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Based on interviews and review of the facility's policy, it was determined the facility failed to adhere to facility Policy Number: HP 08-27, current as of 11/09, that stated all specimens must be labeled at the patient's bedside with a minimum of patient name and hospital number and the individual collecting the specimen was responsible for delivering it to the laboratory.

The findings include:

Review of the facility's policy to obtain laboratory specimens; Policy Number: HP 08-27, current as of: 11/09, revealed all specimens must be properly labeled at the patient's bedside in the presence of the patient, the patient's armband and the specimen label must match in regard to patient name and hospital number and the individual collecting the specimen is responsible for delivering the specimen to the laboratory. Further review of the policy revealed and additional note that specimens must not be removed from the patient's bedside until they were labeled.

Interview with the complainant, on 07/19/13 at 3:50 PM, via phone, revealed he/she found three (3) unlabeled vials of a red fluid in a biohazard bag (e-mailed the surveyor a picture) among Patient #10's belongings, in the patient's bag upon his/her return from the Emergency Room on 07/17/13.

Interviews with the Administrative Manager of the Enterprise Laboratories and the Accreditation Department Regional Program Manager, on 07/19/13 at 4:00 PM, revealed the procedure for specimen collection was for the person collecting the specimen to scan the patient's arm band and generate a label. They stated the specimen was collected and labeled at the bedside and transported to the laboratory by the person that collected the sample.

Interview with the Patient Care Manger of the Emergency Department, on 07/19/13 at 4:29 PM, revealed a system was in place to ensure bedside labeling of all specimens. The Patient Care Manager stated labels were printed immediately after scanning the patient's identifier armband. Once the labels were printed (on a bedside/portable printer) the staff member collecting the specimen was expected to label the specimens prior to leaving the patient's bedside. In addition, the Patient Care Manager of the Emergency Department stated employees were trained on proper labeling of specimens during orientation. Further interview revealed they were unaware of how the specimens ended up in Patient #10's belongings.