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Based on clinical record review, interview and review of the Risk Management and Safety Plan, it was determined, the facility failed to implement corrective actions and mechanism to minimize risk of injury to patients and provide care in a safe setting. The deficient practice is evidenced by: Failure to develop facility wide corrective action plans addressing the root cause of 1 of 1 incident reviewed involving Patient #1. The event resulted in delay in care and services and subsequent patient's death. The facility failed to develop and implement monitoring tools to minimize reoccurrence.

The findings included:

Investigation of the event involving Patient #1 was conducted on 01/25/24 and 01/26/24. The investigation indicates multiple failures that may have contributed to the patient's death.

The corrective actions implemented by the facility failed to include facility wide staff education including hand off communication, bed placement changes since the event, assessment and reassessment, staff competency, and the development of monitoring tools to sustain compliance with corrective actions needed to maintain a safe environment for patient care.

Interview conducted on 01/25/24 at 12:33 PM with The AVP (Assistant Vice President) of Critical Care Services revealed the facility investigation had identified the multiple failures and they have not implemented monitoring tools to ensure the staff is following the new guidelines for proper bed placement, oxygen use and hand off communication.

Interview with The Risk Manager and The Interim Director of Quality conducted on 01/26/24 at approximately 1:50 PM confirmed the education provided only included two units; the staff competency related to telemetry monitoring was only assigned to the technician involved; and monitoring tools to ensure proper bed placement, escalation of changes in telemetry rhythm or oxygen needs and proper hand off communication have not been developed.

Risk Management Program revised 06/14/18 documents:
The department of Risk Management and Patient Safety is recognized as a specialized discipline that incorporates the concepts of loss prevention and loss control towards reducing the frequency and severity of losses. The department engages in key patient safety functions within the framework of a patient safety evaluation system whereby, Patient Safety Work Product (PSWP) is collected, analyzed and reviewed for submission to the Patient Safety Partnership (PSP).
Administrative The risk managers are responsible for promoting safety by:
1. Maintaining a comprehensive incident reporting system to receive, investigate and evaluate incidents.
2. Re-enforcing the legal duty of all healthcare providers and employees to report adverse incidents within three business days of the occurrence to Risk Management through an electronic Incident reporting system, or a paper Incident Report, downtime form and/or as necessary, via a telephone call.
3. Managing the health system's loss potential through early identification, analysis of risks in the health care environment and promoting strategies for risk avoidance.
4. Investigating, analyzing and recording the frequency, causes and general categories and specific types of adverse incidents.
5. Determining methods of managing risks, including avoidance, reduction, retention, and transfer.
6. Assisting various departments in identifying and correcting environmental conditions and work practices.
9. Serving as active participants in various entity, system-wide and medical staff committees; acting as liaisons, resources and consultants.
10. Assisting in complying with local, state, and federal rules, regulations, laws and accreditation requirements as related to risk management and patient safety.

Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 1 of 1, out of 5 sampled patients reviewed for nursing services, (Patient #4) as evidenced by failure to reassess patient's condition during a blood transfusion as specified per facility protocols.


The findings included:

Facility policy titled "Blood and Blood Component Procurement, Consent and Transfusion" dated 09/19/23, documents guidelines for the safe administration of blood components.
Administration
Refer to the approved electronic reference resource for procedural guidelines.
Documentation
In the patient's medical record, record the following:
Blood component type
Unit component number
Date and time the transfusion is started and completed
Amount of saline infused
All vital signs taken, before, during and after transfusion
Any adverse effects
Signature of transfusionist and witness.


Mosby's guidelines for blood transfusions:
Verify that the patient pre transfusion temperature, pulse, respirations, and blood pressure (TPR and BP) are within normal limits, documented and were taken no more than one hour prior to administration .....
Monitor vital signs (TPR and BP) and document in the EHR (Electronic Health Record)
15 minutes after transfusion started.
60 minutes after transfusion started.
At the completion of the transfusion.
If there is a change in the patient's vital signs notify the ordering provider (a temperature increase of 1.8 degrees Fahrenheit is significant).


Clinical record review conducted on 01/25/24 revealed Patient #4 was prescribed a blood transfusion on 01/16/24.
The record indicates the staff obtained pre transfusion vital signs at 1:18 PM; the transfusion started at 1:20 PM. The staff monitored the patient with partial vital signs at 1:22 PM, did not obtain a temperature reading, and did not wait the recommended fifteen minutes for reaction monitoring. The one-hour monitoring also lacked temperature readings.

Interview with The Patient Care Manager, who navigated the electronic clinical record, conducted on 01/25/24 at approximately 1:31 PM revealed the facility follows Mosby recommendations for blood transfusion monitoring and confirmed the vital signs as noted above.

Review of the Nurses Notes, Nursing Shift Assessments and Assessment and Reassessment documentation and blood administration record failed to provide evidence a complete set of the patient vital signs was obtained at the fifteen minutes and one-hour interval of the blood transfusion.

On 01/26/24 at 1:08 PM The Interim Director of Quality, confirmed the document given to the surveyor, Mosby recommendations for blood transfusion was the correct form.