HospitalInspections.org

The Critical Assess Hospital (CAH) reported a census of two patients. Based on policy review, observation and interview the CAH failed to ensure six units of blood products remained viable at the correct temperature, while stored in a continuously monitored Blood Bank refrigerator.

Findings include:

- Review on 7/26/12 at 10:00am of a policy titled "Quality Control and Improvement Program in Blood Bank" directs staff, under " 2. Equipment...Instruments and alarms checks are done to ensure optimum functionality. Continual monitoring of Blood Bank refrigerator..."

- Observations made on 7/25/12 at 9:00am revealed staff D testing the blood bank alarm located at the nurses station. Nursing staff failed to call the laboratory after ten minutes of the alarm test.

Laboratory Staff D interviewed on 7/25/12 at 9:10am acknowledged when the audible alarm sounds the procedure requires nursing staff, to call the laboratory immediately, within one minute of the alarm sound.

Administrative Staff A interviewed on 7/25/12 at 9:20am, confirmed the CAH failed to ensure nursing staff followed the facility procedures for responding to the Blood Bank alarm.

The failure of nursing staff to respond to the audible blood bank alarm had the potential to affect all patients that required a blood transfusion.

The Critical Assess Hospital (CAH) reported a census of two patients. Based on observation and interview the CAH failed to ensure nursing staff followed nursing procedures that required nursing to immediately notify the laboratory when the Blood Bank alarm sounded at the nursing station. The Blood Bank alarm ensured the CAH to safely store six unit's of blood at the required temperature in the blood bank refrigerator. The failure of nursing staff to respond to the blood bank alarm had the potential to affect all patients that required a blood transfusion.

Findings include:

- Observations made on 7/25/12 at 9:00am revealed staff D testing the blood bank alarm located at the nurses station. Staff D interviewed at this time acknowledged the alarm sounds at the nurse's station and the nursing staff calls the laboratory within one minute to let them know the alarm is sounding.

Continued observation for three minutes revealed nursing staff failed to call the laboratory. Staff D at 9:10am, ten minutes later, walked to the nurse's station to inquire if an alarm sounded. Nursing aide Staff B interviewed at 9:13am confirmed the alarm sounded and they called maintenance.

Administrative staff A interviewed on 7/25/12 at 9:20am verified nursing staff receive education at the Annual Nursing Skills Fair where Certified Nurse Aides (CNA), take a competency exam that requires nursing staff to notify the laboratory within one minute of the alarm sounding. Staff A verified staff B failed to follow the CAH's procedure for the Blood Bank alarm.

The Critical Assess Hospital (CAH) reported a census of two patients. Based on policy review, observation and interview the CAH failed to ensure six units of blood products remained viable at the correct temperature, while stored in a continuously monitored Blood Bank refrigerator.

Findings include:

- Review on 7/26/12 at 10:00am of a policy titled "Quality Control and Improvement Program in Blood Bank" directs staff, under " 2. Equipment...Instruments and alarms checks are done to ensure optimum functionality. Continual monitoring of Blood Bank refrigerator..."

- Observations made on 7/25/12 at 9:00am revealed staff D testing the blood bank alarm located at the nurses station. Nursing staff failed to call the laboratory after ten minutes of the alarm test.

Laboratory Staff D interviewed on 7/25/12 at 9:10am acknowledged when the audible alarm sounds the procedure requires nursing staff, to call the laboratory immediately, within one minute of the alarm sound.

Administrative Staff A interviewed on 7/25/12 at 9:20am, confirmed the CAH failed to ensure nursing staff followed the facility procedures for responding to the Blood Bank alarm.

The failure of nursing staff to respond to the audible blood bank alarm had the potential to affect all patients that required a blood transfusion.

The Critical Assess Hospital (CAH) reported a census of two patients. Based on observation and interview the CAH failed to ensure nursing staff followed nursing procedures that required nursing to immediately notify the laboratory when the Blood Bank alarm sounded at the nursing station. The Blood Bank alarm ensured the CAH to safely store six unit's of blood at the required temperature in the blood bank refrigerator. The failure of nursing staff to respond to the blood bank alarm had the potential to affect all patients that required a blood transfusion.

Findings include:

- Observations made on 7/25/12 at 9:00am revealed staff D testing the blood bank alarm located at the nurses station. Staff D interviewed at this time acknowledged the alarm sounds at the nurse's station and the nursing staff calls the laboratory within one minute to let them know the alarm is sounding.

Continued observation for three minutes revealed nursing staff failed to call the laboratory. Staff D at 9:10am, ten minutes later, walked to the nurse's station to inquire if an alarm sounded. Nursing aide Staff B interviewed at 9:13am confirmed the alarm sounded and they called maintenance.

Administrative staff A interviewed on 7/25/12 at 9:20am verified nursing staff receive education at the Annual Nursing Skills Fair where Certified Nurse Aides (CNA), take a competency exam that requires nursing staff to notify the laboratory within one minute of the alarm sounding. Staff A verified staff B failed to follow the CAH's procedure for the Blood Bank alarm.