HospitalInspections.org

The facility failed to ensure the Governing Body (GB) reviewed, adapted, and implemented corporate policy and procedures to confirm they were specific to the facility in 1 of 1 (Blood Product Administration) policies reviewed.

A review of the policy titled, "Blood Product Administration" Number 3.120 with a revised date of 9/23 did not have any statement that it was for this specific facility. The policy gave information for two states (TX and LA).

A review of the Blood Product Administration was as follows:

" ...II. OBJECTIVE: To provide guidelines for the administration of blood and blood products in CHRISTUS Health ministries in non-emergent situations that do not require rapid infusion or massive transfusion guidelines.

GUIDELINE STATEMENT: Blood product transfusion is one of the most common invasive procedures performed in the health care setting. Transfusion involves the introduction of active biological products (cells and proteins) from a living donor to a patient, and thus, complex biological reactions may occur. Completing key safety elements can help ensure that the risk of an adverse event involving blood administration is minimized. Additionally, understanding the possible complications of transfusion and recognizing reactions at the bedside contribute to the best patient outcomes. This document establishes the guidelines for the key elements of safe blood administration.
...
B. Initiating and continuing the transfusion:
...
2. Prior to initiating the transfusion, all identifying information for the blood component and the patient must be validated at the bedside using a two-person verification process completed by licensed caregivers, one being an RN, or a one-person verification process accompanied by automated identification technology as defined in facility/ministry policy completed by the licensed caregiver initiating the transfusion ...

...V. REGULATIONS/REQUIREMENTS:

The Joint Commission ...
CMS CoP ...
Texas Administrative Code ...
Louisiana Admin Code ..."


An interview was conducted with Staff #15 on 11/30/2023 after 1:00 PM. Staff #15 was asked why the blood administration policy for the hospital was using recommendations and requirements that referred to another state. Staff #15 stated, "There is nothing that says another state cannot be in the policy. You need to show me where that says that in a rule." Staff #15 was asked why a facility in Texas would be required to adopt a policy that referred to other state laws. Staff #15 was asked what part of the policy referred to the Texas Rule and what part referred to the Louisiana rule. Staff #15 stated, "I would not put anything in the policy that contradicted the Texas rules." Again, she was asked what part of the policy referred to the Louisiana rule. Staff #15 did not answer the question after multiple requests.

An interview was conducted with Staff #3 on 11/29/2023 after 1:00 PM. Staff #3 was asked what facility/ministry policy was the policy referring to under the "B. Initiating and continuing the transfusion" section of the policy. Staff #3 confirmed Policy Number 3.120 was the facility/ministry policy. Staff #3 stated, "This is the facility policy. There is not another one. Corporate is referring this policy to itself. We are not allowed to change the policies in any form. Our policy here is to have two nurses confirm any blood products at the bedside of the patient. We have always done it that way and it will not change because that is the safest."

An interview was conducted with Staff #1 and Staff #3 on 11/29/2023 after 2:00 PM. Staff #1 was informed that during the interview with Staff #15, it was confirmed the policy referred to another state as part of its requirements and regulations. Staff #1 confirmed the policy would be corrected to fit the needs of the facility, adopted, and implemented in this specific facility.

Staff #1, #2, and #3 confirmed the facility policy was not specific to the hospital campus.