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Based on review of facility documents and staff interview (EMP),it was determined the facility failed to ensure implemented performance improvement actions were measures for success and tracked for performance to ensure improvements were sustained regarding missing blood transfusion on the Crossmatch Transfusion Tag throughout the facility.

Findings include:

Review on July 11, 2016, of the facility's Plan For Performance Improvement and Clinical Excellence FY 2016" revealed "A. Mission/Purpose ... The purpose of this plan is to provide guidance for performance improvement (PI) to all areas of Robert Packer Hospital ... The scope of the performance improvement plan shall sufficiently satisfy prevailing regulatory and accrediting requirements; however, it is not meant to be all inclusive. ... Objectives Our overall goal is to promote excellence in services to meet or exceed our patient expectations and to achieve quality patient outcomes. Objectives include: Promote patient safety (avoiding injury or harm from care that is intended to help them) and reducing risk to all customers of, and within, Robert packer Hospital, Ensure care and services that are efficacious and based on scientific knowledge, Embrace out patients as key customers and keeping patients at the center of all we do, Design processes/systems that result in timely care and services, assuring that systems and processes are consistent, with minimal variation and align with Lean Management principles, Promote efficacy by responsible stewardship of our resources which includes minimizing waste through the use of sound economic principles in our decision making process, Provide services that are equable (impartial and unbiased) regardless of the gender, ethnicity and socioeconomic status of our customers D. Establishing Priorities ...Performance improvement initiatives/priorities foster a proactive environment throughout the organization with the intent to: focus on systems and processes, focus on eliminating variability in systems and processes, Developing standard work, encourage the identification of actual/potential risks to patients and the initiation of actions to reduce risks ..."

1) Review of the facility provided Transfusion and Compatibility Event reports for July 2014 to June 2016, revealed the following missing or incorrect transfusion documentation for July to December 2014:

The Emergency Department reported 1 transfusion documentation missing number and empty blood bag not returned to Blood Bank; 2 blood products wasted (patient's condition did not warrant it); and, a transfusion ticket was sent to Medical Records with no identifying information in August; 2 units of RBCs ordered with no consent obtained; patient's name spelled incorrectly in October; and, 1 blood bag missing end of transfusion date/time and signature in December.

The Ambulatory Infusion Department reported 1 empty blood bag did not have an end date and time when returned to Blood Bank in September.

The Intensive / Coronary Care - 624 Department reported 2 blood bags missing required information when returned to Blood Bank in July; 2 blood bags missing required information when returned to Blood Bank; 1 blood bag placed on wrong patient chart in August; 4 blood bags missing required information when returned to Blood Bank in September; 2 blood bags missing required information when returned to Blood Bank in October and November; and 6 blood bags missing required information when returned to Blood Bank in December.

The Interventional Radiology Department reported 1 blood bag missing required information when returned to Blood Bank in September

The Labor and Delivery Department reported 1 blood bag placed in wrong patient chart in September and 1 blood bag missing required information when returned to Blood Bank in October.

The Med / Surg - 7 Main - 663 Department reported 1 blood bag missing required information when returned to Blood Bank in July and 1 blood bag missing required information when returned to Blood Bank; 1 bag found in wrong patient chart in October.

The Med / Surg - 6 SW - 616 Department reported 1 blood bag missing required information when returned to Blood Bank in August, September, November and December.

The Med / Surg - 6th NW - 611 Department reported 2 blood bags missing required information when returned to Blood Bank in August and November.

The Med / Surg 8th NW - 610 Department reported 1 blood bag missing required information when returned to Blood Bank in July and October; 2 blood bags missing required information when returned to Blood Bank in August; and, 3 blood bags missing required information when returned to Blood Bank in November.

The Oncology - 5 Main - 614 Department reported 1 bag found in wrong patient chart in November.

The Operating Room Department reported 1 blood bag missing required information when returned to Blood Bank in July, September and November.

The Prep Recovery Unit - 661 Department reported 1 blood bag missing required information when returned to Blood Bank in July.

2) Review of the facility provided Transfusion and Compatibility Event reports for July 2014 to June 2016, revealed the following missing or incorrect transfusion documentation for January to December 2015:

The 4 West Department reported 2 empty blood bags did not have an end date and time when returned to Blood Bank in January.

The Emergency Services Department reported 2 blood bags missing required information when returned to Blood Bank in January, March and April; and, 1 empty blood bag missing required information when returned to Blood Bank in February, May, June, July, September and October.

The Hemodialysis Department reported 1 empty blood bag missing required information when returned to Blood Bank in February.

The Intensive / Coronary Care - 624 Department reported 6 blood bags missing required information when returned to Blood Bank and 1 blood requested for wrong patient in January; 5 blood bags missing required information when returned to Blood Bank in February; 3 blood bags missing required information when returned to Blood Bank and 2 blood bags placed in wrong patient chart in March; 3 blood bags missing required information when returned to Blood Bank in April; 9 blood bags missing required information when returned to Blood Bank in May; 3 blood bags missing required information when returned to Blood Bank June; 3 blood bags missing required information when returned to Blood Bank in July; September - 2 blood bags missing required information when returned to Blood Bank; 2 blood bags missing required information when returned to Blood Bank in October; and, 1 blood bag missing required information when returned to Blood Bank in December.

The Joint Camp Department reported 1 blood bag missing required information when returned to Blood Bank in May and November.

The Med / Surg - 7 Main - 663 Department reported 1 blood bag missing required information when returned to Blood Bank in March and July.

The Med / Surg - 6 SW - 616 Department reported 2 blood bags missing required information when returned to Blood Bank in January and April; 3 blood bags missing required information when returned to Blood Bank in March; and, 4 blood bags missing required information when returned to Blood Bank in June.

The Med / Surg 6th NW - 611 Department reported 1 blood bag missing required information when returned to Blood Bank in March and July and 2 blood bags missing required information when returned to Blood Bank in June.

The Med / Surg 8th NW - 610 Department reported 1 blood bag missing required information when returned to Blood Bank in January, April and October and 2 blood bags missing required information when returned to Blood Bank in February.

The Oncology 5 Main - 614 Department reported 1 blood bag missing required information when returned to Blood Bank in February, April and June.

The Operating Room Department reported 1 blood bag missing required information when returned to Blood Bank in January.

The Prep Recovery Unit - 661 Department reported 1 blood bag missing required information when returned to Blood Bank in May.

3) Review of the facility provided Transfusion and Compatibility Event reports for July 2014 to June 2016, revealed the following missing or incorrect transfusion documentation for January to July 2016:

The 4 West Department reported 1 transfusion event for fresh frozen plasma (FFP) administered before the physician signed the procedural consent in April.

The Emergency Services Department reported 1 patient name and B [medical record number] number incorrect in February.

The 7 ICU Department reported 2 Blood bags placed in wrong charts in March and 1 blood requested for wrong patient in May.

The Intensive / Coronary Care - 624 Department reported 2 blood bags missing required information when returned to Blood Bank in January and 1 blood bag missing required information when returned to Blood Bank; 1 blood request label for wrong patient in February.

Interview with EMP2 on July 12, 2016, at approximately 11:45 AM revealed the facility identified missing or incorrect transfusion documentation on the Crossmatch Transfusion Tag during 2015. The facility completed facility wide training regarding correct completion of the Crossmatch Transfusion Tag. The facility was monitoring staff compliance regarding the completion of the Crossmatch Transfusion Tag for missing and incorrect information. EMP2 revealed there continued to be a problem with staff compliance with ensuring the information on the Crossmatch Transfusion Tag was complete and accurate.

4) Review of MR20, MR21, MR22 and MR26 on July 12, 2016, revealed these patients were currently inpatients in the facility and had received blood transfusions. Review of MR20, MR21, MR22 and MR26 revealed missing or incorrect transfusion documentation on the Crossmatch Transfusion Tag.

Interview with EMP2 on July 12, 2016, at approximately 12:00 PM confirmed MR20, MR21, MR22 and MR26 were currently inpatients in the facility and the transfusion documentation on the patients' Crossmatch Transfusion Tag was missing or incorrect.

Cross reference:
482.23(c)(4) Blood Transfusions and IV Medications

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the required information was documented on the Crossmatch Transfusion Tag for six of nine applicable medical records reviewed (MR20, MR21, MR22, MR26, MR30 and MR31).

Findings include:

Review on July 12, 2016, of the facility's "Blood Administration" policy, effective December 17, 2015, revealed "Policy: Measures are in place for the safe administration of Blood and Blood products. ... III. Administration of Blood A. Blood needs to be verified at the bedside by two authorized users (one of whom must be an RN), or one RN [Registered Nurse] and one LPN [Licensed Practical Nurse], independently of each other. They must check and verify the name and medical record number on the patient's wrist identification band against the information on the compatibility tag. Also at this time check the ABO [blood group system], Rh [blood type], unit number, and expiration date on the blood/blood product container with the compatibility tag to be certain it agrees. ... C. Complete the bottom of the tag of each unit of Blood/Blood product at the time of administration, including date, time and signatures. D. Record pre-transfusion vital signs, time transfusion started, and unit number of blood product in the medical record. ..."

Review on July 12, 2016, of the facility's "Crossmatch Transfusion Tag" no review date, revealed an area at the bottom of the document labeled PreTransfusion for staff to sign documenting "I checked this slip with container label and patient wrist band to verify patient name [and] No., ABO, Rh, And Donor No." There were two areas for the Signature, Date and Time [the time the blood was started] for the two staff to complete who verified and checked the blood. On the right side of the "Crossmatch Transfusion Tag" there was an area for staff to document where the blood was "Issued To" which included a date and time to be completed. There was a Post Transfusion area for the signature of the person the Blood/Blood Product was stopped by, an area for the date, time, amount given, and if there was or was not a reaction.

Review of MR20 on July 12, 2016, revealed the patient was admitted to the facility on July 9, 2016, following a motor vehicle accident. The physician order dated July 9, 2016, instructed nursing staff to transfuse one unit of red blood cells (RBC). The Crossmatch Transfusion Tag revealed the unit of blood was released to EMP25 on September 9, 2016, at 23:09.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR20 was admitted to the facility following a motor vehicle accident; the physician order instructing nursing staff to transfuse one unit of red blood cells; MR20's Crossmatch Transfusion Tag for this unit of blood was released to EMP25 on September 9, 2016, at 23:09, and the date of September 9, 2016, was an incorrect date. EMP2 confirmed the correct date for this unit of RBC's should be July 9, 2016.

Review of MR21 on July 12, 2016, revealed the patient was admitted to the facility on June 30, 2016, with a diagnosis of sepsis. The physician order dated July 11, 2016, instructed nursing staff to transfuse two units of RBCs. The Crossmatch Transfusion Tag revealed the unit of blood was released to EMP26 on July 11, 2016, at 12:38. There was no documentation of the time the unit of RBCs was started on MR21.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR21 was admitted to the facility with a diagnosis of sepsis; the physician order instructing nursing staff to transfuse two units of RBCs; the Crossmatch Transfusion Tag for the unit of blood was released to EMP26 on July 11, 2016, at 12:38, and there was no documentation of the time the unit of RBCs were started on MR21.

Review of MR22 on July 12, 2016, revealed the patient was admitted on July 10, 2016, following a traumatic injury. The operating room physician instructed nursing staff to transfuse multiple units of RBCs, thawed plasma and apheresis platelets. Two of the Crossmatch Transfusion Tags were missing the second authorized signature verifying the correct patient and patient information.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR22 was admitted following a traumatic injury; an operating room physician instructed nursing staff to transfuse multiple units of RBCs, thawed plasma and apheresis platelets; and two of the Crossmatch Transfusion Tags were missing a second authorized signature verifying the correct patient and patient information.

Interview with OTH3 on July 14, 2016, at approximately 9:15 confirmed an operating room physician instructed nursing staff to transfuse multiple units of RBCs, thawed plasma and apheresis platelets, and two of the Crossmatch Transfusion Tags were missing a second authorized signature verifying the correct patient and patient information.

Review of MR26 on July 12, 2016, revealed the patient was admitted on July 5, 2016, with a diagnosis of atherosclerosis of the carotid arteries requiring surgery. The physician order dated July 5, 2016, instructed nursing staff to transfuse four units of RBCs. The Crossmatch Transfusion Tag revealed the unit of blood was released to EMP27 on July 5, 2016, at 8:10. Continued review revealed no documentation indicating when the unit of RBCs was completed on MR26.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR26 was admitted to the facility with a diagnosis of atherosclerosis of the carotid arteries requiring surgery; the physician order instructing nursing staff to transfuse four units of RBCs; the Crossmatch Transfusion Tag revealed the unit of blood was released to EMP27 on July 5, 2016, at 8:10; and there was no documentation indicating when the unit of RBCs was completed on MR26.

Review of MR26 on July 12, 2016, revealed a Crossmatch Transfusion Tag with documentation the unit of RBCs was released to EMP26. EMP26 documented June 8, 2016, at 10:33 the on the unit of RBCs. The Crossmatch Transfusion Tag was checked by two authorized users on July 8, 2016, at 14:15.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed EMP26 documented June 8, 2016, at 10:33 on MR26's Crossmatch Transfusion Tag and the unit of RBCs was checked by two authorized users on July 8, 2016, at 14:15. EMP2 confirmed the date on MR26's unit of RBCs should have been July 8, 2016, and not June 8, 2016.

Review of MR30 on July 12, 2016, revealed the patient was admitted on March 24, 2016, with a diagnosis of cellulitis. The physician order dated March 25, 2016, instructed nursing staff to transfuse two units of RBCs. The Crossmatch Transfusion Tag revealed the unit of blood was released to EMP28 on March 25, 2016, at 18:44. There was no documentation on the Crossmatch Transfusion Tag indicating the date and time the unit of RBCs was completed. There was no documentation if a post transfusion reaction occurred.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR30 was admitted with a diagnosis of cellulitis; the physician order instructing nursing staff to transfuse two units of RBCs; the Crossmatch Transfusion Tag for the unit of blood was released to EMP28 on March 25, 2016, at 18:44; and there was no documentation on the Crossmatch Transfusion Tag indicating the date and time the unit of RBCs was completed; and there was no documentation if a post transfusion reaction occurred.

Review of MR31 on July 12, 2016, revealed the patient was admitted on February 17, 2016, with a diagnosis of a gastrointestinal bleed. The physician order dated February 18, 2016, instructed nursing staff to administer two units of fresh frozen plasma (FFP). The Crossmatch Transfusion Tag revealed the unit of FFP was released to EMP29 on February 18, 2016, at 01:14. The Crossmatch Transfusion Tag was missing a second authorizing signature verifying the correct patient and patient information. There was no documentation of whether there was a post transfusion reaction. The Crossmatch Transfusion Tag also contained documentation the unit of FFP was transfused on January 18 with no year documented.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR31 was admitted with a diagnosis of a gastrointestinal bleed; the physician order instructing nursing staff to administer two units of FFP; the Crossmatch Transfusion Tag revealed the unit of FFP was released to EMP29 on February 18, 2016, at 01:14. EMP2 confirmed the Crossmatch Transfusion Tag was missing a second authorized signature verifying the correct patient and patient information and documentation of whether there was a post transfusion reaction. EMP2 confirmed the Crossmatch Transfusion Tag also contained documentation the unit of FFP was transfused on January 18 with no year documented. EMP2 revealed the correct date for MR31's Crossmatch Transfusion Tag should be February 18, 2016.

Based on review of facility policy, observation tour, and staff interview (EMP), it was determined the facility failed to ensure medical records were properly secured in locations where they are protected from water damage, and failed to ensure a blood spill, a potentially infectious material, was properly cleaned from a patient's medical record for one of 64 medical records reviewed (MR22).

Findings include:

Review on July 13, 2016, of the facility policy "Ownership, Security, Medical Records," last revised January 4, 2016, revealed "Policy Statement The medical records of the Robert Packer Hospital are the property of the hospital, although patients may be allowed access to information in their records. Guthrie Clinic records are the property of the Clinic. For continuity of care purposes, the clinic records are filed either in the hospital's hard copy medical record or in Epic. Pennsylvania State law requires no medical record be removed from the facility except as directed by subpoena, court order, or state statute. It is the responsibility of the facilities to safeguard both the record and its informational content against loss, defacement, tampering, and unauthorized use. ... "

1) Observation tour on July 11, 2016, at approximately 1300, of the Medical Record Department located on the third floor of the main building revealed file room 13-73 and high file room 77-99 contained previous patient paper medical records stored on metal shelves. The metal shelves were open on the top and sides. Above the metal shelves was the fire sprinkler system.

Interview with EMP1 on July 11, 2016, at approximately 1300 confirmed file room 13-73 and high file room 77- 99 contained patient medical records on open shelves, and there was a fire sprinkler system above the metal shelves.

Observation tour on July 11, 2016, at approximately 1330 of a medical record storage area on the first floor revealed an area that contained deceased patient medical records in paper format and micro-film back up. The records were stored on metal shelves that were open on the top and sides. Above the metal shelves was the fire sprinkler system.

Interview with EMP1 on July 11, 2016, at approximately 1330 confirmed the storage area on the first floor contained deceased patient medical records in paper format and micro-film back up. EMP1 confirmed there was a fire sprinkler system above the metal shelves.

Observation tour on July 11, 2016 at approximately 1420, of the Enterprise Building located at 703 Wilbur Avenue revealed a storage area on the first floor that stores sixty (60) paper boxes of deceased patient's medical records on metal shelves that are open on both sides. The area revealed water pipes directly above the shelving unit.

Interview with EMP10, on July 11, 2016 at approximately 1420 confirmed the storage area in the Enterprise Building where 60 boxes of deceased patient's medical records are stored is an area with open shelves and water pipes directly above the shelves.

2) Review on July 13, 2016, of the facility's "Bodily Fluid Contaminated Medical Records" policy, effective August 25, 2015, revealed "Policy Statement This policy has been developed to protect staff should the medical record become visibly contaminated with blood, bodily fluids, secretions, or excretions. Interpretation 1. In the event the medical record becomes contaminated, the area where the record is contaminated is responsible to adhere to the following process: a. Place the involved documents in a plastic cover. b. Make a copy of the document and label it as such. c. Place the copy of the document into the paper chart to send to Medical Records. d. Put the contaminated document in the biohazard garbage can for disposal. 2. Note that washing/disinfecting your hands after handling blood, other bodily fluids, secretions, and excretions will help prevent contamination of the medical record."

Review of MR22 on July 13, 2016, revealed a red-brown-colored smear, measuring approximately 1.5" x 0.25" on a paper in MR22's medical record. This paper contained documentation regarding MR22's medical treatment while an inpatient in the facility.

Interview with EMP2 on July 13, 2016, at the time of the observation confirmed the red-brown-colored smear on MR22's medical record was dried blood. EMP2 confirmed the facility's established policy regarding treating a contaminated medical record was not followed.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure staff wore acceptable operating room attire for seven of eight staff in operating room 15 (PF1, PF2, PF11, CF1, CF3, OTH1, and OTH2).

Findings include:

Review of facility policy "Surgical Attire," last revised February 2, 2015, revealed "Policy: All persons entering the area will be required to wear surgical scrub attire as provided by this facility. Street clothes are not to be worn within the semi-restricted and restricted areas of the OR [operating room]. Procedure: ... 7. Disposable hats or hoods that completely cover all head and facial hair are to be worn by all personnel entering the OR restrictive areas. 8. Personnel at surgical field will remove all jewelry prior to scrubbing. A. Earrings more than one inch below ear lobes B. Necklaces or chains must be removed unless they are long enough to remain under the gown. ..."

Interview with EMP17 at approximately 2:00 PM on July 13, 2016, revealed the facility follows the Association of periOperative Registered Nurses (AORN) Guidelines for Perioperative Practice. EMP17 provided a copy of the guidelines covering surgical attire to the surveyor.

Review on July 13, 2016, of "2015 Guidelines for Perioperative Practice, last revised September 2014, Copyright 2015 AORN, Inc." revealed the following recommendations: Staff in the semi-restricted and restricted areas of the perioperative setting should wear clean surgical attire that covers their head, hair, ears and facial hair. Surgical head covers worn by staff, should confine hair and completely cover ears, scalp skin, sideburns and nape of neck. A long-sleeved jacket should be worn in the restricted area to cover arms. Jewelry should be contained or confined within scrub attire or be removed. Shoes should be clean and dedicated for use within the perioperative environment.

Observation in OR15 at 10:00 AM on July 11, 2016, revealed PF1, PF2, PF11, OTH1 and OTH2 wearing cloth head covers. PF1, PF2 and PF11 had one or more inches of hair showing below their cloth head coverings.

Further observation in OR15 at 10:00 AM on July 11, 2016, revealed CF1 wearing a disposable skull cap with 1"of hair showing below the cap. CF1 also had approximately 2" x 2" sections of beard showing above the face mask on both sides of their face.

Observation of CF3 in OR15 at 10:00 AM on July 11, 2016, revealed approximately 1.5" of CF3's hair bun showing below their disposable skull cap.

Additional observation in OR15 at 10:00 AM on July 11, 2016, revealed PF1 wearing approximately 1" long hoop earrings showing below their head covering.

Interview with EMP17 and EMP18 at approximately 10:15 AM on July 12, 2016, confirmed PF1, PF2, PF11, OTH1, and OTH2 were wearing cloth head covers. EMP17 confirmed the cloth head covers were not disposable. EMP17 and EMP18 confirmed PF1, PF2 and PF11 had one or more inches of hair showing below their cloth head covering. EMP17 and EMP18 confirmed CF1 had 1" of hair showing below their skull cap and approximately 2" x 2" sections of beard showing above the face mask on both sides of their face. Further interview with EMP17 and EMP18 confirmed PF1 had approximately 1" long hoop earrings showing below their head covering.

Additional interview with EMP17 at approximately 2:00 PM on July 13, 2016, confirmed the facility policy stated disposable caps were to be worn in the operating room. EMP7 confirmed industry standards recommended surgical head covers worn by staff, should confine hair and completely cover ears, scalp skin, sideburns and nape of neck. A long-sleeved jacket should be worn in the restricted area to cover arms. Jewelry should be contained or confined within scrub attire or be removed. Shoes should be clean and dedicated for use within the perioperative environment.

This is a repeat citation regarding appropriate surgical attire, cited during a complaint investigation (CHL14CQ4LI) completed on January 8, 2015. This was cited when completing the Patient Safety Initiative for Infection Control under tag 0749.

Based on review of facility documents and staff interview (EMP),it was determined the facility failed to ensure implemented performance improvement actions were measures for success and tracked for performance to ensure improvements were sustained regarding missing blood transfusion on the Crossmatch Transfusion Tag throughout the facility.

Findings include:

Review on July 11, 2016, of the facility's Plan For Performance Improvement and Clinical Excellence FY 2016" revealed "A. Mission/Purpose ... The purpose of this plan is to provide guidance for performance improvement (PI) to all areas of Robert Packer Hospital ... The scope of the performance improvement plan shall sufficiently satisfy prevailing regulatory and accrediting requirements; however, it is not meant to be all inclusive. ... Objectives Our overall goal is to promote excellence in services to meet or exceed our patient expectations and to achieve quality patient outcomes. Objectives include: Promote patient safety (avoiding injury or harm from care that is intended to help them) and reducing risk to all customers of, and within, Robert packer Hospital, Ensure care and services that are efficacious and based on scientific knowledge, Embrace out patients as key customers and keeping patients at the center of all we do, Design processes/systems that result in timely care and services, assuring that systems and processes are consistent, with minimal variation and align with Lean Management principles, Promote efficacy by responsible stewardship of our resources which includes minimizing waste through the use of sound economic principles in our decision making process, Provide services that are equable (impartial and unbiased) regardless of the gender, ethnicity and socioeconomic status of our customers D. Establishing Priorities ...Performance improvement initiatives/priorities foster a proactive environment throughout the organization with the intent to: focus on systems and processes, focus on eliminating variability in systems and processes, Developing standard work, encourage the identification of actual/potential risks to patients and the initiation of actions to reduce risks ..."

1) Review of the facility provided Transfusion and Compatibility Event reports for July 2014 to June 2016, revealed the following missing or incorrect transfusion documentation for July to December 2014:

The Emergency Department reported 1 transfusion documentation missing number and empty blood bag not returned to Blood Bank; 2 blood products wasted (patient's condition did not warrant it); and, a transfusion ticket was sent to Medical Records with no identifying information in August; 2 units of RBCs ordered with no consent obtained; patient's name spelled incorrectly in October; and, 1 blood bag missing end of transfusion date/time and signature in December.

The Ambulatory Infusion Department reported 1 empty blood bag did not have an end date and time when returned to Blood Bank in September.

The Intensive / Coronary Care - 624 Department reported 2 blood bags missing required information when returned to Blood Bank in July; 2 blood bags missing required information when returned to Blood Bank; 1 blood bag placed on wrong patient chart in August; 4 blood bags missing required information when returned to Blood Bank in September; 2 blood bags missing required information when returned to Blood Bank in October and November; and 6 blood bags missing required information when returned to Blood Bank in December.

The Interventional Radiology Department reported 1 blood bag missing required information when returned to Blood Bank in September

The Labor and Delivery Department reported 1 blood bag placed in wrong patient chart in September and 1 blood bag missing required information when returned to Blood Bank in October.

The Med / Surg - 7 Main - 663 Department reported 1 blood bag missing required information when returned to Blood Bank in July and 1 blood bag missing required information when returned to Blood Bank; 1 bag found in wrong patient chart in October.

The Med / Surg - 6 SW - 616 Department reported 1 blood bag missing required information when returned to Blood Bank in August, September, November and December.

The Med / Surg - 6th NW - 611 Department reported 2 blood bags missing required information when returned to Blood Bank in August and November.

The Med / Surg 8th NW - 610 Department reported 1 blood bag missing required information when returned to Blood Bank in July and October; 2 blood bags missing required information when returned to Blood Bank in August; and, 3 blood bags missing required information when returned to Blood Bank in November.

The Oncology - 5 Main - 614 Department reported 1 bag found in wrong patient chart in November.

The Operating Room Department reported 1 blood bag missing required information when returned to Blood Bank in July, September and November.

The Prep Recovery Unit - 661 Department reported 1 blood bag missing required information when returned to Blood Bank in July.

2) Review of the facility provided Transfusion and Compatibility Event reports for July 2014 to June 2016, revealed the following missing or incorrect transfusion documentation for January to December 2015:

The 4 West Department reported 2 empty blood bags did not have an end date and time when returned to Blood Bank in January.

The Emergency Services Department reported 2 blood bags missing required information when returned to Blood Bank in January, March and April; and, 1 empty blood bag missing required information when returned to Blood Bank in February, May, June, July, September and October.

The Hemodialysis Department reported 1 empty blood bag missing required information when returned to Blood Bank in February.

The Intensive / Coronary Care - 624 Department reported 6 blood bags missing required information when returned to Blood Bank and 1 blood requested for wrong patient in January; 5 blood bags missing required information when returned to Blood Bank in February; 3 blood bags missing required information when returned to Blood Bank and 2 blood bags placed in wrong patient chart in March; 3 blood bags missing required information when returned to Blood Bank in April; 9 blood bags missing required information when returned to Blood Bank in May; 3 blood bags missing required information when returned to Blood Bank June; 3 blood bags missing required information when returned to Blood Bank in July; September - 2 blood bags missing required information when returned to Blood Bank; 2 blood bags missing required information when returned to Blood Bank in October; and, 1 blood bag missing required information when returned to Blood Bank in December.

The Joint Camp Department reported 1 blood bag missing required information when returned to Blood Bank in May and November.

The Med / Surg - 7 Main - 663 Department reported 1 blood bag missing required information when returned to Blood Bank in March and July.

The Med / Surg - 6 SW - 616 Department reported 2 blood bags missing required information when returned to Blood Bank in January and April; 3 blood bags missing required information when returned to Blood Bank in March; and, 4 blood bags missing required information when returned to Blood Bank in June.

The Med / Surg 6th NW - 611 Department reported 1 blood bag missing required information when returned to Blood Bank in March and July and 2 blood bags missing required information when returned to Blood Bank in June.

The Med / Surg 8th NW - 610 Department reported 1 blood bag missing required information when returned to Blood Bank in January, April and October and 2 blood bags missing required information when returned to Blood Bank in February.

The Oncology 5 Main - 614 Department reported 1 blood bag missing required information when returned to Blood Bank in February, April and June.

The Operating Room Department reported 1 blood bag missing required information when returned to Blood Bank in January.

The Prep Recovery Unit - 661 Department reported 1 blood bag missing required information when returned to Blood B

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the required information was documented on the Crossmatch Transfusion Tag for six of nine applicable medical records reviewed (MR20, MR21, MR22, MR26, MR30 and MR31).

Findings include:

Review on July 12, 2016, of the facility's "Blood Administration" policy, effective December 17, 2015, revealed "Policy: Measures are in place for the safe administration of Blood and Blood products. ... III. Administration of Blood A. Blood needs to be verified at the bedside by two authorized users (one of whom must be an RN), or one RN [Registered Nurse] and one LPN [Licensed Practical Nurse], independently of each other. They must check and verify the name and medical record number on the patient's wrist identification band against the information on the compatibility tag. Also at this time check the ABO [blood group system], Rh [blood type], unit number, and expiration date on the blood/blood product container with the compatibility tag to be certain it agrees. ... C. Complete the bottom of the tag of each unit of Blood/Blood product at the time of administration, including date, time and signatures. D. Record pre-transfusion vital signs, time transfusion started, and unit number of blood product in the medical record. ..."

Review on July 12, 2016, of the facility's "Crossmatch Transfusion Tag" no review date, revealed an area at the bottom of the document labeled PreTransfusion for staff to sign documenting "I checked this slip with container label and patient wrist band to verify patient name [and] No., ABO, Rh, And Donor No." There were two areas for the Signature, Date and Time [the time the blood was started] for the two staff to complete who verified and checked the blood. On the right side of the "Crossmatch Transfusion Tag" there was an area for staff to document where the blood was "Issued To" which included a date and time to be completed. There was a Post Transfusion area for the signature of the person the Blood/Blood Product was stopped by, an area for the date, time, amount given, and if there was or was not a reaction.

Review of MR20 on July 12, 2016, revealed the patient was admitted to the facility on July 9, 2016, following a motor vehicle accident. The physician order dated July 9, 2016, instructed nursing staff to transfuse one unit of red blood cells (RBC). The Crossmatch Transfusion Tag revealed the unit of blood was released to EMP25 on September 9, 2016, at 23:09.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR20 was admitted to the facility following a motor vehicle accident; the physician order instructing nursing staff to transfuse one unit of red blood cells; MR20's Crossmatch Transfusion Tag for this unit of blood was released to EMP25 on September 9, 2016, at 23:09, and the date of September 9, 2016, was an incorrect date. EMP2 confirmed the correct date for this unit of RBC's should be July 9, 2016.

Review of MR21 on July 12, 2016, revealed the patient was admitted to the facility on June 30, 2016, with a diagnosis of sepsis. The physician order dated July 11, 2016, instructed nursing staff to transfuse two units of RBCs. The Crossmatch Transfusion Tag revealed the unit of blood was released to EMP26 on July 11, 2016, at 12:38. There was no documentation of the time the unit of RBCs was started on MR21.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR21 was admitted to the facility with a diagnosis of sepsis; the physician order instructing nursing staff to transfuse two units of RBCs; the Crossmatch Transfusion Tag for the unit of blood was released to EMP26 on July 11, 2016, at 12:38, and there was no documentation of the time the unit of RBCs were started on MR21.

Review of MR22 on July 12, 2016, revealed the patient was admitted on July 10, 2016, following a traumatic injury. The operating room physician instructed nursing staff to transfuse multiple units of RBCs, thawed plasma and apheresis platelets. Two of the Crossmatch Transfusion Tags were missing the second authorized signature verifying the correct patient and patient information.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR22 was admitted following a traumatic injury; an operating room physician instructed nursing staff to transfuse multiple units of RBCs, thawed plasma and apheresis platelets; and two of the Crossmatch Transfusion Tags were missing a second authorized signature verifying the correct patient and patient information.

Interview with OTH3 on July 14, 2016, at approximately 9:15 confirmed an operating room physician instructed nursing staff to transfuse multiple units of RBCs, thawed plasma and apheresis platelets, and two of the Crossmatch Transfusion Tags were missing a second authorized signature verifying the correct patient and patient information.

Review of MR26 on July 12, 2016, revealed the patient was admitted on July 5, 2016, with a diagnosis of atherosclerosis of the carotid arteries requiring surgery. The physician order dated July 5, 2016, instructed nursing staff to transfuse four units of RBCs. The Crossmatch Transfusion Tag revealed the unit of blood was released to EMP27 on July 5, 2016, at 8:10. Continued review revealed no documentation indicating when the unit of RBCs was completed on MR26.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR26 was admitted to the facility with a diagnosis of atherosclerosis of the carotid arteries requiring surgery; the physician order instructing nursing staff to transfuse four units of RBCs; the Crossmatch Transfusion Tag revealed the unit of blood was released to EMP27 on July 5, 2016, at 8:10; and there was no documentation indicating when the unit of RBCs was completed on MR26.

Review of MR26 on July 12, 2016, revealed a Crossmatch Transfusion Tag with documentation the unit of RBCs was released to EMP26. EMP26 documented June 8, 2016, at 10:33 the on the unit of RBCs. The Crossmatch Transfusion Tag was checked by two authorized users on July 8, 2016, at 14:15.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed EMP26 documented June 8, 2016, at 10:33 on MR26's Crossmatch Transfusion Tag and the unit of RBCs was checked by two authorized users on July 8, 2016, at 14:15. EMP2 confirmed the date on MR26's unit of RBCs should have been July 8, 2016, and not June 8, 2016.

Review of MR30 on July 12, 2016, revealed the patient was admitted on March 24, 2016, with a diagnosis of cellulitis. The physician order dated March 25, 2016, instructed nursing staff to transfuse two units of RBCs. The Crossmatch Transfusion Tag revealed the unit of blood was released to EMP28 on March 25, 2016, at 18:44. There was no documentation on the Crossmatch Transfusion Tag indicating the date and time the unit of RBCs was completed. There was no documentation if a post transfusion reaction occurred.

Interview with EMP2 on July 12, 2016, at the time of the observation confirmed MR30 was admitted with a diagnosis of cellulitis; the physician order instructing nursing staff to transfuse two units of RBCs; the Crossmatch Transfusion Tag for the unit of blood was released to EMP28 on March 25, 2016, at 18:44; and there was no documentation on the Crossmatch Transfusion Tag indicating the date and time the unit of RBCs was completed; and there was no documentation if a post transfusion reaction occurred.

Review of MR31 on July 12, 2016, revealed the patient was admitted on February 17, 2016, with a diagnosis of a gastrointestinal bleed. The physician order dated February 18, 2016, instructed nursing staff to administer two units of fresh frozen plasma (FFP). The Crossmatch Transfusion Tag revealed the unit of FFP was released to EMP29 on February 18, 2016, at 01:14. The Crossmatch Transfusion Tag was missing a second authorizing signature verifying the correct patient and patient information. There was no documentation of whether there was a post transfusion reaction. The Cros