HospitalInspections.org

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Based on medical record (MR) review, document review and interviews, in 2 (two) of 6 (six)medical records, there was no documented evidence that the primary care physician was notified by the nursing staff when the patient (pt.) had a suspected transfusion reaction.
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This lack of notification could result in the physician ordering additional transfusions for the patient without appropriate pre-transfusion precautions.
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Findings include:
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The facility policy and procedure (P&P) titled "Blood Products, Management of the Patient: Pre, During and Post Transfusion," lasted revised 12/04/2017 stated: "If a transfusion reaction is suspected or apparent... call the mid-level practitioner (MLP) to assess the patient or call a Rapid Response ...[and] the physician of record will be notified ..."
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Patient #12's MR identified that on 12/10/2017 from 1:30 PM to 5:35 PM, the pt. was transfused two units of Fresh Frozen Plasma (FFP) for an elevated International Normalized Ratio (INR) [the length of time it takes for blood to clot]. The nurse documented, "Pt. tolerated transfusion well. Vital signs remain stable throughout." The nurse then documented at 8:00 PM, two and a half hours later, "At change of shift pt. noted to be tachypneic (fast shallow breathing) and having rigors (severe exaggerated shivering). Audible expiratory wheeze .... Rapid Response called ... Transfusion reaction and Sepsis protocol followed."
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The Physician Assistant (PA) documented at 11:06 PM "Rapid Response called at 7:30 PM. Pt with shortness of breath, chills and unable to obtain pulse oxygenation .... [Pt.] hypoxia [condition in which tissues of the body are starved of oxygen], dyspnea [severe shortness of breath] [with] fever. Status post 2 units of FFP, rule out blood transfusion reaction, rule out Transfusion-Related Acute Lung Injury (TRALI)" [a rare but serious sudden acute respiratory distress following transfusion].
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Review of the physicians progress notes from 12/11/2017 found no evidence the attending physician (physician of record) or any of the consulting physicians were notified by the nursing staff at the time the patient had the suspected transfusion reaction.
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Patient #13's MR identified that on 10/27/17 from 12:30 PM to 6:30 PM, the pt. was transfused two units of Packed Red Blood Cells (PRBC) for anemia without incident. The nurse documented at 9:41 PM (three hours later), "Pt with axillary temperature of 102.2. Called house Physician Assistant (PA). Pt. received 2 units of PRBCs today, possible transfusion reaction."
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The PA then documented at 2:11 AM "Called by RN to evaluate pt. with possible blood transfusion reaction .... Transfusion reaction work-up, Sepsis work-up ... registered nurse (RN) to notify primary medical doctor (PMD).
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Review of the physician progress notes identified there was no documented evidence that the PMD / attending physician (physician of record) was notified by the nurse.
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These findings were confirmed by Staff K (nurse educator) stating "I see what you mean," during reviews of the MRs on 5/2/2018.

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Based on Medical Record (MR) review, document review and interview, in 4 (four) of 5 (five) medical records, the nursing staff did not consistently document skin assessments on patients (pt.) admitted with pressure ulcers.
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This inconsistent documentation may affect other providers' ability to monitor the patients' condition or provide appropriate care.
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Findings include:
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Patient #17's MR identified that the patient presented to the emergency department (ED) at 7:12 pm on 4/26/18 from a Skilled Nursing Facility (SNF). The patient had a past medical history of Hypertension, Anemia, End Stage Renal Disease requiring Hemodialysis, Chronic Obstructive Pulmonary Disease and bilateral vascular foot ulcers.
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The physician documented at 7:42 PM that "the patient's daughter states ... the patient has an ulcer of the right hip ..." and the physical exam documents the patient has a "4 cm by 3 cm region of necrosis (dead tissue) with pustular (purulent exudate / pus) discharge on the right hip."
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The wound care nurse then documented on 4/27/18 at 8:29 AM, "patient admitted with ...right hip unstageable pressure injury 4cm by 2cm by 0.1 cm. ... wound bed 100 % ...black necrotic (black / brown dead tissue) tissue ...likely when debrided would be a Stage 4 Pressure Injury."
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Review of the nursing notes on 4/26/18 at 7:29 PM revealed there is no documentation by the emergency room nurse related to the right hip pressure ulcer and the nursing flow sheets document the first assessment of the right hip pressure injury when the patient was admitted to the in-patient unit at 4:14 AM on 4/27/18.
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Patient # 3 MR identified that the patient presented to the ED from a SNF on 4/27/18 with a history of CVA, Hypertension, Diabetes, DVT and MVR. The patient is ventilator dependent with a gastrotomy feeding tube. The patient was documented to have a chronic sacral wound with blisters on the abdomen, flank and back but there is no documentation found related to a pressure injury on the patient's right foot.
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The nurse then documents two days later, at 6:44 PM on 4/29/18 " ...left message for [nurse] ...in wound care to assess bottom of patient's right foot for possible DTI (deep tissue injury)".
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The wound care nurse then documented on 5/2/18 at 10:13AM, " ...right planter surface of foot patient's heel [with] deep tissue injury ...due to wound being discovered 48 hours after admission ...likely the injury resulted at the prior institution ....".
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The same inconsistent documentation regarding skin assessments for patients with pressure ulcers was found in MRs of Patient #18 and #19.
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These findings were confirmed by Staff K (nurse educator) during review of the MRs in the morning on 5/3/2018.
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The "Registered Nurse (RN) flowsheet" education for charting expectations dated 3/2018 - 4/2018, includes instruction for the nursing staff to "chart [patient] exam using the flowsheets in the ED narrator ...if the patient is to be admitted ...they need a skin assessment by the ED RN ... [and]chart any wounds."
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The facility policy and procedure (P&P) titled "Assessment / Reassessment", lasted revised 10/2016, states the following: "All patients admitted for treatment will be screened for wounds at the time the RN (Registered Nurse) completes the admission history and assessment."
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The facility policy and procedure (P&P) titled "Pressure Injury Prevention, Management and Treatment", lasted revised 09/2016, states the following: "all registered nurses are responsible for/to: completely assess each patient skin upon admission".
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Based on observation and interview, staff did not ensure an intravenous medication solution was appropriately dated, in 1 (one) out 3 (three) observations. This may have placed patients at risk for receiving an expired medication.

Observation in the facility's C unit during a tour on 5/2/18 between 11:08 AM and 12:20 PM, an Intravenous Piggy Back (IVPB) containing Vancomycin was found in the medication room refrigerator for Patient #10, without a preparation date, beyond use date or expiration date. This finding was confirmed with Staff I (Nurse Manager) at the time of the observation.

Per interview, Staff I stated that the bag should have had dates on it, and if it was no longer needed, then it should have been put in a bin for the Pharmacy department to pick up.

The findings were discussed with Staff P (Assistant Director of Pharmacy) at 2:30 PM on 5/3/18.

Based on observation, document review, medical record (MR) review and interview, in 2 (two) of 2 (two) MRs, the nursing staff did not educate visitors on isolation precautions and document such education in the electronic medical records (EMRs).

The facility policy and procedure (P&P) titled "Isolation Precautions including Standard Precautions," last revised 2/2017, stated: "Visitors are provided education about infection control practices...Patients and their visitors are educated about the rationale for isolation and their role in preventing transmission in the hospital and post-discharge. This education is documented in the Patient Education Record in the EMR."

Observation in the facility's 2 East unit during a tour between 11AM and 12:15PM on 5/1/18 identified a visitor in an Isolation room without personal protective equipment (PPE). A Contact Precaution isolation sign on the door of Patient #5's room instructed anyone entering the room to don gown and gloves.

Per interview with Staff F (Registered Nurse), the visitor was a companion from the nursing home where Patient #5 resides. Per interview of visitor, she reported she never dons gowns during her visits. This was confirmed with Staff A (Director of Critical Care) and Staff B (Nurse Manager).

Review of Patient #5's MR revealed she was positive for Extended Spectrum Beta Lactamase (ESBL) [enzymes produced by many species of bacteria which destroy one or more antibiotics] in the urine, and was placed on Contact Isolation Precautions. There was no documented evidence of visitor education on the use of PPE and Isolation Precautions.

The same lack of documented isolation precaution education was found in Patient #6's MR reviewed on 5/1/18.