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Based on interview, and record reviews, the facility did not ensure emergency supplies and equipment were ready for use when the facility's nursing staffs did not check the emergency crash carts for missing/expired medications or nonfunctioning equipment and supplies, placing patients at risk of worsening of conditions during cardiovascular resuscitation, respiratory distress or other situations requiring emergency resuscitation.

Findings include:

Review of the facility's emergency crash carts, which contanted cardiac defibrillators, oxygen and airway supplies, and emergency medications, revealed the following missed cart preparedness checks in 2022:

Emergency Room Crash Cart:
9/3, 9/6, and 9/9

Medical Surgical Unit:
7/1, 7/9, 7/12, 7/16, 7/19-7/21, 7/23, 7/27, 7/30
8/2, 8/11 - 8/12, 8/17, 8/20, 8/23, 8/27
9/1, 9/2, 9/8

Obstetrics Unit:
8/4, 8/8, 8/13, 8/15, 8/23, 8/25, 8/29, 8/30
9/7, 9/12

During an interview, on the morning of 9/13/22, Staff #2, Medical Surgical Director, stated, "We check the crash carts at least daily, they should have been checked... The pharmacy refills the medications."

The facility was asked for a policy; however, the facility did not provide a policy for the crash cart checks.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff were adequately trained and oriented, aware of the nursing policies and procedures, supervised, and that their clinical activities were evaluated when,

a.) the facility did not ensure all nurses had been re-educated following an incident where a patient was administered the wrong blood during a transfusion and suffered a hemolytic (breakdown of blood cells) reaction. The failure places patients at risk of receiving the wrong blood and may result in a blood transfusion reaction, pain, kidney failure, and death.

b.) The nursing staffs did not check the emergency crash carts for missing/expired medications or nonfunctioning equipment and supplies, placing patients at risk of worsening of conditions such as cardiovascular resuscitation, respiratory distress or other situations requiring emergency resuscitation.

c.) The nursing staff were using undated glucose test strips and expired or undated quality control chemicals to test patients' blood glucose levels, placing patients at risk of inadequate treatments for misdiagnosed hypoglycemic and hyperglycemic (low and high blood sugars) levels, organ failure, and possible death.



Findings include:

a.) Review of the facility provided Transfusion Crossmatch Report reflected, the document has the name of the patient, blood type, donor identification number, the patient's vital signs before and after the transfusion, the initials of the staff issuing and receiving the blood, and the names of the two staff members certifying, " (we) certify that, before starting transfusion, (we) have checked the KEY TRANSFUSION numbers appearing on; (1) Recipient's Blood Band, (2) unit to be transfused, and (3) TRANSFUSION CROSSMATCH/ REPORT.
TAKE THIS COPY TO BLOOD BANK TO OBTAIN UNIT FOR TRANSFUSION
BLOOD WILL NOT BE RELEASED WITHOUT THIS FORM"

Review of Patient #1's Transfusion Crossmatch Report reflected a 17-year-old female with a Cross Match Infusion Report dated 7/06/22. The form only had one staff member sign the attestation of the correct blood band, unit transfused, and transfusion crossmatch report. The vital signs were not recorded and had "Cancelled" written across the report. The blood type was listed as A (+) positive. The transfusion was recorded as having started start at 1829. The report did not indicate how much blood had been transfused, when the transfusion was stopped, and if there was a transfusion reaction.

Review of Patient #2's nursing progress notes, dated 07/06/22 at 6:32 pm, reflected, "Pt (patient) c/o (complaint of) Lt (left) arm feeling numb. Swelling and tightness noted to arm. Blood transfusion stopped. Less than 85 ml (milliliters, same as cc or cubic centimeters) infused of blood. Pt denies s/s (signs or symptoms) of blood transfusion reaction. IV dc'd (intravenous catheter removed) at this time. Catheter intact. Pressure dressing applied."

Review of Patient #2's TRANSFUSION REACTION WORK-UP AND SUMMARY, dated 7/6/22, completed by Staff #4, Laboratory Director, reflected a 34-year-old female diagnosed with a post-partum hemorrhage, received a blood transfusion at 1800 and stopped at 1832; the patient had been administered 84 cc of A+ blood the patient is O+. The document's laboratory workup reflected blood in the urine. The WORK UP INTERPRETATION, dated 07/07/22, reflect, "Unit was transfused to the incorrect patient."

During an interview on the afternoon of 09/13/22, in the administrative conference room, Staff #17, OB (Obstetrics) Director stated, "We educated all the nursing staffs on the Blood transfusion policy." When asked to identify the signatures on the in-service log of the nursing staffs that had received the blood transfusion education, Staff #17 confirmed there were six nursing staff that had not received the training.

Review of the facility-provided policy titled, "Transfusion of Blood and Blood Products" (approved 1/20/20 reflected, "It is the policy of Seminole Memorial Hospital to provide a uniform method of administering blood and blood products including Whole blood and packed cells, platelets, fresh frozen plasma, and albumin.

STANDARD OF CARE
ORDERS AND CONSENT: Blood and blood product transfusion requires the order of a physician. A transfusion consent form is required to be signed by patient or family, except for a true-life threatening emergency with no family present.
Contact the physician if the patient has signed a refusal to permit transfusion of blood and blood products form.
Type and crossmatch must be performed prior to the scheduled administration of blood.

OBTAINING BLOOD FROM BLOOD BANK:
A licensed nurse who has been in-serviced in blood procurement will pick up blood or blood product when blood bank notifies emergency department or inpatient department that it is ready. The nurse that is procuring the blood will follow this procedure:
1. Take preprinted patient identification label to blood bank and give to blood bank personnel; inform blood bank personnel of the desired component. All units of blood and blood components must be checked out by a technologist with a licensed nurse.
2. The patients name, record number, doctor, donor number, donor and patients type and Rh, and the expiration date of the blood component must be compared with that listed in the blood bank logbook, the patient's blood transfusion sheet and the unit of blood.
3. After determining that all information checks, the technologist must fill out the log with the information required and the licensed nurse must sign the blood bank log book along with date and time.
4. Receive blood bank system transfusion record for each unit...

PREPARING TO ADMINISTER BLOOD/BLOOD PRODCUT [SIC]
Use the official current version of this procedure located in the SMH online policy portal
Two licensed staff members, one being a registered nurse, will check blood bag id, transfusion record and patient id at the bedside ..."

b.) Review of the facility's emergency crash carts, which contanted cardiac defibrillators, oxygen and airway supplies, and emergency medications, revealed the following missed cart preparedness checks in 2022:

Emergency Room Crash Cart:
9/3, 9/6, and 9/9

Medical Surgical Unit:
7/1, 7/9, 7/12, 7/16, 7/19-7/21, 7/23, 7/27, 7/30
8/2, 8/11 - 8/12, 8/17, 8/20, 8/23, 8/27
9/1, 9/2, 9/8

Obstetrics Unit:
8/4, 8/8, 8/13, 8/15, 8/23, 8/25, 8/29, 8/30
9/7, 9/12

During an interview, on the morning of 9/13/22, Staff #2, Medical Surgical Director, stated, "We check the crash carts at least daily, they should have been checked... The pharmacy refills the medications."

The facility was asked for a policy; however, the facility did not provide a policy for the crash cart checks.


c.) Observations made on the morning of 9/13/22, accompanied by Staff #2, Medical Surgical Director, revealed the following:
*the Medical Surgical unit's Glucometer's high and low control chemicals had expiration dates of 2/17/22.
*the Glu-test strips (glucometer strips to place samples and contol chemials) had not been dated when opened, so the expiration date could not be determined.
Staff #2, Medical Surgical Director, confirmed the findings and instructed the staff to replace the items and run the controls on the glucometer.

Observations made on the morning of 9/13/22, accompanied by the Staff #17, OB Director, revealed the following:
*the OB unit's Glucometer's high and low control chemicals had not been labeled when they were opened, therefore, the expiration date could not be determined
*the Glu-test strips had not been dated when opened and the expiration date could not be determined.
Staff #17, OB Director, confirmed the findings and instructed the staff to replace the items and run the controls on the glucometer.

Observations made on the morning of 9/13/22, accompanied by the Staff #1, Emergency Director, revealed the following:
*the ER unit's Glucometer's high control chemical had expired on 9/1/11
*the low control chemical had not been labeled when they were opened, so the expiration date could not be determined.
*the Glu-test strips had not been dated when opened and or expired.
Staff #1, ER Director, confirmed the glucometer strips and control chemicals needed to be dated when expired and instructed the staff to replace the items and run the controls on the glucometers.