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Based on observation, interview, and record review, the facility failed to ensure the nursing staff provided the necessary nursing care as evidenced by:

1. The nursing staff failed to activate the nursing care plan for one of five sampled patients (Patient 3) who was on airborne isolation.

2. The nursing staff failed to placed a verbal order when discontinuing the isolation precaution for one of five sampled patients (Patient 3).

3. The medication was left unattended.

These failures increased the risk of substandard healthcare outcomes to the patients.

Findings:

1. Patient 3's medical record was reviewed on 12/9/24, with the Director of Clinical Quality Improvement. Patient 3's medical record showed Patient 3 was admitted to the hospital on 12/4/24.

a. Review of the hospital's P&P titled Interdisciplinary Plan of Care dated 06/2021, showed the following:

* Care plans can be initiated from the orders section of the EMR.
* The "suggested" care plans (based on the patient diagnosis) found in the orders section of the EMR can be initiated if appropriate to the patient's clinical status and modified as the patient processes through the continuum of care.
* Additional plan of care can be added as needed.
* The plan of care will be reviewed, modified as needed, or completed and/or discontinued at least once a shift.

On 12/9/24 at 1019 hours, Patient 3's door was observed wide oped. The airborne signage was also observed on the door.

Review of the Physician's Order dated 12/8/24 at 0720 hours, showed to place an airborne precaution to rule out TB.

Review of the Physician's Order dated 12/9/24 at 1027 hours, showed to discontinue the airborne precaution for Patient 3.

However, further review of medical record showed failed to show the nursing care plan was activated for airborne isolation precaution.

b. Review of the hospital's P&P titled Physician Orders (Verbal or Telephone) dated 1/2024 showed a licensed nurse (RN), pharmacist, or other authorized person enters the order (telephone or verbal) follows the order entry process.

On 12/9/24 at 1019 hours, Patient 3's door was observed wide open. The airborne signage was also observed on the door.

On 12/9/24 at 1021 hours, RN 1 was interviewed. When asked, RN 1 stated he cared for Patient 3 yesterday and today. RN 1 also stated the physician verbally stated that Patient 3 could be de-isolated from the airborne isolation precautions.

Review of the Physician's Order dated 12/8/24 at 0720 hours, showed to place an airborne precaution to rule out TB.

Review of the Physician's Order dated 12/9/24 at 1027 hours, showed to discontinue the airborne precaution for Patient 3. The airborne isolation precaution was discontinued prior to the physician's order.

2. Review of the hospital's P&P titled Medication Handling dated 8/2023 showed the following:

* All medications obtained from an approved medication storage area will be removed just prior to the designated administration time.

* Once medications are removed from the approved storage area, they will remain with a licensed individual at all times, and will not be left unattended (unless appropriately labeled and secured).

During a tour of Med 1 with the ED Director on 12/9/24 at 1015 hours, a vial of Admelog (insulin) 100 unit/ml with high alert warning sticker was observed on the nurses' rolling working station.

On 12/9/24 at 1500 hours, the Director of Clinical Quality Improvement verified the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital's P&P for the administration of blood and blood products for one of five sampled patients (Patient 5) as evidenced by:

a. Complete vital signs were not assessed or documented during the blood transfusion.

b. There was no documentation of the blood transfusion rate.

c. A urine specimen was not collected after a suspected transfusion reaction.

These failures posed the risk of potential complications, including undetected changes in the patient's condition, delayed interventions, and overall compromised patient safety during and after the blood transfusion process.

Findings:

Review of the hospital's P&P titled Administration of Blood and Blood Products dated 1/2024 showed the following:

* Take the patient's vital signs (temperature, pulse, respirations, and blood pressure) before beginning the infusion and document them in the EMR. Do not document vital signs more than 30 minutes prior to starting the transfusion. Record vital signs at 15 minutes after starting the transfusion, every hour during the transfusion, and within 15 minutes of completion.

* Begin the transfusion by unclamping the tubing and starting the infusion slowly (approximately 2 mL per minute or 125 mL per hour) for the first 15 minutes. Stay with the patient during this time, as reactions can occur after a small volume enters the patient's circulation. Record vital signs at the end of 15 minutes. If no signs or symptoms of a reaction occur, increase the infusion rate appropriately based on the patient's condition.

* If signs or symptoms of an adverse reaction occur at any time during the infusion, immediately clamp the tubing to stop the transfusion, notify the Blood Bank and physician, and keep the vein open with normal saline and new IV tubing. A Rapid Response may be called as needed. As soon as possible, the nurse will collect and label a urine specimen, complete a Per Protocol order for a Urobilinogen test, and send it to the lab with "suspected transfusion reaction" indicated on the request.

On 12/9/24 at 0944 hours, review of Patient 5's medical record was conducted with the Clinical Informatics Specialist, MD 1, Lead Clinical Lab Scientist, and the LIS Manager.

Patient 5's medical record showed the patient was admitted to the hospital on 11/12/24.

Review of the physician's order dated 12/6/24, showed an order to transfuse one unit of platelets to Patient 5.

Review of Patient 5's medical record showed the transfusion of the platelets was started on 12/6/24 at 1205 hours, and stopped at 1237 hours.

a. Review of Patient 5's medical record showed the patient's respiratory rate was not assessed or documented at the completion of the transfusion.

b. Review of Patient 5's medical record did not show documented evidence the transfusion was infused slowly at 125 ml per hour during the first 15 minutes as per the hospital's P&P.

On 12/9/24, during the record review, the Clinical Informatics Specialist verified Patient 5's respiratory rate was not assessed or documented at the completion of the transfusion, and there was no documentation to show the transfusion was infused at 125 ml per hour during the first 15 minutes. The Clinical Informatics Specialist added that it was not the hospital's practice to document the infusion rate for blood transfusions.

c. Review of the Nursing Narrative dated 12/6/24 at 1346 hours showed that Patient 5 complained of itching on her ears and forehead. Upon assessment, the patient had an elevated heart rate of 122 beats per minute and was noted to have hives on her face, chest, and lower back. The patient also began complaining of lightheadedness and a feeling of passing out. A Rapid Response was called at 1306 hours. The patient had just completed a platelet transfusion. The physician and blood bank were notified of a potential platelet transfusion reaction, and the reaction protocol was initiated.

Review of Patient 5's medical record did not show that a urine specimen was collected as soon as possible after the patient had a suspected blood transfusion reaction.

On 12/9/24, during the interview and concurrent record review, MD 1 stated the purpose of the urine collection was to detect hemolysis (the breakdown of red blood cells, releasing hemoglobin into the bloodstream), which was one component of the transfusion reaction workup, along with collecting blood samples. MD 1 stated the urinalysis was to detect hemoglobinuria (the presence of free hemoglobin in the urine, often a sign of hemolysis) or elevated urobilinogen, which can indicate hemolysis and may lead to severe consequences such as kidney damage or failure.

On 12/9/24, during the interview and concurrent record review, the LIS Manager confirmed a urine specimen was not collected.