HospitalInspections.org

Based on document review, interview, and observation 1) in 6 of 6 personnel/credential files, Staff A, Obstetrical (OB) Registered Nurse (RN), Staff B, OB RN, Staff C, OB Educator, Staff D, Obstetrician, Staff E, Obstetrician, Staff F, and Certified Nurse Midwife (CNM) reviewed, each lacked an annual screening for tuberculosis (TB) and/or annual health assessment. This lack of screening could lead to transmission of communicable diseases. Additionally, 2) supplies in the nursery were not adequately maintained and the hospital lacked a policy and procedure (P&P) instructing staff to check patient care items for expiration dates. This has potential risk to patient safety.

Findings related to 1) include:

-- Review of Staff A's personnel file revealed his/her last annual health assessment and TB screening was 2020.

-- Review of Staff B's personnel file revealed his/her last annual health assessment and TB screening was 2020.

-- Review of Staff C's personnel file revealed his/her last annual TB screening was 2021.

-- Review of Staff D's credential file revealed his/her last annual health assessment and TB screening was 2019.

-- Review of Staff E's credential file revealed his/her last TB screening was 2019.

-- Review of Staff F's credential file revealed his/her last annual TB screening was 2021.

-- Per interview of Staff G, Occupational Health Specialist on 4/27/2023 at 2:35 pm, he/she confirmed the above findings.

Findings related to 2) include:

-- Per observation on 4/26/2023 at 12:40 pm, the following expired items/supplies were found in the nursery:
- 1 bottle of Safe-T-Fill-Plastic Blood Gas Capillary tubes, expired 2/2023
- 3 BD Connecta 3 way stock cocks, expired 3/2023
- 1 Foley catheter 8 CH/Fr, expired 3/2023
- 1 package sterile surgical gloves size 6 1/2, expired 9/2022
- 1 package sterile surgical gloves size 7, expired 6/2022
- 1 package sterile surgical gloves size 7 1/2, expired 8/2022

-- Per interview of Staff H, OB Nurse Manager on 4/26/2023 at 1:00 pm, supplies are checked daily by the registered nurses. He/she acknowledged the above findings and confirmed there was not a checklist documenting supplies were checked daily.

-- Per email from Staff I, Director of Quality and Regulatory Affairs on 5/2/2023 at 8:16 am, he/she was unable to find a P&P on expired supplies.

Based on document review, medical record (MR) review, and interview, in 1 of 1 MRs, Patient #1's anesthesia consent form included if the patient would accept/decline a blood transfusion. A blood consent form must be a separate form. This could lead to a patient not being fully informed about a blood transfusion.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Informed Consent," dated 4/2020, indicated consent forms are required for surgical procedures and blood/blood component transfusions.

-- Review of the hospital's P&P titled "Blood and Blood Products: Transfusion of and Suspected Transfusion Reactions," dated 8/2022, indicated informed consent must be obtained by the provider prior to blood/blood product administration except in case of emergency. Patient specific consent form (Form/Packet ID N8A, titled Blood Consent Form) is printed from FormFast within the patient's EHR (electronic health record). In FormFast, open consent forms - RRH (Rochester Regional Health), select and print Blood Consent Form (Form/Packet ID N8A). Confirm appropriate informed consent has been signed by the provider and patient (or patient's legal representative).

-- Per review of Patient #1's MR, she was admitted to the hospital on 4/25/2023 for a primary cesarean section (PCS). The "Anesthesia Consent Form (Form CPH32822OR)" signed by the patient included to "accept a blood transfusion".

-- Per interview of Staff I, Director of Quality and Regulatory Affairs on 4/28/2023 at 3:45 pm, hospital staff should be using the Blood Transfusions/Blood Products consent form from FormFast. He/she acknowledged the above findings.