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ST JOSEPHS HOSPITAL 3001 W MARTIN LUTHER KING JR BLVD TAMPA, FL 33677 Aug. 17, 2016
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
Based on medical record review, policy review and staff interview it was determined the nursing staff failed to administer blood for two (#3, #8) of six patient receiving a blood transfusion from a sample of ten patient according to policy and physician orders.

Findings included:

1. A review of Patient #3's medical record showed on 04/28/2016 at 8:05 a.m. Patient's #3 hemoglobin [Hgb] was 6.8 g/dl [grams per deciliter]. The review of the physician orders sheet noted blood for transfusion was order at 6:11 p.m. At 7:00 p.m. Patient #3 Hgb was 6.4 g/dl.

A detailed review of the medical record revealed no documentation Patient #3 received the physician ordered blood transfusion.

An interview conducted on 08/17/2016 at 2:00 p.m. with the Nursing Manager confirmed the above findings.

2. Review of Patient #8's medical record showed a physician order for STAT (immediate) blood transfusion on 08/13/2016 at 8:45 p.m. Further review of the record showed the blood transfusion began on 08/14/2016 at 4:21 a.m., 7 hours and 36 minutes after the STAT order was received.

Review of the facility a policy and procedure titled "Turn-Around-Time Procedure" showed the laboratory will process samples for testing in order to accommodate customer expectation in meeting required turn-around times (TAT) for quality patient care and expected outcomes. If the testing is delayed, a notification to the patient care area will occur. Further review of the policy revealed blood components should be administered based on the order status of the component.

An interview on 08/17/2016 at 1:00 p.m. with Physician (A) stated a STAT blood transfusion should be given immediately and if delayed beyond an hour the ordering physician should be notified.

An interview on 08/17/2016 at 1:05 p.m. with Physician (B) stated a STAT blood transfusion should be given right away and if delayed beyond an hour the physician should be notified.

A detailed review of the record revealed no documentation of physician notification.

An interview conducted on 08/17/2016 at 2:00 p.m. with the Nursing Manager confirmed the above findings