by two nurses which resulted in Patient ID #1 being administered another patients blood and an incompatible blood type.

The hospital's "Blood and Blood Component Administration" policy, last revised in 11/2019, states in part,

1. "Procuring Blood and Blood Products from the Blood Bank for Transfusion ...2. Transporting staff (RN, transporter ...) that has been trained to retrieve blood or blood products brings the completed Passport (document from the nursing unit where the blood is to be administered) to the Blood Bank.

On 11/17/2020 at 9:45 AM surveyor interviewed the Transporter, Staff C, who retrieved the blood from the Blood Bank for this event. He stated that policy has deviated regarding the transporter obtaining the Passport from the nursing unit and bringing it to the Blood Ban and instead of following the hosptial policy by physically transporting the Passport someone from the nursing unit sends the Passport to the Blood Bank through the "lab shoot".

During an interview with the Director of Risk Management on 11/17/2020 at 11:55 AM, she acknowledged that the unit nurses had deviated from the policy by sending the Passport to the lab and bypassing the safety mechanism of the Passport being retrieved by the transporter.

2. "Identification and Verification: 1. Using the double read back method, the RN (registered nurse) administering the blood or blood product with another RN or provider confirms the identification of the blood product and the recipient in the presence of the patient. The two individuals verify and document on the Blood Bank Transfusion record all the patient information is correct and aligns with provider order, the patient registration/identification wrist band, and the yellow Blood Bank identification wrist band before preparing the product for transfusion. The information includes patient name and date of birth, blood unit tag number, unique number/letter combination on the yellow Blood Bank identification wrist band, room number, provider name, date, patient blood type, donor blood type, expiration date and compatibility ..."

Additionally, two signatures on the "Blood Bank Transfusion Record Bedside Verification" attests to "We have verified in the presence of the patient that: 1.) The patient's name, WB # (wrist band number) and hospital # are identical on the unit compatibility label, wristband, and Transfusion Record. 2.) The donor unit # and the blood type are identical on the unit compatibility label, Transfusion Record, and the blood blank unit ...."

On 11/17/2020 at 10:51 AM the surveyor interviewed Staff A, the registered nurse caring for the patient. Staff A acknowledged she did not follow the blood administration policy and procedure as she administered blood to Patient ID #1 without any patient identifiers on the blood bag to verify the blood was for Patient ID #1. She also stated that both nurses neglected to verify Patient ID #1's blood type during the identification and verification process. Nurse A stated she was aware she should not administer the blood without a patient label attached to the blood bag.

On 11/17/2020 at 11:15 AM the surveyor interviewed Staff B, the registered nurse responsible for being the second person for the blood administration identification and verification process. Staff B stated that throughout the identification and verification process she was unaware of the patients name and failed to ask his/her name.

Staff B stated she did not refer to the Blood Bank Transfusion record at any time during the process; however, she acknowledged that if she had the Transfusion Record in front of her, as per hospital policy, she would have identified the recipient patients name, date of birth, yellow Blood Bank number and donor blood type were incorrect. Instead, she stated she referred to the patient information that was on the computer screen in the patient's room, which was on the screen upon her arrival and contained patient information relative to Patient ID #1 and not to the blood being administered.

She stated there was no two-person verification of the bag of blood, transfusion record or wristband, all of which resulted in the Patient ID #1 being administered blood intended for another patient.

Staff B stated the only time she viewed the Transfusion record was as she was leaving the room, when Staff A asked her to sign the "Blood Bank Transfusion Bedside Verification." She further stated that she signed the Bedside Verification without reading it.

During an interview with the Director of Risk Management and the CNO/COO on 11/16/2020 at 12:30 PM, they acknowledged that the two nurses failed to confirm the blood product and the recipient in the presence of the patient which resulted in Patient ID #1 receiving blood product intended for another patient in the hospital.