HospitalInspections.org

Based on institutional plan and budget review and interview the hospital failed to ensure that its institutional plan provided for a 3-year plan for capital expenditures. This lack of a 3-year capital expeniture plan has the potential to compromise the hospital's ability to effectively plan for purchases of land, improvements of land, buildings and equipment and the replacement, modernization and expansion of buildings and equipment. The findings are:

A. On 07/19/11 the hospital provided its institutional plan and budget for review. Attached to the Hospital - 2011 Budget was a sticky note which read, "included 2011 operating budget - 2011 capital budget. We have never done a 3 yr. capital."

B. On 07/21/11 at 11:50 am the Chief Financial Officer stated, "We do not have a 3-year capital budget."

Based on record review, facility policy and interview, the hospital failed to ensure that the nursing staff personnel completed the blood transfusion records in accordance with the facility policy and procedure for 10 of 10 sampled patients who received blood products in the last four months (Patient #17, 18, 19, 20, 21, 22, 23, 24, 25 and 26). As a result of this failed practice, there is a likelihood that the facility will not promptly initiate measures to control any complications that may occur during and after blood transfusions. The findings are:

A. Review of Patient #17, 18, 19, 20, 21, 22, 23, 24, 25 and 26's Blood Component Administration Records revealed the following:

1. Patient #17 received one unit of blood on 03/09/11. The Blood Component Administration Record indicated that the patient's Donor Recipient Identification Band (DRIB) (an Ident-A Blood Recipient System which provides a documented link between the patient and each unit of blood prepared for transfusion, ensuring that the right blood gets to the right patient every time) is firmly secured to the patient's wrist. This identification number was not documented on the Blood Component Administration Record. Further review revealed that the 15-minute post vital signs, which include the patient's temperature, pulse, respirations and blood pressure, were not taken. The vital signs could identify any possible complications that may occur during and after the blood transfusion.
2. Patient #18 received two units of blood on 03/01/11. For the first of the two units, the Blood Component Administration Record revealed that the vital signs were not documented at the one and two hour intervals. The record also revealed that the blood was completed at 1930 (7:30 pm). There is no documentation to indicate that vital signs were taken at 1945 (7:45 pm) -- 15 minutes post blood transfusion -- which could identify any possible complications. For the second unit of blood, the transfusion record revealed that the DRIB number is not documented on the form.
3. Patient #19 received two units of blood on 03/20/11. For the first of the two units, the Blood Component Administration Record indicated that the DRIB number was not documented on the form and the 15-minute post vital signs were not documented. The vital signs could identify any possible complications that may occur during and after the blood transfusion. For the second unit of blood, the Blood Component Administration Record revealed the same lack of documentation as for the first unit.
4. Patient #20 received two units of blood on 04/26/11. For the first of the two units, the Blood Component Administration Record indicated that the DRIB number was not documented on the form. For the second unit of blood, the Blood Component Administration Record revealed the same lack of documentation as for the first unit.
5. Patient #21 received one unit of blood on 03/05/11. The Blood Component Administration Record indicated that the DRIB number was not documented on the form and the 15-minute post vital signs were not documented. The vital signs could identify any possible complications that may occur during and after the blood transfusion.
6. Patient #22 received two units of blood on 06/24/11. For the first of the two units, the Blood Component Administration Record indicated that the DRIB number was not documented on the form. For the second unit of blood, the Blood Component Administration Record revealed the same lack of documentation as for the first unit.
7. Patient #23 received one unit of blood on 02/28/11. The Blood Component Administration Record indicated the DRIB number was not documented on the form and the 15-minute post vital signs were not documented. The vital signs could identify any possible complications that may occur during and after the blood transfusion.
8. Patient #24 received two units of blood on 04/03/11. For the first of the two units, the Blood Component Administration Record indicated that the DRIB number was not documented on the form and the 15-minute post vital signs were not documented. The vital signs could identify any possible complications that may occur during and after the blood transfusion. Further review of the Blood Component Administration Record revealed that the box to indicate if there was a suspected transfusion reaction was not marked. For the second unit of blood, the DRIB number was not indicated on the form.
9. Patient #25 received two units of blood on 02/07/11. For the first of the two units, the Blood Component Administration Record indicated that the DRIB number was not documented on the form. For the second unit of blood, the Blood Component Administration Record revealed the same lack of documentation as for the first unit.
10. Patient #26 received two units of blood on 06/15/11. For the first of the two units, the Blood Component Administration Record indicated that the DRIB number was not documented on the form and the 15-minute post vital signs were not documented. The vital signs could identify any possible complications that may occur during and after the blood transfusion. For the second unit of blood, the DRIB number was not indicated on the form and the vital signs were not taken at the appropriate times for the one hour interval, and the 15-minute post vital signs were not documented.

B. Review of the facility policy and procedure titled "Blood Use," last revised on 04/10, revealed the following: "...Once the unit is obtained, get another R.N., L.P.N., Paramedic or provider to assist in the patient/blood band identification process. The following must match exactly...The patient's blood band number -- on the patient blood armband and the Blood Component Administration Record...Obtain the patient's vital signs including B/P, HR, RR and temp and record...Vital signs are repeated 15 minutes after blood/component infusion is initiated, every 30 minutes during transfusion and upon completion of transfusion...Complete the Blood Component Administration Record...Observe the patient closely for signs of transfusion reaction during the initial 15 minutes and throughout the transfusion."

C. On 07/20/11 at 1:40 pm, during interview, the Director of Nursing confirmed that the Blood Component Administration Records were not completed as required by hospital policy.

Based on information from the State Agency Clinical Loboratory Improvement Act (CLIA) surveyor and confirmation from the hospital, the hospital laboratory did not have a current CLIA certification due to recent problems with the laboratory operation. The failure to have a current CLIA certification impaired the laboratory's ability to provide laboratory services to patients that are in compliance with federal CLIA regulations. The findings are:

A. On 07/18/11 at 3:30 pm the survey team was advised by the State Agency CLIA surveyor that the hospital did not have a current CLIA certificate because of ongoing problems with the lab operation.

B. On 07/18/11 at 4:10 the Chief Quality Officer confirmed that the hospital did not have a current CLIA certificate and that the hospital was working to rectify the identifed problems.