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Based on interview, record review, and policy review, the provider failed to ensure appropriate services were provided for two of two reviewed services offered (laboratory services and nursing services).Findings include:

1. Review of laboratory services on 8/2/11 and on 8/3/11 revealed emergency blood products were not properly released, laboratory results were not accurately reported, and physician orders were not properly clarified and written. Refer to C282, finding 1.

2. Review of nursing services on 8/2/11 and on 8/3/11 revealed physician orders were not written and complete, staff did not have adequate training related to the provider's forms, nursing documentation was not complete and accurate, and inappropriate nursing delegation had occurred. Refer to C294, finding 1 and 2; C297, finding 1; C302, findings 1, 2, 3, and 4; and C323, finding 1.

Based on record review, interview, and policy review, the provider failed to:
*Ensure appropriate procedures were followed when emergency blood was prepared for one of three sampled patients (1) who received emergency blood transfusions.
*Document and clarify telephone/verbal orders received for blood distribution.
Findings include:

1. Review of patient 1's entire medical record revealed:
*She had been in a car versus pedestrian accident on 7/7/11 resulting in multiple traumatic injuries.
*During the course of her treatment in the emergency room she became unstable and required blood transfusions.
*No written orders for transfusion of blood were present on the record.
*Her blood had been typed and screened prior to the blood transfusion but had not been crossmatched.
*She had received a total of three units of A positive blood during her stay in the emergency room prior to being transported via helicopter.
*The laboratory (lab) had reported the patient was A positive blood type.
*It was not reported by the laboratory that an error had occurred in the reporting of her blood type until after she was on the helicopter. The patient blood type was found to be B positive.

Review of the provider's blood bank worksheet for 7/6-8/11 revealed:
*The initial type and screen preformed prior to patient 1 becoming unstable showed the result to be B positive.
*A total of eight units of A positive blood were prepared for delivery to the emergency room.
*Two different types of hand writing were noted on the sheet.

Interview on 8/3/11 at 9:50 a.m. with laboratory technician F revealed:
*She had drawn the initial blood sample from patient 1 for the type and screen and had delivered it to lab technician H to run the test, as she was in charge of the blood bank that day.
*She was in the emergency room when the trauma physician had called for blood. The trauma physician had not specified how many units to prepare at that time. She had not written an order related to the blood request. She had assumed someone in the trauma room would write the order. Her explanation for the initial three units of blood prepared by lab technician H was they had assumed that was about how many they would initially need.
*Five additional units were prepared by lab technician H at the request of the lab manager. The lab manager informed her the physician from the Sioux Falls emergency room had called and requested five additional units of blood be prepared for the flight team to take with them. She stated she never saw a written order for that.
*Lab technician G found an error had been made in both reporting and verification of the blood type of patient 1 after the patient had left the emergency room in the helicopter. That error was reported immediately to the lab manager that resulted in a call to the flight team via its Sioux Falls communication center to discontinue the transfusion of the A positive blood.
*She agreed that errors had occurred in both the reporting of patient 1's blood type in to the provider's computer system as well as verification of the units of blood against the blood bank worksheet prior to delivery.

Interview on 8/3/11 at 1:10 p.m. with lab technician G revealed:
*He confirmed the information given by lab technician F.
*He found both errors mentioned above when he was entering the information from the blood tags onto the blood bank worksheet. When asked why he was entering the information into the blood bank worksheet he stated he was trying to help out lab technician H. When asked why the information on the blood tags was not written and cross verified at the time of its removal from the blood bank he stated he did not know. It had been lab technician H who had removed the units from the refrigerator. He did however agree the blood should have been verified and documented prior to leaving the blood bank as that was what he normally did.

Multiple interviews, record review, and policy review on 8/2/11 and 8/3/11 with the laboratory manager revealed:
*He confirmed the information given by lab technician F and G.
*Lab technician H had resigned from her position at the facility and would not be available for interview.
*He had received an order from a Sioux Falls physician for an additional five units of blood to be prepared and ready for the flight team. He was unsure as to the physician's exact name who had given him that order. He had not documented that order in patient 1's medical record nor had he notified the trauma surgeon in charge of patient 1's care of that order.
*Five units of A positive blood were sent with the flight team.
*He agreed a total of eight units of the wrong type of blood had been prepared and delivered for patient 1.
*He agreed errors had occurred in both the reporting of patient 1's blood type in to the provider's computer system as well as verification of the units of blood against the blood bank worksheet prior to delivery.
*He agreed the provider's policy and procedure on emergency release of blood prior to the incident did not include verification and documentation of the units of blood on the blood bank worksheet at the time of removal. He further agreed if verification had been done the error might have been noted prior to delivery of the units of blood.
*He agreed he should have documented the order received from the Sioux Falls physician as well as notified the trauma surgeon in charge of the patient's care to ascertain a valid physician's order for the release of blood. He further agreed as a result of not ascertaining an order from the provider's trauma surgeon only three units had the appropriate provider's signed physician release for un-crossmatched blood.
*He agreed the trauma surgeons verbal order to prepare blood received by laboratory technician F and the rest of the trauma team should had been clarified as to how many units of blood he wanted prepared as well as followed by a written order.

Review of the provider's revised May 2011 medical staff rules and regulations revealed verbal/telephone orders should have been documented in the patient's medical record at the time the orders were received.

Based on interview, record review, and policy review, the provider failed to ensure:
*Physician's verbal orders were written and complete for one of five sampled (1) trauma patients .
*Facility staff were properly trained on the use of the trauma flow sheet instituted by the provider.
*Appropriate and complete nursing documentation was present for one of five sampled (1) trauma patients.
*Nursing staff were knowledgeable of the provider's policies and rules related to the administration of anesthesia.
Findings include:

1. Interview and record review on 8/2/11 at 4:00 p.m. with the trauma physician regarding patient 1's 7/7/11 trauma code revealed:
*He agreed several of his verbal orders during the patient's trauma code had not been written and signed for including:
-Intravenous fluids.
-Emergency drugs atropine and epinephrine.
-Blood transfusion.
-Use of the rapid infuser.
*He had not ordered the anesthesia drugs on the flow sheet as the certified nurse anesthetist was in charge of managing patient 1's airway.
*He had not signed, dated, and timed the trauma code sheet indicating he had ordered the medications, blood, or intravenous fluid indicated on the sheet.

Interview and record review on 8/2/11 at 4:40 p.m. with the director of the emergency room regarding patient 1's 7/7/11 trauma code revealed:
*She was not present the day of the patient's trauma code.
*She agreed no written orders existed for the three units of blood transfused into the patient at the facility.
*She agreed no written orders existed for the preparation of the five units of blood that were sent with the flight team. Refer to C282, finding 1.
*She agreed no physician had signed for the medications, blood, or intravenous fluids indicated as given on the trauma code sheet making them invalidated orders.
*She agreed the nursing notes that were part of the trauma flow sheet did not explain the care the patient had received during the time the patient had been in cardiac arrest. She further agreed the nursing notes were not complete and left many key areas of care in question.
*She agreed no formal anesthesia record was part of the patient's record.
*She agreed the only time the patient's temperature had been documented was when the patient had been admitted. She stated the patient's temperature should have been monitored before and during the time the patient was receiving transfusions to monitor for transfusion reaction.
*The provider had started using the new trauma flow sheet used for patient 1's trauma record several months ago after approval of the trauma committee. However no training had been provided to staff related to documenting on and utilizing that form. When asked by this surveyor why staff had not been trained on the new form she was unable to give an answer.
*She agreed the three units of blood used during the trauma code did not have properly completed transfusion forms.

Interview and record review on 8/3/11 at 8:40 a.m. with registered nurse A regarding patient 1's 7/7/11 trauma code revealed:
*She was the nursing supervisor on duty that day and was present at the patient's trauma code.
*She agreed with the statements of the director of the emergency room made above.
*She had not reviewed the documentation of the trauma code and signed for her participation in the trauma code.
*She had never had any training in relation to trauma code documentation or use of the new trauma flow sheet form.
*The team never met post trauma code to ensure all necessary documentation and orders were present.

Interview and record review on 8/3/11 at 10:25 a.m. with registered nurse B regarding patient 1's 7/7/11 trauma code revealed:
*She had been assigned to be the recorder of the trauma code.
*She agreed her documentation of the events of that trauma code did not paint the picture of what had occurred at that trauma code. She further agreed multiple areas related to the cardiac arrest of the patient and the subsequent treatments were completely missing.
*She agreed with the statements the director of the emergency room made above.
*That day was the first time she had seen the provider's new trauma flow sheet.
*She had never had any training in relation to trauma code documentation or use of the new trauma flow sheet form.
*She agreed with the statements the director of the emergency room made above.

Interview and record review on 8/3/11 at 11:00 a.m. with certified registered nurse anesthetist E regarding patient 1's 7/7/11 trauma code revealed:
*He had not completed any documentation related to the care that he provided to patient 1.
*He was under the impression all of his interventions were being documented by the recorder.
*He had not reviewed or signed the trauma flow sheet indicating what interventions/care he had provided.
*He had never had any training in relation to trauma code documentation or use of the new trauma flow sheet form.
*He agreed with the statements of the director of the emergency room made above.

Interview and record review on 8/3/11 at 11:45 a.m. with registered nurse D regarding patient 1's 7/7/11 trauma code revealed:
*She had taken part in the trauma code that day. She had assisted with the insertion of the patient's chest tube, had administered medications, and cardiac arrest interventions.
*She had not been listed under the trauma team members. She stated she did not know why she had not been listed. When asked by this surveyor if she had reviewed the trauma flow sheet post trauma she stated no. She went on to say when the trauma was over everyone just went back to there other assignments, no one reviewed the trauma flow sheet record.
*She had never had any training in relation to trauma code documentation or use of the new trauma flow sheet form.
*She agreed with the statements of the director of the emergency room made above.

Interview and record review on 8/3/11 at 4:00 p.m. with the vice president of nursing and the quality/risk director regarding patient 1's 7/7/11 trauma code revealed they agreed:
*No physician orders were present for the blood the patient had received.
*The trauma flow sheet had not been signed, timed, and dated by the physician making medications given on that record valid orders.
*Facility staff were not properly trained on the use of the trauma flow sheet instituted by the provider.
*The nursing documentation of the patient's trauma code was not complete and accurate in multiple areas.
*With the statements the director of the emergency room made above.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, Mo.,2005, pg's 293, 294, and 419 revealed:
*Data documentation is the last part of a complete nursing assessment.
*"A thorough, concise, and accurate documentation of facts is necessary when recording client data. If an item is not recorded, it is lost and unavailable to anyone else caring for the client."
*It is both the legal and professional responsibility of the nurse to accurately and completely document all observations and care rendered.
*Verbal orders should only be used during emergencies and then written and signed by the physician as soon as possible.

Review of the provider's revised April 2011 hospital/legal medical record policy revealed:
*All staff were responsible to document according to professional, legal, and regulatory standards.
*The patient's medical record should describe the patient's status, medical care, care provided by other disciplines, and the patient's response to care.

Review of the provider's revised 2011 medical staff rules and regulations revealed:
*Verbal/telephone orders should have been documented in the patients' medical record at the time the orders were received.
*Verbal/telephone orders should have been written according to current professional standards, as well as according to federal and state regulations.

2. Interview, record review, and policy review on 8/2/11 and on 8/3/11 revealed nursing staff were not knowledgeable of the provider's policies and rules related to the administration of anesthesia. Refer to C323, finding 1.

Based on record review, interview, and policy review, the provider failed to ensure physician's orders for medications and blood had been properly documented, written, and signed for one of five sampled (1) trauma code patients. Findings include:

1. Record review, interviews, and policy review on 8/2/11 and on 8/3/11 regarding patient 1's 7/7/11 admission revealed physician's orders had not been properly documented, written, and signed. Refer to C282, finding 1; C294, finding 1; and C323, finding 1.

Based on record review, interview, and policy review, the provider failed to ensure clinical records were complete, comprehensive, and accurate for four of ten sampled patients (1, 5, 8, and 10). Findings include:

1. Record review, interview, and policy review revealed on 8/2/11 and on 8/3/11 regarding patient 1's 7/7/11 admission revealed the patient's record was not complete, comprehensive, and accurate. Refer to C282, finding 1; C294, finding 1; C297, finding 1; and C323, finding 1.

2. Review of patient 5's 7/30/11 blood transfusion forms revealed the unit of blood administered at 5:30 p.m. did not have the following:
-A co-signature for verification of the unit of blood.
-The date the nurse had signed for the unit of blood.
-Documentation that patient identity had been established.
-Documentation that the type of the unit and the patient were verified.
-Documentation of the verification of the patient's wrist band.
-Documentation of verification of the expiration date on the unit of blood was checked.
-Documentation of verification the patient received education and instructions.

3. Review of patient 8's 7/29/11 trauma flow sheet revealed of the eight staff members involved in the patients trauma code only one signed the provider's trauma code record.

4. Review of patient 10's 7/29/11 trauma flow sheet revealed of the ten staff members involved in the patient's trauma code only one had signed the provider's trauma code record.

Interview on 8/3/11 at 5:45 p.m. with the quality/risk director regarding the documentation discrepancies noted for patient's 5, 8, and 10 revealed she agreed:
*Patient 5's transfusion form was not completely and accurately filled out.
*She agreed all staff that rendered care to patient's 8 and 10 should have signed for the care they had provided.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, Mo.,2005, pg's 293, 294, and 419 revealed:
*Data documentation is the last part of a complete nursing assessment.
*"A thorough, concise, and accurate documentation of facts is necessary when recording client data. If an item is not recorded, it is lost and unavailable to anyone else caring for the client."
*It is both the legal and professional responsibility of the nurse to accurately and completely document all observations and care rendered.

Based on record review, interview, and policy review, the provider failed to ensure anesthesia medications were administered by a qualified provider of anesthesia services for one of four sampled trauma code patients (1). Findings include:

1. Review of patient 1's medical record revealed:
*She had been in a car versus pedestrian accident on 7/7/11 resulting in multiple traumatic injuries.
*During the course of her treatment in the emergency room she had become unstable, and it was determined she needed to be intubated.
*Medications for rapid sequence induction (RSI) of anesthesia (Etomidate, Zemuron, and Anectine) were noted as given by registered nurse (RN) A. Those medications were not noted as ordered per the physician or certified nurse anesthetist (CRNA) E on the provider's trauma flow sheet.
*No anesthesia documentation related to the induction of anesthesia was noted on the medical record.

Interview on 8/3/11 at 8:40 a.m. with RN A who had responded to patient 1's trauma code revealed:
*She had administered the Etomidate, Zemuron, and Anectine as indicated on the patient's trauma flow sheet.
*She stated she was very uncomfortable giving those medications, as she had never given them before and was not even sure what those medications did. When asked by this surveyor if she had realized she was inducing anesthesia at that time she stated no. When asked by this surveyor why she had administered them she stated she felt pressured by CRNA E to do so.
*RN A described the events leading to her administering the anesthesia medications as follows: She stated CRNA E had handed her three unlabeled syringes and said give this. She questioned CRNA E as to what she was giving at that time, and CRNA E responded to her "Just give it." After asking three times CRNA E told her the contents of the syringes and again directed her to give the above mentioned medications. However RN A stated she still did not know the purpose of those medications at that time. RN A complied with CRNA E direction despite her concerns on 7/7/11 at 3:30 p.m. Once patient 1 was given the anesthesia medications by RN A she had informed CRNA E and he had responded by saying to her I guess we are committed to intubate now.
*She had not brought the above situation forward to her supervisor.
*No post trauma code debriefing had been held to discuss the teams performance or review clinical documentation.
*She agreed no written order existed for the anesthesia medications she had administered.
*She was not aware at that time she was practicing outside her scope of practice by administering those medications.

Interview on 8/3/11 at 10:25 a.m. with RN B who had responded to patient 1's trauma code revealed:
*She had been designated as the recorder of patient 1's trauma code.
*She had documented RN A had given the above mentioned anesthesia medications on 7/7/11 at 3:30 p.m.
*She was standing in close proximity to RN A and CRNA E during the time the anesthesia medications had been given and confirmed RN A's account of the situation in her own words. She further stated that she had to have CRNA E spell the drugs for her to put them on the trauma flow sheet, as she had never heard of them before.
*She agreed no written order existed for the anesthesia medications she had documented as administered.
*RN A and CRNA E had not reviewed the documentation and orders post trauma code.

Interview on 8/3/11 at 11:00 a.m. with CRNA E who had responded to patient 1's trauma code revealed:
*He agreed he had delegated administration of RSI anesthesia to RN A.
*He was not aware it was not in the scope of practice of an RN to administer anesthesia at the time he had delegated it to RN A.
*He had not created any documentation of the anesthesia services he provided to the patient.
*He had not reviewed the trauma flow sheet post trauma to ensure appropriate anesthesia documentation existed.

Interview and review of the revised May 2011 medical staff rules and regulations on 8/3/11 at 4:00 p.m. with the vice president of nursing and the quality/risk director revealed:
*Administration of anesthesia by a registered nurse should not have been allowed.
*The only personnel at patient 1's trauma code qualified to administer anesthesia were CRNA E and the trauma physician.
*They were not aware an RN had been directed to administer anesthesia medications until the time of this survey.

Review of the South Dakota Board of Nursing Declaratory Ruling 89-1 revealed "Although registered nurses, under the direction of a physician, may administer narcotics, analgesics, sedatives, and tranquilizing medications to patients, registered nurses may not administer any medication for the purpose of inducing general anesthesia. It is not within the authority of the board to determine how or for what purpose a specific drug with multiple uses is being administered at any given time. Institutional or agency protocol must address this."

Review of South Dakota Administrative Rule 20:48:04:01 revealed
*"A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person."
*"The registered nurse shall recognize and understand the legal implications of delegation and supervision."