HospitalInspections.org

Based on blood transfusion policy review, transfusion document chart reviews and staff interview, the hospital failed to administer blood transfusions in accordance with approved medical staff policies and procedure for four (#2-3, #5-6) of ten patients.

Findings include:

1. The policy, "Blood Transfusion Therapy", revised 8/09, read:
"All nursing entries should be initialed on the blood administration profile.
Signed informed consent by patient, next of kin or responsible/legal medical representative.
Vital signs must be taken at 15-20 minutes after starting transfusion and recorded on Blood Administration Profile. Vital signs should be taken post transfusion in a 60-90 minute time frame and recorded on the Blood Administration Profile.
The nurse starting the transfusion must observe the patient at the bedside for the first 15 minutes and vital signs documented as defined above."

2. Review of ten patients receiving blood units indicated four did not have complete documentation on the Blood Administration Profile:

PATIENT #2
--UNIT administered on 1/15/10 at 0443: There was no documentation for who documented the end time and vital signs; there was no documentation which nurse ended the blood administration

PATIENT #3
--UNIT administered on 1/07/10 at 0944: There was no documentation for who started the unit
--UNIT administered on 1/07/10 at 1241: There was no documentation for who started the unit

PATIENT #5
--UNIT administered on 12/29/09 at 1135: The transfusion end time was documented at 1425; however, the post-transfusion 60-90 minutes time was documented at 1325 which was 1 hour before the end time

PATIENT #6
--UNIT administered on 12/13/09 at 1451: The start time administration began at 1451; however, the 15-20 minute post start vital signs were documented at 1416 which was before the 1451 start time

3. On 1/18/10 at 11:00 a.m., Staff member #5 acknowledged that the above-listed patients had received blood without vital signs completed per policy.

Based on document review and staff interview, the facility failed to ensure policies were reviewed annually for hospital wide policies.

Findings include:

1. Facility policy titled "Policy Development" last revised June 2009 stated under policy statement: "........The policy and procedures will be reviewed at least every three years."

2. Review of facility policies including, but not limited to, emergency department, surgery department and infection control polices indicated the following:
(A) The emergency department policies were last reviewed/revised in 11/07.
(B) The surgery department polices were last reviewed/revised ranging from 8/07 to 7/08.
(C) The infection control policies were last reviewed in 4/08.

3. Staff member #N1 verified the above at 10:00 on 1/21/10.

Based on document review and staff interview, the facility failed to ensure an ongoing activities program was provided according to the activities assessment for 3 of 3 swing bed patients.

Findings include:

1. Review of patient #N20 medical record indicated the following:
(A) The record lacked documentation that activities were provided according to the patient's initial assessment.
(B) The swing bed activity assessment dated 9/9/09 indicated the patient's hobbies and interest included music and television.
(C) The record lacked documentation that the patient was provided activities from 9/9/09 through 9/16/09. Narrative notes dated 9/16/09 stated ".........states she is tired and refuses visit at this time. AD, SSD will visit again in a few days."
(D) Narrative notes dated 9/18/09 stated "........Pt is working with nurse at this time. AD, SSD will visit again in a few days."

2. Review of patient #N21 medical record indicated the following:
(A) The record lacked documentation that activities were ongoing during his/her hospital stay.
(B) The swing bed activity assessment dated 9/9/09 indicated the patient's hobbies and interest included spiritual/religious activities, volunteer visits, reading, and bird feeding/watching.
(C) Narrative notes indicated the patient was not visited by activities until 9/16/09.
(D) The record lacked documentation that the patient was provided activities from 9/9/09 through 9/16/09.

3. Review of patient #N26 medical record indicated the following:
(A) The record lacked documentation that activities were provided according to the patient's initial assessment.
(B) The swing bed activity assessment dated 11/28/09 indicated the patient's hobbies and interest include spiritual/religious activities and television.
(C) The only narrative note by activities was dated 11/30/09 and stated "Pt seen in room. alert & pleasant. Pt has company, she received gift. Pt seems to be interacting well. AD, SSD did not interrupt visit. AD-SSD will visit again in a few days.

4. Staff member #N2 verified the above at 11:00 on 1/21/10.