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400 ROSALIND REDFERN GROVER PARKWAY

MIDLAND, TX 79701

PATIENT RIGHTS

Tag No.: A0115

Based on interview and record review, the facility failed to protect a patient's right to receive care in a safe setting as evidenced by:


- Patients #2 and #5 were discharged within 15 minutes of the completion of their blood transfusions, preventing the nurses from completing the facility's required one-hour post-transfusion reaction monitoring, placing the patients at risk of injury or death from a blood transfusion reaction.


- Patient #2 and 5 were discharged with low hemoglobin and hematocrits and continued bleeding, placing them at risk of dizziness, injury and death.


- The Emergency Room Nursing staff did not follow the facility's Policy and Procedures for the safe administration of blood products. The staffs did not have two licensed staff check for the compatibility of the blood types and the correct patient prior to the transfusion. This practice places patients at risk of blood transfusion reactions and death.

Cross refer to A00386 and A1104

NURSING SERVICES

Tag No.: A0385

Based on observation, interview, and record review, the facility failed to provide nursing services to ensure safe care to patients in that


a.) The Emergency Room Nursing staff did not follow the facility's Policy and Procedures for the safe administration of blood products. The staffs did not have two licensed staff check for the compatibility of the blood types and the correct patient prior to the transfusion. This practice places patients at risk of blood transfusion reactions and death.


b.) Patients #2 and #5 were discharged within 15 minutes of the completion of their blood transfusions, preventing the nurses from completing the facility's required one-hour post-transfusion reaction monitoring, placing the patients at risk of injury or death from a blood transfusion reaction.


c.) Staff did not reassess patients (Patient #1, 7, 11) after pain medications were given.

Cross Refer to A0386

ORGANIZATION OF NURSING SERVICES

Tag No.: A0386

Based on interview and record review, the facility failed to provide nursing services to ensure the provision of safe care to patients in that:


a.) The Emergency Room Nursing staff did not follow the facility's Policy and Procedures for the safe administration of blood products. The staffs did not have two licensed staff check for the compatibility of the blood types and the correct patient prior to the transfusion. This practice places patients at risk of blood transfusion reactions and death.


b.) Patients #2 and #5 were discharged within 15 minutes of the completion of their blood transfusions, preventing the nurses from completing the facility's required one-hour post-transfusion reaction monitoring, placing the patients at risk of injury or death from a blood transfusion reaction.


c.) Staff did not reassess patients (Patient #1, 7, and 11) after pain medications were given, placing the patients at risk of continued or worsening pain or oversedation from the pain medications.


Findings:


POLICY

Review of the facility policy for Transfusion of Blood Components (RBC, Plasma, Cryoprecipitate, Platelets and RH Immunoglobulin (RHIG) (dated 03/03/2017) reflected, "Pre-Transfusion Process

Purpose: To instruct the licensed provider (transfusionist) on the pre-transfusion preparation process for non-emergent and emergent transfusion....

At the bedside with the blood component the transfusionist and another licensed provider will...

3. The two licensed patient care providers (one must be an RN or a physician) will sign their first initial and last name, one at Nurse 1 and the other at Nurse 2 on the Crossmatch Report Slip attached to the blood component.

4. Each licensed provider will verify in the presence of the patient the following by initialing under Nurse 1 and Nurse 2 at the bottom of the Crossmatch Report Slip in the Patient Identification Infusion Record section:

a) The patient's name and date of birth on the MMH Identification band and the Crossmatch Report slip attached to the blood product are identical

b) The BB Band ID on the Crossmatch Report Slip and the one on the patient's blood bank band are identical (write it at BB Band ID on the slip)

c) The Product Unit number on the Crossmatch Report Slip and the one on the unit are identical

d) The donor unit ABO/Rh on the slip and on the unit are identical (write the ABO/Rh at ABO/Rh on the slip) ....

10. Take Vital signs immediately prior to the start of the transfusion, at 15 and 30 minutes after it is started, then every 30 minutes until transfusion is finished, when the transfusion is completed, and 1-hour post transfusion....

11. Assess patient for signs and symptoms of a possible transfusion reaction each time vital signs are assessed....

Patient Education... 2. Give the patient information regarding signs and symptoms of transfusion reactions and what to do if they suspect they are having a delayed transfusion reaction....

References:
AABB. Standards of blood Banks and Transfusion Services. 30th edition. 2016. Bethesda, Marlyland ...
Infusion Nursing Standards of Practice. (2006) Journal of Infusion Nursing Supplement. Lippincott, Williams & Wilkins...."


During an interview on the morning of 2/25/19, when asked for a specific Transfusion Protocol for the Emergency room, Staff #10 stated, "We don't have one, we use the hospital's policy."


a.) During an interview on the afternoon of 2/25/19, in the facility's emergency room, when asked how soon after a blood transfusion can a patient be discharged to home Staff #11 RN, Emergency Department stated, "... I run saline for at least 15 minutes, to make sure they get all the product...." Staff #11 was not aware of the required one-hour post infusion monitoring.


During an interview on the afternoon of 2/25/19, in the facility's emergency room when asked how soon after a blood transfusion can a patient be discharged to home Staff #12 RN, Emergency Department stated, "I don't know." When asked if two licensed staff check the blood compatibility before starting the blood transfusions Staff #12 stated, "We don't have to have two nurses check when we hang the blood; the Bridge (computer scanning program) is the second check." Staff #12 confirmed receiving training on the hospitals blood transfusion policy and procedure.


b.) Review of Patient #2's blood Transfusion Details reflected,

Date/Time started 1/11/19 9:32 am

Date/Time ended 1/11/19 11:01 am

Volume transfused 308 ml

Vital 1/11/19 at 11:08 am

No temperature recorded, Heart Rate 113 H (Reference Range 50-100), Respiratory rate 16, blood Pressure 116/69, Oxygen saturation 97% on room air.


Discharge Information
Recorded Date-1/11/19
Recorded Time- 11:10 am


Review of Patient #5's blood Transfusion Details reflected,
Date/ Start Time: 2/18/19 at 6:26 am
Date/ End Time: 2/18/19 at 8:47 am
Red Blood Cells Volume Transfused 345 milliliters
Discharge Date and Time: 02/18/19 09:00


During an interview on the afternoon of 2/25/19, in an administrative office, when asked if the emergency room nurses have a separate policy for blood transfusion administration and monitoring, Staff #10 Educator, Emergency Department stated, "We just have general hospital guidelines.... Vital signs should be taken temperature, blood Pressure, O2 saturation, heart rate and respirations... should be a full set." Staff #10 confirmed that three reviewed patients had been discharged prior to the policy's required one- hour post-transfusion monitoring.


c.) Review of clinical record of Patient #1 revealed Patient #1 was admitted to the ED (Emergency Department) by ambulance on 1/20/19 and triaged at 12:07 p.m. Patient #1's chief complaint was "chest pain and abdominal pain that started yesterday afternoon associated with nausea."


Review of Patient #1's pain assessment performed on 1/20/19 at 1:39 p.m. revealed Numeric Rating Pain Scale as "10 = Worst possible pain" in the abdominal area.


Review of Patient #1's MAR (Medication Administration Record) revealed 2 mg (milligram) of morphine (pain medicine) was given as IV (intravenous) push on 1/20/19 at 1:41 p.m.


Review of Patient #1's clinical record revealed no documented evidence patient was reassessed for pain after pain medicine was given on 1/20/19 at 1:41 p.m.


Three of 12 patients (Patients #1, 7, 11) reviewed for reassessments revealed they were not reassessed for pain after pain medication was given.


In an interview with Staff #3, Director of ED on 2/25/19 at 4:30 p.m., these missing pain reassessment findings were confirmed in his office while reviewing patient records.


In an interview with Staff #6, ED RN on 2/25/19 at 3:40 p.m., he stated pain medication reassessment should be done "usually within 30 minutes to 1 hour. Document pain level, location, effectiveness, and vital signs."


In an interview with Staff #10, ED Educator on 2/26/19 at 10:45 a.m., she stated when pain medicines are administered, she expected staff to reassess patient documenting vital signs and pain scale.


In an interview with Staff #13, ED RN on 2/26/19 at 11:37 a.m., she stated pain reassessment should be done within 30 minutes of giving administration and document should include vitals and pain level.


Review of facility policy for "Assessment and Reassessment in Emergency Department" dated 7/27/2012 stated in part under:

- Assessment: "Assessments shall be initial and ongoing."

- Secondary Survey: "Vital signs: a complete set of vital signs, when clinically indicated, including... pain scale should be obtained."

- Reassessment: "Unstable patients should be reassessed as frequently as needed in order to assess... response to interventions."


Review of facility policy "Pain Management" dated 9/14/17 stated in part under:
- Pain Air Cycle Framework (Assessment, Intervention, Reassessment): "Pain will be evaluated and managed utilizing the Pain AIR Cycle Framework...within an hour of the intervention, pain must be reassessed and documented."

EMERGENCY SERVICES

Tag No.: A1100

Based on interview and record review, the facility failed to provide emergency services in accordance with acceptable standards of practuce as evidenced by:


o The Emergency Room Nursing staff did not follow the facility's Policy and Procedures for the safe administration of blood products. The staffs did not have two licensed staff check for the compatibility of the blood types and the correct patient prior to the transfusion. The practice places patients at risk of blood transfusion reactions including death.


o Patients #2 and #5 were discharged within 15 minutes of the completion of their blood transfusions, preventing the nurses from completing the facility's required one-hour post-transfusion reaction monitoring, placing the patients at risk of injury or death from a blood transfusion reaction

Cross refer to A0386 and A1104

EMERGENCY SERVICES POLICIES

Tag No.: A1104

Based on interview and record review, the facility failed to ensure Policies and Procedures were enforced for the safe administration of blood transfusions as evidenced by:


a.) The ER staff did not follow the hospital policy of having two licensed personnel check the blood product for the compatibility and the correct patient.


b.) The Nursing staffs did not conduct the one-hour post-transfusion monitoring and recording of vital signs and assessing for signs/symptoms of blood transfusion reactions.


Findings:

POLICY

Review of the facility provided policy Transfusion of Blood Components (RBC, Plasma, Cryoprecipitate, Platelets and RH Immunoglobulin (RHIG) (dated 03/03/2017) reflected, "Pre-Transfusion Process

Purpose: To instruct the licensed provider (transfusionist) on the pre-transfusion preparation process for non-emergent and emergent transfusion....

At the bedside with the blood component the transfusionist and another licensed provider will...

3. The two licensed patient care providers (one must be an RN or a physician) will sign their first initial and last name, one at Nurse 1 and the other at Nurse 2 on the Crossmatch Report Slip attached to the blood component.

4. Each licensed provider will verify in the presence of the patient the following by initialing under Nurse 1 and Nurse 2 at the bottom of the Crossmatch Report Slip in the Patient Identification Infusion Record section:

a) The patient's name and date of birth on the MMH Identification band and the Crossmatch Report slip attached to the blood product are identical

b) The BB Band ID on the Crossmatch Report Slip and the one on the patient's blood bank band are identical (write it at BB Band ID on the slip)

c) The Product Unit number on the Crossmatch Report Slip and the one on the unit are identical

d) The donor unit ABO/Rh on the slip and on the unit are identical (write the ABO/Rh at ABO/Rh on the slip) ....

10. Take Vital signs immediately prior to the start of the transfusion, at 15 and 30 minutes after it is started, then every 30 minutes until transfusion is finished, when the transfusion is completed, and 1-hour post transfusion....

11. Assess patient for signs and symptoms of a possible transfusion reaction each time vital signs are assessed....
Patient Education... 2. Give the patient information regarding signs and symptoms of transfusion reactions and what to do if they suspect they are having a delayed transfusion reaction....

References:
AABB. Standards of blood Banks and Transfusion Services. 30th edition. 2016. Bethesda, Marlyland ...
Infusion Nursing Standards of Practice. (2006) Journal of Infusion Nursing Supplement. Lippincott, Williams & Wilkins...."


During an interview on the morning of 2/25/19, when asked for a specific Transfusion Protocol for the Emergency room, Staff #10 stated, "We don't have one, we use the hospital's policy."


a.) During an interview on the afternoon of 2/25/19, in the facility's emergency room, when asked how soon after a blood transfusion can a patient be discharged to home Staff #11 RN, Emergency Department stated, "... I run saline for at least 15 minutes, to make sure they get all the product...." Staff #11 was not aware of the required one-hour post infusion monitoring.


During an interview on the afternoon of 2/25/19, in the facility's emergency room when asked how soon after a blood transfusion can a patient be discharged to home Staff #12 RN, Emergency Department stated, "I don't know." When asked if two licensed staff check the blood compatibility before starting the blood transfusions Staff #12 stated, "We don't have to have two nurses check when we hang the blood; the Bridge (computer scanning program) is the second check." Staff #12 confirmed receiving training on the hospitals blood transfusion policy and procedure.


b.) Review of Patient #2's blood Transfusion Details reflected,
Date/Time started 1/11/19 9:32 am
Date/Time ended 1/11/19 11:01 am
Volume transfused 308 ml

Vital 1/11/19 at 11:08 am

No temperature recorded, Heart Rate 113 H (Reference Range 50-100), Respiratory rate 16, blood Pressure 116/69, Oxygen saturation 97% on room air.

Discharge Information
Recorded Date-1/11/19
Recorded Time- 11:10 am


Review of Patient #5's blood Transfusion Details reflected,
Date/ Start Time: 2/18/19 at 6:26 am
Date/ End Time: 2/18/19 at 8:47 am
Red Blood Cells Volume Transfused 345 milliliters
Discharge Date and Time: 02/18/19 09:00


During an interview on the afternoon of 2/25/19, in an administrative office, when asked if the emergency room nurses have a separate policy for blood transfusion administration and monitoring, Staff #10 Educator, Emergency Department stated, "We just have general hospital guidelines.... Vital signs should be taken temperature, blood Pressure, O2 saturation, heart rate and respirations... should be a full set." Staff #10 confirmed that three reviewed patients had been discharged prior to the policy's required one- hour post-transfusion monitoring.