The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

METROPOLITAN HOSPITAL OF MIAMI 5959 NW 7TH ST MIAMI, FL April 27, 2012
VIOLATION: QAPI Tag No: A0263
The facility was determined to be out of compliance with 42 CFR 482.21 Conditions of Participation for Quality Assessment and Performance Improvement Program based on the facility's failure to: 1) provide an ongoing program that shows measurable improvement, 2) to measure, analyze and track quality indicators of adverse patient events and other aspects of performance that assesses processes of care, hospital services and operations.
Refer to A-0265 and A-0267.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to provide an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes.

The findings include:

Review of sample patient #1 revealed that on 3/7/12 at 12:50 p.m. the physician wrote an order for Vitamin K 25 milligrams with 150 milliliters of normal saline intravenously over one hour. On 3/7/12 at 3:42 p.m. the physician ordered to discharge the Vitamin K order and transfuse 2 units of fresh frozen plasma. Further review of sample patient #1 revealed that on 3/7/12 at 4:30 p.m. the physician ordered 2 units of packed red blood cells to be transfused "today". Documentation revealed that one unit of blood was administered at 8 p.m. on 3/7/12 and the second unit began at 12:30 a.m. on 3/8/12. Documentation in the record revealed that the fresh frozen plasma was never administered. Sample patient #1 expired on [DATE] before finishing the second unit of packed red blood cells.

Interview with the Chief Compliance Officer on 4/25/12 at 10:07 a.m revealed that there was no quality improvement plan put in to place after the incident with sample patient #1 neither for the scanned orders not being received in the pharmacy or the death of the patient.

Interview with the Director of the Pharmacy on 4/25/12 at 1:40 p.m. revealed that he was aware of the situation with sample patient #1. The Director of the Pharmacy stated that the initial order was written by the physician at 12:50 p.m., the order was then scanned to the pharmacy and documented as scanned at 1:15p.m. At approximately 2 p.m. the nurse from the emergency department called the pharmacy asking about the whereabouts of the Vitamin K and was told by the pharmacist that the order was never received. The order was to be re-scanned to the pharmacy. The Director of the Pharmacy stated that at 3:15p.m. the Director of the Emergency Department called the pharmacist in search of the Vitamin K order and was told that Vitamin K was on national back order. The Director of the Emergency Department asked the pharmacist what could be given as a substitute and the pharmacist replied "blood." The Director of Pharmacy stated that the scanning system has had some previous issues where all the pages do not go through and this is what must have happened on this event. Furthermore he stated that there were three pages to be scanned to pharmacy for sample patient #1 and only two pages went through. The Director of the Pharmacy provided documentation that showed two pages (medication reconciliation and one page orders) received in the pharmacy on 3/7/12 at 1:17 p.m. The third page was received in the pharmacy at 3:36 p.m. The Director of the Pharmacy stated that the pharmacy staff is unaware of how many pages the units are scanning so they would not know if a page is missing. The surveyor asked the Director of Pharmacy was has been done to ensure this type incident does not happen again and the Director of the Pharmacy stated "I have contacted [pharmacy software manufacturer] regarding how we can confirm that all orders are scanned through to the pharmacy." Furthermore the Director of the Pharmacy stated that no other plans have been put in to place to avoid scanning errors in the future. The Director of the Pharmacy stated that the problem could be easily fixed by requiring the nurses and secretaries to scan one page at a time but at this time nothing has been put in to policy.

The facility was unable to provide the surveyor with information regarding the facility's identifying and reviewing the patient's death, potential care issues associated with the patient death and the delay of pharmacy ordered medications and administration of blood products to the patient.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to measure, analyze and track quality indicators of adverse patient events and other aspects of performance that assesses processes of care, hospital services and operations.

The findings include:

Review of sample patient #1 revealed that on 3/7/12 at 12:50 p.m. the physician wrote an order for Vitamin K 25 milligrams with 150 milliliters of normal saline intravenously over one hour. On 3/7/12 at 3:42 p.m. the physician ordered to discharge the Vitamin K order and transfuse 2 units of fresh frozen plasma. Further review of sample patient #1 revealed that on 3/7/12 at 4:30 p.m. the physician ordered 2 units of packed red blood cells to be transfused "today". Documentation revealed that one unit of blood was administered at 8 p.m. on 3/7/12 and the second unit began at 12:30 a.m. on 3/8/12. Documentation in the record revealed that the fresh frozen plasma was never administered. Sample patient #1 expired on [DATE] before finishing the second unit of packed red blood cells.

Interview with the Chief Compliance Officer on 4/25/12 at 10:07 a.m revealed that there was no quality improvement plan put in to place after the incident with sample patient #1 neither for the scanned orders not being received in the pharmacy or the death of the patient.

Interview with the Director of the Pharmacy on 4/25/12 at 1:40 p.m. revealed that he was aware of the situation with sample patient #1. The Director of the Pharmacy stated that the initial order was written by the physician at 12:50 p.m., the order was then scanned to the pharmacy and documented as scanned at 1:15p.m. At approximately 2 p.m. the nurse from the emergency department called the pharmacy asking about the whereabouts of the Vitamin K and was told by the pharmacist that the order was never received. The order was to be re-scanned to the pharmacy. The Director of the Pharmacy stated that at 3:15p.m. the Director of the Emergency Department called the pharmacist in search of the Vitamin K order and was told that Vitamin K was on national back order. The Director of the Emergency Department asked the pharmacist what could be given as a substitute and the pharmacist replied "blood." The Director of Pharmacy stated that the scanning system has had some previous issues where all the pages do not go through and this is what must have happened on this event. Furthermore he stated that there were three pages to be scanned to pharmacy for sample patient #1 and only two pages went through. The Director of the Pharmacy provided documentation that showed two pages (medication reconciliation and one page orders) received in the pharmacy on 3/7/12 at 1:17 p.m. The third page was received in the pharmacy at 3:36 p.m. The Director of the Pharmacy stated that the pharmacy staff is unaware of how many pages the units are scanning so they would not know if a page is missing. The surveyor asked the Director of Pharmacy was has been done to ensure this type incident does not happen again and the Director of the Pharmacy stated "I have contacted [pharmacy software manufacturer] regarding how we can confirm that all orders are scanned through to the pharmacy." Furthermore the Director of the Pharmacy stated that no other plans have been put in to place to avoid scanning errors in the future. The Director of the Pharmacy stated that the problem could be easily fixed by requiring the nurses and secretaries to scan one page at a time but at this time nothing has been put in to policy.

An interview was conducted with the Director of the Pharmacy on 4/27/12 at 10:53 a.m. the Director informed the surveyor that there was not a policy in place at this time regarding how to resolve the scanning issue that some documents do not go through to the pharmacy. The Director stated there have been previous incidents with the same issue of not all scanned documents from the nursing units arriving in the pharmacy. The Director of the Pharmacy stated that for sample patient #1 an incident report was not filed because it was caught in a timely manner but on other occasions an incident report was filed.

A copy of an incident report dated 4/11/11 revealed sample patient # 10 had a physician order dated 4/11/11 at 8 a.m. for Prednisone 20 milligrams by mouth daily. The order was never scanned to the pharmacy and consequently never entered into the patient's profile. The ordering physician found that the medication had never been given on 4/13/11. The action taken on the incident report was "The Pharmacy Director has looked at the incident and reviewed the role the pharmacy department played in the patient missing the medication and determined their was nothing else the Pharmacy could have done to avoid this error." There is no further documentation on this incident.

The facility was unable to provide the surveyor with information regarding the facility's identifying and reviewing the patient's death, potential care issues associated with the patient death and the delay of pharmacy ordered medications and administration of blood products to the patient.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to measure, analyze and track quality indicators of adverse patient events and other aspects of performance that assesses processes of care, hospital services and operations.

The findings include:

Review of sample patient #1 revealed that on 3/7/12 at 12:50 p.m. the physician wrote an order for Vitamin K 25 milligrams with 150 milliliters of normal saline intravenously over one hour. On 3/7/12 at 3:42 p.m. the physician ordered to discharge the Vitamin K order and transfuse 2 units of fresh frozen plasma. Further review of sample patient #1 revealed that on 3/7/12 at 4:30 p.m. the physician ordered 2 units of packed red blood cells to be transfused "today". Documentation revealed that one unit of blood was administered at 8 p.m. on 3/7/12 and the second unit began at 12:30 a.m. on 3/8/12. Documentation in the record revealed that the fresh frozen plasma was never administered. Sample patient #1 expired on [DATE] before finishing the second unit of packed red blood cells.

Interview with the Chief Compliance Officer on 4/25/12 at 10:07 a.m revealed that there was no quality improvement plan put in to place after the incident with sample patient #1 neither for the scanned orders not being received in the pharmacy or the death of the patient.

Interview with the Director of the Pharmacy on 4/25/12 at 1:40 p.m. revealed that he was aware of the situation with sample patient #1. The Director of the Pharmacy stated that the initial order was written by the physician at 12:50 p.m., the order was then scanned to the pharmacy and documented as scanned at 1:15p.m. At approximately 2 p.m. the nurse from the emergency department called the pharmacy asking about the whereabouts of the Vitamin K and was told by the pharmacist that the order was never received. The order was to be re-scanned to the pharmacy. The Director of the Pharmacy stated that at 3:15p.m. the Director of the Emergency Department called the pharmacist in search of the Vitamin K order and was told that Vitamin K was on national back order. The Director of the Emergency Department asked the pharmacist what could be given as a substitute and the pharmacist replied "blood." The Director of Pharmacy stated that the scanning system has had some previous issues where all the pages do not go through and this is what must have happened on this event. Furthermore he stated that there were three pages to be scanned to pharmacy for sample patient #1 and only two pages went through. The Director of the Pharmacy provided documentation that showed two pages (medication reconciliation and one page orders) received in the pharmacy on 3/7/12 at 1:17 p.m. The third page was received in the pharmacy at 3:36 p.m. The Director of the Pharmacy stated that the pharmacy staff is unaware of how many pages the units are scanning so they would not know if a page is missing. The surveyor asked the Director of Pharmacy was has been done to ensure this type incident does not happen again and the Director of the Pharmacy stated "I have contacted [pharmacy software manufacturer] regarding how we can confirm that all orders are scanned through to the pharmacy." Furthermore the Director of the Pharmacy stated that no other plans have been put in to place to avoid scanning errors in the future. The Director of the Pharmacy stated that the problem could be easily fixed by requiring the nurses and secretaries to scan one page at a time but at this time nothing has been put in to policy.

An interview was conducted with the Director of the Pharmacy on 4/27/12 at 10:53 a.m. the Director informed the surveyor that there was not a policy in place at this time regarding how to resolve the scanning issue that some documents do not go through to the pharmacy. The Director stated there have been previous incidents with the same issue of not all scanned documents from the nursing units arriving in the pharmacy. The Director of the Pharmacy stated that for sample patient #1 an incident report was not filed because it was caught in a timely manner but on other occasions an incident report was filed.

A copy of an incident report dated 4/11/11 revealed sample patient # 10 had a physician order dated 4/11/11 at 8 a.m. for Prednisone 20 milligrams by mouth daily. The order was never scanned to the pharmacy and consequently never entered into the patient's profile. The ordering physician found that the medication had never been given on 4/13/11. The action taken on the incident report was "The Pharmacy Director has looked at the incident and reviewed the role the pharmacy department played in the patient missing the medication and determined their was nothing else the Pharmacy could have done to avoid this error." There is no further documentation on this incident.

The facility was unable to provide the surveyor with information regarding the facility's identifying and reviewing the patient's death, potential care issues associated with the patient death and the delay of pharmacy ordered medications and administration of blood products to the patient.
VIOLATION: NURSING SERVICES Tag No: A0385
The facility was determined to be out of compliance with 42 CFR 482.23 Conditions of Participation for Nursing Services based on the facility's failure to: 1) provide nursing care plans that are consistent with the attending physician's plan for medical care and are revised as the needs of the patient change, 2) administer blood products as ordered by the physician.

Refer to A-0396 and A-0405.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to ensure that nursing care plans are consistent with the attending physician's plan for medical care and are revised as the needs of the patient change.

The findings include:

Record review of sample patient #1 revealed that the patient was admitted on [DATE] with a gastrointestinal bleed. On 3/7/12 at 3:42 p.m. the physician ordered 2 units of fresh frozen plasma. On 3/7/12 at at 4:30 p.m. the physician ordered 2 units of packed red blood cells to be transfused today. The blood bank documented they contacted sample patient #1's nurse at 5:50 pm to notify the blood was ready. Documentation revealed that sample patient #1 received the first unit of packed red blood cells from 8p.m. until midnight. The second unit of packed red blood cells was began at 12:30 a.m. on 3/8/12. The 2nd unit was never completed, the patient expired.

Record review of sample patient #2 revealed that the patient was admitted for blood in both the stool and emesis on 3/12/12. The diagnosis noted was acute gastritis with upper gastrointestinal bleeding. Hematology report dated 3/14/12 revealed sample patient #2's hemoglobin was "7.7g/dL[grams per deciliter]" at 6 a.m. and "reference range 14.0 - 18.0 g/dL[grams per deciliter]." On 3/14/12 at 8:50 a.m. the physician ordered "T + C [type and cross] 3 units packed cells +[and] transfuse early today." The order was stamped scanned at 9:02 a.m. on 3/14/12. Documentation revealed that sample patient #2 had been type and crossed on 3/12/12 at 6:01 pm so an additional type and cross was not completed. The blood bank documented that the nurse of sample patient #2 was notified the 3 units of packed red blood cells were ready at 12:10pm on 3/14/12 (3 hours and 20 minutes after the physician ordered and 3 hours and 8 minutes after the order had been scanned.) Documentation revealed that the first unit of packed red blood cells began transfusing at 2:30p.m. (5 hours and 40 minutes after the physician wrote the order and 2 hour and 20 minutes after the blood bank had notified that the packed red blood cells were ready) and did not finish until 7:30 p.m., the second unit began on 3/15/12 at 12:05 a.m. and finished at 3:35 a.m. and the third unit began on 3/15/12 at 4:45 a.m. finishing at 8:30 a.m. ( 23 hours and 40 minutes after the physician wrote the order.)

Record review of sample patient #4 revealed that the patient was admitted for blood in the stool on 3/2/12. On 3/9/12 at 11:30 a.m. the physician wrote an order to "Transfuse 2 PRBC's [packed red blood cells] today". The order is stamped as scanned at 12:20 p.m. Documentation revealed that the specimen for type and cross was received in the blood bank at 6:04 pm and the blood bank notified the nurse of sample patient #4 at 6:45 pm that the 2 units of packed red blood cells were ready. The transfusion record revealed that the first unit of packed red blood cells began infusing the following day (3/10/12) at 2 a.m. and the 2nd unit began infusing at 8:50 a.m. Documentation revealed that the 2nd unit finished infusing at 12:35pm on 3/10/12 (25 hours and 5 minutes after the physician's order to transfuse today.)

Interview with the Director of Inpatient Services on 4/26/12 at 12:10 p.m. revealed that she could find no reason for the delay in administering the blood products on sample patient #2 and #4. The Director of Inpatient Services stated that there were no time parameters in place for following a physician's routine orders. Furthermore, she was not able to explain why the nurses had not transfused the units of packed blood cells as ordered by the physicians "....today." On sample patient #4 the Director of Inpatient Services pointed out that the blood was ready and called to the nurse at 6:45 pm which is only 15 minutes before shift change. The Director of Inpatient Services stated that the 7am-7pm nurse probably reported to the 7pm-7am to administer the blood. Furthermore the Director of Inpatient Services stated that the 7p-7a would have to assess his/her patients and pass medications before beginning the blood. The Director of Inpatient Services stated she had no documentation or evidence this is what happened she was only speculating based on nursing experience.

Record review of sample patient #5 revealed that the patient was admitted for severe anemia on 3/6/12. On 3/10/12 at 2:10 pm the physician wrote an order "Type and transfuse 2 units PRBC [packed red blood cells] each to run @ [at] 3 hrs [hours]." Documentation revealed that the specimen for type and cross was received in the laboratory on 3/10/12 at 5:46 p.m. and the packed red cells were ready and the nurse notified at 6:41 p.m. The first unit of packed red blood cells began transfusing on 3/10/12 at 11:30 p.m. and the 2nd unit of packed red blood cells were begun on 3/11/12 at 5:35 a.m.

Record review of sample patient #8 revealed the patient was admitted on [DATE] for malignant neoplasm of the breast. On 3/5/12 at 11:30 a.m. the physician ordered "give 4 units FFP [fresh frozen plaza] today." The times the 4 units of fresh frozen were began were 3/5/12 at 5:50pm, 3/6/12 at 2:20 a.m., 3/6/12 at 3:40 a.m. and 3/6/12 at 6:10 a.m.

Interview with the Chief Nursing Officer on 4/26/12 at 10 a.m. revealed that there are no time parameters in place for following through a routine order. The Chief Nursing Officer stated that the only time parameters on following out a physicians order are on STAT orders.

Interview with the Chief Nursing Officer on 4/27/12 at 12:30 p.m. confirmed that the facility has no policy in place for the timeliness of following through a routine physician order. The Chief Nursing Officer stated "no one in the community has policy on time parameters, only for STAT orders. I have called several other facilities."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to administer blood products as ordered by the physician in 5 of 10 sampled patients (#1, #2, #4, #5, #8).

The findings include:

Record review of sample patient #1 revealed that the patient was admitted on [DATE] with a gastrointestinal bleed. On 3/7/12 at 3:42 p.m. the physician ordered 2 units of fresh frozen plasma. On 3/7/12 at at 4:30 p.m. the physician ordered 2 units of packed red blood cells to be transfused today. The blood bank documented they contacted sample patient #1's nurse at 5:50 pm to notify the blood was ready. Documentation revealed that sample patient #1 received the first unit of packed red blood cells from 8p.m. until midnight. The second unit of packed red blood cells began at 12:30 a.m. on 3/8/12. The 2nd unit was never completed, the patient expired.

Record review of sample patient #2 revealed that the patient was admitted for blood in both the stool and emesis on 3/12/12. The diagnosis noted was acute gastritis with upper gastrointestinal bleeding. Hematology report dated 3/14/12 revealed sample patient #2's hemoglobin was "7.7g/dL[grams per deciliter]" at 6 a.m. and "reference range 14.0 - 18.0 g/dL[grams per deciliter]." On 3/14/12 at 8:50 a.m. the physician ordered "T + C [type and cross] 3 units packed cells +[and] transfuse early today." The order was stamped scanned at 9:02 a.m. on 3/14/12. Documentation revealed that sample patient #2 had been type and crossed on 3/12/12 at 6:01 pm so an additional type and cross was not completed. The blood bank documented that the nurse of sample patient #2 was notified the 3 units of packed red blood cells were ready at 12:10pm on 3/14/12 (3 hours and 20 minutes after the physician ordered and 3 hours and 8 minutes after the order had been scanned.) Documentation revealed that the first unit of packed red blood cells began transfusing at 2:30p.m. (5 hours and 40 minutes after the physician wrote the order and 2 hour and 20 minutes after the blood bank had notified that the packed red blood cells were ready) and did not finish until 7:30 p.m., the second unit began on 3/15/12 at 12:05 a.m. and finished at 3:35 a.m. and the third unit began on 3/15/12 at 4:45 a.m. finishing at 8:30 a.m. ( 23 hours and 40 minutes after the physician wrote the order.)

Record review of sample patient #4 revealed that the patient was admitted for blood in the stool on 3/2/12. On 3/9/12 at 11:30 a.m. the physician wrote an order to "Transfuse 2 PRBC's [packed red blood cells] today". The order is stamped as scanned at 12:20 p.m. Documentation revealed that the specimen for type and cross was received in the blood bank at 6:04 pm and the blood bank notified the nurse of sample patient #4 at 6:45 pm that the 2 units of packed red blood cells were ready. The transfusion record revealed that the first unit of packed red blood cells began infusing the following day (3/10/12) at 2 a.m. and the 2nd unit began infusing at 8:50 a.m. Documentation revealed that the 2nd unit finished infusing at 12:35pm on 3/10/12 (25 hours and 5 minutes after the physician's order to transfuse today.)

Interview with the Director of Inpatient Services on 4/26/12 at 12:10 p.m. revealed that she could find no reason for the delay in administering the blood products on sample patient #2 and #4. The Director of Inpatient Services stated that there were no time parameters in place for following a physician's routine orders. Furthermore, she was not able to explain why the nurses had not transfused the units of packed blood cells as ordered by the physicians "....today." On sample patient #4 the Director of Inpatient Services pointed out that the blood was ready and called to the nurse at 6:45 pm which is only 15 minutes before shift change. The Director of Inpatient Services stated that the 7am-7pm nurse probably reported to the 7pm-7am to administer the blood. Furthermore the Director of Inpatient Services stated that the 7p-7a would have to assess his/her patients and pass medications before beginning the blood. The Director of Inpatient Services stated she had no documentation or evidence this is what happened she was only speculating based on nursing experience.

Record review of sample patient #5 revealed that the patient was admitted for severe anemia on 3/6/12. On 3/10/12 at 2:10 pm the physician wrote an order "Type and transfuse 2 units PRBC [packed red blood cells] each to run @ [at] 3 hrs [hours]." Documentation revealed that the specimen for type and cross was received in the laboratory on 3/10/12 at 5:46 p.m. and the packed red cells were ready and the nurse notified at 6:41 p.m. The first unit of packed red blood cells began transfusing on 3/10/12 at 11:30 p.m. and the 2nd unit of packed red blood cells were begun on 3/11/12 at 5:35 a.m.

Record review of sample patient #8 revealed the patient was admitted on [DATE] for malignant neoplasm of the breast. On 3/5/12 at 11:30 a.m. the physician ordered " give 4 units FFP [fresh frozen plaza] today." The times the 4 units of fresh frozen were began were 3/5/12 at 5:50pm, 3/6/12 at 2:20 a.m., 3/6/12 at 3:40 a.m. and 3/6/12 at 6:10 a.m.

Interview with the Chief Nursing Officer on 4/26/12 at 10 a.m. revealed that there are no time parameters in place for following through a routine order. The Chief Nursing Officer stated that the only time parameters on following out a physicians order are on STAT orders.

Interview with the Chief Nursing Officer on 4/27/12 at 12:30 p.m. confirmed that the facility has no policy in place for the timeliness of following through a routine physician order. The Chief Nursing Officer stated "no one in the community has policy on time parameters. only for STAT orders. I have called several other facilities."
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
The facility was determined to be out of compliance with 42 CFR 482.25 Conditions of Participation for Pharmaceutical Services based on the facility's failure to: 1) provide pharmacy supervision to develop, supervise and coordinate all activities of the pharmacy.

Refer to A-0492.
VIOLATION: PHARMACIST RESPONSIBILITIES Tag No: A0492
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to provide pharmacy supervision that developed, supervised and coordinated all activities of the pharmacy.

The findings include:

Review of sample patient #1 revealed that on 3/7/12 at 12:50 p.m. the physician wrote an order for Vitamin K 25 milligrams with 150 milliliters of normal saline intravenously over one hour. On 3/7/12 at 3:42 p.m. the physician ordered to discharge the Vitamin K order and transfuse 2 units of fresh frozen plasma. Documentation in the record revealed that the fresh frozen plasma was never administered and sample patient #1 expired on [DATE].

Interview with the Director of the Pharmacy on 4/25/12 at 1:40 p.m. revealed that he was aware of the situation with sample patient #1. The Director of the Pharmacy stated that the initial order was written by the physician at 12:50 p.m., the order was then scanned to the pharmacy and documented as scanned at 1:15p.m. At approximately 2 p.m. the nurse from the emergency department called the pharmacy asking about the whereabouts of the Vitamin K and was told by the pharmacist that the order was never received. The order was to be re-scanned to the pharmacy. The Director of the Pharmacy stated that at 3:15p.m. the Director of the Emergency Department called the pharmacist in search of the Vitamin K order and was told that Vitamin K was on national back order. The Director of the Emergency Department asked the pharmacist what could be given as a substitute and the pharmacist replied "blood." The Director of Pharmacy stated that the scanning system has had some previous issues where all the pages do not go through and this is what must have happened on this event. Furthermore he stated that there were three pages to be scanned to pharmacy for sample patient #1 and only two pages went through. The Director of the Pharmacy provided documentation that showed two pages (medication reconciliation and one page orders) received in the pharmacy on 3/7/12 at 1:17 p.m. The third page was received in the pharmacy at 3:36 p.m. The Director of the Pharmacy stated that the pharmacy staff is unaware of how many pages the units are scanning so they would not know if a page is missing. The surveyor asked the Director of Pharmacy was has been done to ensure this type incident does not happen again and the Director of the Pharmacy stated "I have contacted [pharmacy software manufacturer] regarding how we can confirm that all orders are scanned through to the pharmacy." Furthermore the Director of the Pharmacy stated that no other plans have been put in to place to avoid scanning errors in the future. The Director of the Pharmacy stated that the problem could be easily fixed by requiring the nurses and secretaries to scan one page at a time but at this time nothing has been put in to policy.
VIOLATION: WRITTEN DESCRIPTION OF SERVICES Tag No: A0584
Based on record review and interview the facility failed to ensure that the written description of laboratory services timelines was followed by laboratory staff in 2 of 10 (#2, #4) sampled patients.

The findings include:

Record review of sample patient #2 revealed that the patient was admitted for blood in both the stool and emesis on 3/12/12. The diagnosis noted was acute gastritis with upper gastrointestinal bleeding. Hematology report dated 3/14/12 revealed sample patient #2's hemoglobin was "7.7g/dL[grams per deciliter]" at 6 a.m. and "reference range 14.0 - 18.0 g/dL[grams per deciliter]." On 3/14/12 at 8:50 a.m. the physician ordered "T + C [type and cross] 3 units packed cells +[and] transfuse early today." The order was stamped scanned at 9:02 a.m. on 3/14/12. Documentation revealed that sample patient #2 had been type and crossed on 3/12/12 at 6:01 pm so an additional type and cross was not completed. The blood bank documented that the nurse of sample patient #2 was notified the 3 units of packed red blood cells were ready at 12:10pm on 3/14/12 (3 hours and 20 minutes after the physician ordered and 3 hours and 8 minutes after the order had been scanned.)

Record review of sample patient #4 revealed that the patient was admitted for blood in the stool on 3/2/12. On 3/9/12 at 11:30 a.m. the physician wrote an order to "Transfuse 2 PRBC's [packed red blood cells] today". The order is stamped as scanned at 12:20 p.m. Documentation revealed that the specimen for type and cross was received in the blood bank at 6:04 pm and the blood bank notified the nurse of sample patient #4 at 6:45 pm that the 2 units of packed red blood cells were ready.

Review of facility policy for "Transfusion Service Turn Around Time" reads routine transfusion service request "approximate time of completion after receipt of specimens 2-3 hours."

Interview with the Chief Nursing Officer on 4/26/12 at 10 a.m. revealed that there are no time parameters in place for following through a routine order. The Chief Nursing Officer stated that the only time parameters on following out a physicians order are on STAT orders.

Interview with the Director of Inpatient Services on 4/26/12 at 12:10 p.m. revealed that there is no policy on timeliness that staff have to follow out physician orders. The Director of Inpatient Services stated she could see where the delay was and that the facility would need to look at implementing a policy for time frames of blood orders.