HospitalInspections.org

Based on interview, medical record and facility document review, the facility failed to identify patient prior to administering diagnostic tests and failed to report this adverse event in the reporting system as required per facility's policy.

The findings include:

Review of Patient #3's (P3) medical record on 10/17/23 at 2:30 p.m. revealed no documentation that the assigned Emergency Department (ED) nurse administered a strep and mononucleosis test to P3 on 8/19/23.

On 10/18/23 at 9:20 a.m., an interview was conducted with Staff Member #8 (S8). S8 stated that the facility received a complaint from a family member of P3 on 9/6/23. The family member stated P3's assigned Emergency Department (ED) nurse administered a strep and mononucleosis test to P3 that was ordered for another patient. S8 stated that the facility staff reviewed P3's medical record and found evidence that P3's assigned ED nurse did administer the tests but once it was discovered that the tests were ordered for another patient, the tests were thrown away and never sent to the laboratory. S8 stated that the details of P3's complaint were entered into the facility's "Safewatch" adverse events reporting system on 9/6/23.

On 10/18/23 at 11:05 a.m., Staff Member #1 (S1) stated that S1 reviewed "Safewatch" for an entry dated 8/19/23 related to administration of wrong tests to P3. S1 stated that there was no documentation of the adverse event. S1 stated that it was entered into "Safewatch" on 9/6/23 as part of the complaint that was received from P3's family member.

A review of the facility's policy "Identification of Patient Prior to Clinical Procedure", last updated 9/2023, stated in part:
"...Purpose: Provide guidance to staff for identifying patients prior to a clinical procedure...
III. Policy Statement(s)
...B. All patients are to be identified using two unique patient identifiers prior to performing any clinical procedure (e.g., specimen withdrawal, medication administration, blood administration, treatment, transfer of patients between any sites of care)...".

A review of the facility's policy "Management of Event Reports and Serious Safety Events", last updated 6/2021, stated in part:
"...I. PURPOSE: ...All staff are trained in the event reporting process and are expected to report all near misses, adverse events and serious safety events...
IV. PROCEDURE: A. The individual who is involved, observes or first becomes aware of the event should submit a report...".

The findings were discussed with Staff Members #1, #3, #4, #6, #12, #13, #14 and #15 on 10/18/23 at 4:15 p.m. during the exit conference.

Based on medical record and facility document review, the facility failed to adhere to the facility's policy for monitoring of vital signs prior and after administration of blood transfusion in one (1) of three (3) patients included in the survey sample.

The findings include:

Review of the facility's policy "Blood Administration, Transfusion Reaction, Blood Warmer", effective date 2/2023, revealed in part:
"...7. Vital signs must be obtained no more than 60 minutes prior to the beginning of transfusion and documented in the medical record...16. Vital signs should be documented within 15 minutes of beginning the transfusion and at the end of transfusion...".

Review of three (3) medical records of patients who received a blood transfusion/s was conducted on 10/17/23 at 3:00 p.m. Patient #6's (P6) medical record documented that P6 received a blood transfusion on 10/10/23 at 9:50 p.m. P6's medical record revealed documented vital signs taken at 11:24 a.m. on 10/10/23, ten (10) hours and twenty-six (26) minutes prior to P6's transfusion. The next set of vital signs were documented at 10:46 p.m., fifty-six (56) minutes after the transfusion began.

The findings were discussed with Staff Members #1, #3, #4, #6, #12, #13, #14 and #15 on 10/18/23 at 4:15 p.m. during the exit conference.