HospitalInspections.org

Surveyor: 10814

Based on the medical record review,
administration interviews and policy review,
the hospital failed to implement the patient's
decisions about receiving blood products by
developing a new consent form prior to surgery.
This was observed in 1 of 10 records,
specifically noted in P #1's record.

Failure to implement the patient's rights
regarding inform decisions about receiving
blood does not ensure the patient's
decisions are incorporated into his/her
care violates the patient's rights.

Findings:

1. On 01/13/2012, the investigator interviewed
the complainant by phone. The complainant
reported the patient was a Jehovah's Witness.
S/he explained that on 12/24/2010, the patient
was given blood transfusions during his/her
heart surgery. The patient had noted on his/her
Durable Power of Attorney documented that
no blood transfusions were to be received
during surgery.

2. On 01/17/2012 & 01/23/2012 the investigator
reviewed the patient's medical record.
On 12/22/2010 the 62 year old patient was
admitted from the Emergency Department
to the surgery unit for further care.
The Emergency Department physician
documented on the record the patient
was admitted with a diagnosis of mitral/aortic
stenosis, coronary athersclerosis disease,
acute diastolic heart failure, diabetes and
other medical problems.

3. During an interview on 01/23/2012
with the Director of Risk Manager.
S/he reported the Transfusion Program
Coordinator (TFP) was not available for
an interview due to a family problem.

4. The TFP Coordinator did sent an email to
the director dated 01/22/2012. The director
explained the TFP Coordinator had
documented on the email that the
patient would accept minor blood fractions.
The TFP Coordinator documented the
patient refused to complete the sections on the
consent form regarding administration
of whole blood products ( i.e. red blood cells,
white blood cells, platelets or plasma) until the
s/he received and reviewed the DPA document.

5. The director reported that a family member
had to go and get the patient's DPA document
from home and bring it to the hospital.
The director explained the TFP Coordinator
documented on the email note that the
coordinator provided the patient with
the TFP 24 hour number. The patient
was instructed to page for assistance
to complete the surgery blood consent form.
This information was handed off to the TFP
Coordinator counterpart who was covering
during the Christmas Holiday on 12/24/2010.

6. On 01/23/2012, the investigator reviewed the
patient's blood consent form. The consent form
entitled, "Transfusion Free Program Consent
For Non-Blood Medical Management" was
dated 12/23/2010. The review determined
the patient's blood consent form was not
completed by the coordinator to include
patient's signature, with date and time.

7. Review of the patient's consent form further
revealed the coordinator wrote a note on the
blood consent form dated 12/23/2010 at
11:40 AM. The note read that the patient's
(DPA) Durable Power of Attorney for Health
Care document explained what blood products
the patient would accepted during the surgery
procedures that related to his/her religious beliefs.

8. On 01/23/2010 the investigator reviewed the
patient's DPA document. It stated in point 2
"I am a Jehovah's Witnesses and I direct that
NO TRANSFUSIONS of whole blood, red cells,
white cells platelets or plasma be given to me
under any circumstances" ........ even in the
opinion of my attending physician that it
may be necessary to preserve life or promote
recovery." The review revealed the patient
signed, dated, and time the DPA document
on 01/07/2007 and the patient included
his/her address on the form. Two other
witnesses signed the patient's DPA form.

9. On 01/23/2012 the investigator reviewed
the physician's documentation that was
entered in the Progress Notes dated
12/23/2010 at 1711. The physician documented
the patient was a Jehovah's Witnesses and
would accept blood clotting factors and platelets,
but no red blood cells during the surgery.

10. Review of the Discharge
Summary documentation was completed by the
physician and dated 12/23/2010. The physician's
written document discussed the patient's blood
decisions on page 2 as follows:
1. The patient was a "Jehovah's Witnesses"
and agreed to accept clotting factors but no
red blood cells.
2. The patient agreed to have the
cardiopulmonary bypass surgery and
3. The patient agreed to the cell salvage blood
procedure where the patient's cells are placed
back into his/her body.

11. On 1/23/2012 the investigator interviewed
the blood Transfusion RN who worked on this
surgery case on 12/24/2010. The nurse
discuss the blood products were ordered by
the surgeon. The nurse reported the patient
received two units of platelets and one
unit of plasma and several units of albumin
were given during the heart surgery procedure.
The nurse discussed the blood products were
ordered by the surgeon.

12. On 01/23/2012 during an interview with the
Blood Laboratory Manager. The manager
reported the Blood Blank released on
12/24/2010 at 9:31 AM 2 units of platelets
and 1 unit of fresh frozen plasma to surgery
for this patient.

13. Review of the hospital's written policy
entitled, "Blood and Blood Components
Documentation was approved
by administration on June 2011. Review
of this blood policy revealed in section C
on page 1 of 12, that .....If the patient changes
their mind about the transfusion decision they
are to tell the doctor and sign a new consent form.

14. Review of the evidence determined the
TFP Coordinator failed to assist the patient
in completing a new blood consent form.
The patient decided to accept platelets.
This decision was discussed with the physician
on 12/23/2010 at 1711 PM. The hospital's blood
policy discussed when patient's change their
mind about receiving blood a new consent form
needs to be completed. The hospital failed to
follow the written blood policy.