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Tag No.: C0205
Based on record review and review of facility policies and procedures, the facility failed to ensure nursing staff members performed blood transfusion procedures according to facility policy and procedure for 2 of 5 patients reviewed (Patients #1, #2).
Failure to perform blood transfusion procedures according to acceptable standards of practice risks transfusion reactions and complications.
Findings:
1. The hospital's policy and procedure entitled "Blood and Blood Products Administration Procedure (Policy #873-0022; Effective 8/10/2010) stated that the registered nurse administering the blood or blood product and a witness (another registered nurse, licensed practical nurse, laboratory technician, or physician) would verify that the information on the unit of blood matched the information on the blood unit's laboratory tag and the patient's blood identification band. The registered nurse transfusing the blood and the witness would sign the transfusion record in the signature area.
2. Review of the records of 5 patients who received blood transfusions during their hospital stay revealed the following:
The transfusion records of 2 of 2 units of packed red blood cells received by Patient #1 on 11/27/2010 did not include the signature of the witness.
The transfusion record of 1 of 2 units of fresh frozen plasma received by Patient #2 on 10/8/2010 did not include the signature of the transfusing nurse.
There was no documentation that two staff members had identified the blood and the blood recipient according to facility policy in those transfusion records.
Tag No.: C0279
Based on interview, record review, and review of facility policies and procedures, the hospital failed to implement its policy for nutritional assessment by a dietician in 2 of 2 records reviewed (Patients #1, #2).
Failure to assess, plan, and provide nutritional care for patients with inadequate intake risks malnutrition of patients and impaired healing.
REPEAT DEFICIENCY - PREVIOUSLY CITED April 2006 and March 2009.
Findings:
1. The facility's policy entitled "Nutritional Screening" (Policy #873-0019; Effective 8/28/2010) stated that a registered nurse would screen all patients on admission for nutritional risk using the "Nutrition Screening Assessment" screen located in the initial interview part of the patient's electronic medical record. Patients determined to be at risk for malnutrition, including surgical patients over 75 years old and patients with pressure ulcers, would be referred to the facility's consultant dietician.
2 Review of the patient care records of Patient #1 on 11/30/2010 and of Patient #2 on 12/2/2010 revealed that both patients were at nutritional risk.
Patient #1 was a 90 year-old patient who had been admitted for hip surgery on 11/27/2010 and was in-house the day of the review. There was no evidence in the patients' records that this patient had been referred to the facility's dietician for a nutritional assessment.
Patient #2 was a 90 year-old patient who had been hospitalized from 10/7/2010 to 10/10/2010 for treatment of a stage 3 pressure ulcer. The admitting nurse initiated a nutritional consult by the dietician. There was no evidence in the record that the dietician completed a nutritional assessment prior to the patient's discharge.
3. An interview with the facility's director of nursing (Staff Member #MS2) on 12/2/2010 at 11:00 AM confirmed that these patients should have been assessed by the dietician. The director stated that the dietician currently under contract was available only on Tuesdays and that the hospital did not have a dietician available on the other days of the week.
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Tag No.: C0322
Based on record review and interview, the hospital failed to ensure that anesthesia providers performed and documented a complete post-anesthesia evaluation for 3 of 7 patients reviewed (Patients #1, #8, #9).
Failure to evaluate patients for adverse outcomes related to anesthesia risks patient harm.
Findings:
1. The hospital's policy and procedure entitled "Anesthesia Scope of Practice" (Policy #704-0001; Effective 9/28/2010) stated that a post-anesthesia assessment would be completed by the anesthesia provider prior to discharge from the surgery and/or anesthesia services. The assessment would be documented on the anesthesia record and would include at a minimum the patient's cardiopulmonary status, level of consciousness, any follow-up care and/or observation when applicable, and any complications that occurred during the post-anesthesia recovery period.
2. Review of the records of 7 patients who received anesthesia during surgical procedures revealed that 7 of 7 records included a form entitled "Anesthesia Record". On the back of this form was an area entitled "Postanesthesia Note". The area included a box for the anesthesia provider to check to indicate that the patient did not experience anesthesia-related complications during surgery and a place for the anesthesia provider's signature, date, and time. In 3 of 7 records reviewed, this area had not been completed by the anesthesia provider.
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