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A. Based on Facility policy and staff interview, it was determined the Facility failed to ensure all blood administration techniques were followed as required. This was evident in 3 ( Pt. #s 14,20,21) of 5 records reviewed with blood administration.

Findings include:

1. Facility policy indicates that when initiating a blood transfusion, page 2, 10.) "assure the patient has an intravenous line and the line should be at least a 20 gauge with no signs of infiltration at the site."

2. In 3 of 5 clinical records reviewed with blood administration, it was documented that the intravenous sites were started with 22 gauge needles.

3. The above findings were verified with the DON on 01/20/10 at 10:00 am.

A. Based on a review of the Medical Record Statistics Form, interview with Hospital staff and a written statement of the Hospital's delinquent medical record rate, it was determined that the Hospital failed to ensure all medical records were completed in a prompt manner.

Findings include:

1. The Medical Record Statistics Form was presented on survey date 01/21/10. It indicated that all records must be completed within thirty days post discharge.

2. On 01/21/10 the Medical Records Director presented a written statement indicating that as of this date, there were 14 delinquent medical records.

3. The above findings were verified with the Chief Nursing Officer on 01/21/10 at 10:00 am.