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400 ROSALIND REDFERN GROVER PARKWAY

MIDLAND, TX 79701

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on review of documentation and interview, it was determined that Patient # 1 did not always receive safe care while a patient at Midland Memorial Hospital.

Findings were:

On 12/1/12, PT/INR results showed a level of 58.5. (Normal values are 9-12). Anticoagulation medications were not immediately held but were continued until the next day causing Patient # 1 to bleed from the nose and IV site. Blood was also observed in the patient ' s urine.

On 12/10/12, family members of Patient # 1 reported perianal skin breakdown. Nursing assessment for that day described Patient # 1 ' s perianal area as "excoriated." There is no documented evidence that Mr. Nagy ' s skin breakdown was treated by nursing staff.

In an interview with the Director of Quality Care on 4/23/13, the above findings were confirmed.

ORDERS FOR DRUGS AND BIOLOGICALS

Tag No.: A0409

Based on review of documentation and interview, it was determined that the facility failed to transfuse blood in a timely manner.

Findings were:

On 12/2/12, an order to give 1 unit of fresh frozen plasma to Patient # 1 was received at 19:40. The plasma was not administered until 23:30-3.5 hours after the order was received.

In an interview with the Director of Quality Management on 4/23/13, it was agreed that the administration of plasma was a high priority and should have been done as soon as the plasma was available.