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Based on document review and interview, the facility failed to measure, analyze and track adverse patient events in 1 of 1 event reviewed.

Findings Include:

1. Review of Incident (PSC17357978) involving Patient 14; during report Registered Nurse was told that Patient 14 received 1 unit of blood; when Blood Bank cooler with Patient 14's blood, O Rh negative, was checked, there were 4 units of blood found. An ECMO (extracorporeal membrane oxygenation) patient in the next room, who did not receive a unit of blood, had a Blood Bank cooler with 3 units of blood, A Rh positive, in it when there was supposed to be 4 units.

2. This Surveyor was given a copy of "Action Items" regarding above event that were completed but it could not be determined that the Quality Committee reviewed, recommended or accepted actions related to the event.

3. Interview on 11/04/21 with P58 (Nurse Manager) at 1:22 pm confirmed that Patient 14's armband was not used as an identifier before receiving blood, therefore, an A Rh positive unit of packed red blood cells was given to a O Rh negative patient (Patient 14).

4. This Surveyor requested any documentation related to the investigation and outcome of event; Surveyor did not receive by time of exit.

Based on document review and interview, nursing administration failed to ensure that proper patient identification process was followed in 1 of 10 patients (Patient 14) reviewed (see tag A398).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the nursing services were provided in a safe manner.

Based on document review and interview, nursing administration failed to ensure that proper patient identification process was followed in 1 of 10 patients (Patient 14) reviewed and to give a written reprimand to persons involved per policy.

Findings Include:

1. Review of policy titled: Patient Identification for Care, Treatment and Services (PolicyStat ID: 10387855) last approved 10/2021, indicated that Patient identification requires 2 identifier sources and the #1 source "must always" be the patient's ID band; #2 source may be a patient label/lab label containing patient name and birth date. Source #1 "must" be compared to source #2 prior to any care, treatment or service. The policy indicated that the identification of a patient using 2 patient identifiers is considered a "Red Rule" and failure to comply will result in corrective action (minimum of a written reprimand).

2. Review of Blood Product Administration (Adult/Pediatric) (PolicyStat ID: 8479417) last approved 02/2021, indicated that when initiating a transfusion, dual verification must occur at the bedside by using 2 identifiers (name, date of birth or medical record number) from the patient's identification band, then compare 3 separate sources of information: blood product label, transfusion flowsheet and patient armband - both individuals must sign, date and time the verification in the electronic medical record or paper Transfusion Record.

3. Review of Incident log from 10/25/20 to 10/25/21 had documentation of 1 incident (PSC17357978) involving Patient 14; during report Registered Nurse was told that Patient 14 received 1 unit of blood; when Blood Bank cooler with Patient 14's blood was checked, there were 4 units of blood found. An ECMO patient in the next room, who did not receive a unit of blood, had a Blood Bank cooler with 3 units of blood in it when there was supposed to be 4 units.

4. Review of letter dated 07/07/21 to the U.S. Food and Drug Administration (FDA) from outside laboratory #P64 (facility Blood Bank) Medical Director indicating:
a. Packed red blood cells (PRBC) ordered for Patient 14.
b. ICU staff brought cooler for Patient 14 at the same time as another ECMO patient and placed in the wrong rooms on 06/29/21 (each held 4 units PRBC).
c. Patient 14's blood type was O, Rh negative and the other patient's blood type was A, Rh positive.
d. At 2:12 pm on 06/29/21, an A, Rh positive unit was removed from the cooler in Patient 14's room and transfusion was initiated. While the transfusion record form was reportedly compared to the labeled unit, Patient 14's armband was not checked by the nursing staff.
e. The unit was completed at 3:55 pm on 6/29/21.
f. Patient 14's clinical condition began to rapidly deteriorate during the evening of 06/29/21; developed acute renal failure, severe hypotension, acidosis and thrombocytopenia and needed pressor medications (4 of them). Patient passed away on 06/30/21 at 1:36 am.

5. Interview on 11/04/21 with P58 (Nurse Manager) at 1:22 pm confirmed that Patient 14's armband was not used as an identifier before receiving blood, therefore, an A Rh positive unit of packed red blood cells was given to a O Rh negative patient (Patient 14).

6. Interview on 11/04/21 with P58 at 2:55 pm confirmed that none of the staff involved in this incident were
given a written reprimand.

Based on document review and interview, the facility failed to ensure complete medical records in 1 of 10 (Patient 14) medical records reviewed.

Findings Include:

1. Review of facility documentation dated 06/29/21 (PSC17357978); during report Registered Nurse was told that Patient 14 received 1 unit of blood; when Blood Bank cooler with Patient 14's blood was checked, there were 4 units of blood found. An ECMO patient in the next room, who did not receive a unit of blood, had a Blood Bank cooler with 3 units of blood in it when there was supposed to be 4 units. Physician notified.

2. Review of Patient 14's medical record lacked documentation of transfusion of 1 A Rh positive packed red blood cells given to Patient 14 who was O Rh negative and contained transfusion records for 4 units of O Rh negative red packed blood cells.

3. Interview on 11/04/21 with P58 (Nurse Manager) at 1:22 pm confirmed that Patient 14 received a unit of blood meant for a different patient; patient's armband was not used as an identifier.