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.

CHRISTUS SOUTHEAST TEXAS- ST ELIZABETH 2830 CALDER AVENUE BEAUMONT, TX 77702 Sept. 20, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview the facility failed to

A. administer and document the blood and blood products according to the facility policy. Review of transfusion clinical records revealed 15 of 15 (1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 17, and 18) patient records had missing documentation. Nursing failed to follow physicians' order for transfusion of blood on 2 (#1 and #18) of 15 (#2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 17, and 18) clinical transfusion records.

Refer to Tag A405 and A409




B. Follow physicians' order for the safe administration of Total Parenteral Nutrition(TPN) to 10 of 10 patients.
Refer to Tag 405 and 144

C. Follow physicians' order for the safe administration of IV fluids for 1 of 10 patients.
Refer to Tag 405 and 144

D. Follow facility's own policy for providing IV fluids as a substitute for TPN for 1 of 10 patient.
Refer to Tag 405 and 144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview the facility failed to:

A. administer and document the blood and blood products according to the facility policy. Review of transfusion clinical records 15 of 15 (#1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 17, and 18) revealed patient records had missing documentation according to the facility policy on administration of blood and blood products.

Review of policy titled: "ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS (WHOLE. PACKED CELLS/LEUKOCYTE POOR RED CELLS, PLASMA. FRESH FROZEN PLASMA. CRYOPRECIPITATE)" Date Adopted: 06/05 Date Reviewed: 08/06 Date Revised: 01/12

POLICY:
1. Blood and blood products will be administered according to physician order. Obtain
consent prior to administration [with the exception of emergency situations (life/death)].
2. Blood and blood components may be administered by peripheral route, central line,
(umbilical artery catheter. and an umbilical vein catheter in pediatrics).
3. Two licensed personnel (RN. LVN, pump technician and/or physician) with one being a RN, must identify blood products prior to administration.

PROCEDURE:
1. Obtain permit or have patient sign refusal of blood permit.
7. At patient bedside, two nurses (one being an RN) must check the name, medical record
number, physician order, blood bank bracelet number, unit number, unit ABO/Rh, patient
ABORh checked, patient arm I.D. band, unit labels, and unit crossmatch tag, including
expiration dates. Sign transfusion record (STE/STM). The unit bag tag should remain
attached to the bag at all times. If a discrepancy exists, contact the Blood Bank.
10. Take patient's blood pressure, pulse, temperature, and respirations. RN to obtain pre
transfusion information to include: IV site, lungs, skin (hives/rash) and urinary output.
RN should record vital signs and physical data before initiation of transfusion.
Assessment by the RN must be done before and after each unit is administered.
12. Insert blood tubing spike into the blood bag. Administration sets that are used for blood
and blood components shall be changed after administration of each unit or at the end of
4 hours, whichever comes first.
14. Open clamp to allow blood to infuse at a slow rate the first 5 minutes. If no reaction,
increase flow rate.
15. If the rate not ordered, infuse over 2 to 4 hours but no longer than 4 hours, with the
exception of specialty areas (i.e.. E.R, ICU's, Surgery, Recovery, Dialysis) where infusion
rate can be faster, based on patient condition. Infusion should be completed 4 hours from
the time of issue from the Blood Bank. Blood should never infuse longer than 4 hours
due to bacterial growth and red cell hemolysis.
16. Blood and components must be completed by expiration date and time, as indicated on
the label.
17. The RN will observe the patient closely for adverse reactions for the first 50 ml or
approximately 15 minutes, since most [DIAGNOSES REDACTED] transfusion reactions occur in this initial
time. In pediatric patients, observe approximately 15 minutes.
a. Monitor patient throughout transfusion therapy for symptoms or signs:
? For a temperature increases of 2 degrees notify the MD and lab (most common reaction being fever and chills).
? Other transfusion reaction symptoms as noted but not limited to: Oliguria, hemoglobinuria, shock, [DIAGNOSES REDACTED], Jaundice, emboli, allergic reactions, circulatory overload, hypothermia, hyperkalemia, urticaria/hives, chest pain, respiratory distress.
b. Temperature, pulse, respirations, blood pressure, will be recorded
preadministration and at approximately 15 minutes and/or 50 m1 and at completion
of the transfusion.
18. If transfusion reaction occurs, stop transfusion immediately, maintain patent IV. Send
blood and saline tubing and urine sample to Lab with a completed transfusion reaction
form (obtain form from the lab). Notify physician and Blood Bank of reaction.
19. If no reaction is present: After completion of unit of blood, flush intravenous line with
normal saline, discontinue the IV unless further therapy is indicated. If the IV is to be
continued, remove empty blood container and tubing and hang appropriate solution with
new tubing. RN to reassess after completed.

DOCUMENTATION:
A. Obtain permit.
B. Transfusion Record /Documentation in Patient's Medical Record:
1. unit number
2. signatures of individuals verifying correctness (one must be a RN).
3. vital signs
4. physical assessment of IV site, lungs, urine output, presence or absence of
rash/hives before and after each unit.
5. Tubing change
6. Presence or absence of transfusion reaction
7. Size of IV catheter
8. type and amount of blood product
9. patient's response

There were 3 (#9,#10 and #11) current clinical records of blood transfusions reviewed and 12 (# 1, 2, 3, 4, 5, 6, 7, 12, 13, 14, 17, and 18) closed transfusion records reviewed. The clinical records reviewed covered dates from 02/21/2012 through 09/20/2012.

Review of patient #1's closed record revealed, on the 4th and 5th units of blood, the permit for transfusing blood was not documented. The record requires permit obtained yes or no; the documentation was left blank. On the third, fourth and fifth units of blood, the blood tubing change was not documented. The policy requires "administration sets that are used for blood and blood components shall be changed after administration of each unit or at the end of 4 hours, whichever comes first." The pre-transfusion documentation requires Hgb(hemoglobin), date, and time to be documented. The date and time documentation was left blank on both units. On the 5th unit the vital signs (temperature, pulse, respiratory rate, and blood pressure) after 50cc or 15 minutes of when the blood transfusion was started were not documented and the nurses' signature was left blank. Also the post transfusion vital signs (temperature, pulse, respiratory rate, and blood pressure) were not documented. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction, nd the documentation for the post blood assessment transfusion form was left blank.

Review of patient #2's closed transfusion record revealed, on the 1st unit of blood, the permit for transfusing blood was not documented. The record requires permit obtained yes or no, the documentation was left blank. The post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The post blood assessment transfusion form was left blank.

Review of 2nd unit of blood revealed the record requires vital signs after 50cc or 15 minutes after the blood has been started, the time, temperature, pulse, respiratory rate, blood pressure, and observed by the registered nurse signature is to be documented. This information was left blank. The post transfusion patient temperature was left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The urinary output was left blank. Review of patient #2's records of transfused units of blood (which was a total of eleven units), revealed the transfusion record requires documentation the blood tubing is changed yes or no; there was no documentation in the record of 5th, 6th, 7th, 8th, 9th, 10th, and 11th units of blood, that the blood tubing was changed.

Review of 10th unit of blood, the permit for transfusing blood was not documented, this area was left blank. The IV (intravenous) site, size, and type were left blank. The blood transfusion assessment requires assessment of the lungs, skin (hives/rash), and urinary output prior to transfusion. This documentation was left blank. The pre-transfusion documentation requires Hb (hemoglobin) date, and time to be documented and the information was left blank.

Review of 11th unit of blood, the permit for transfusing blood was not documented on the transfusion form. The IV (intravenous) site, size, and type were left blank. The pre-transfusion assessment requires assessment of the lungs, skin (hives/rash), and urinary output, this documentation was left blank. The pre transfusion documentation requires Hb (hemoglobin) date, and time to be documented and the information was left blank. The post transfusion temperature, pulse, respiratory rate, and blood pressure were left blank.

Review of patient #3's closed transfusion record revealed, on the 2nd unit of blood transfused the post transfusion time, temperature, pulse, respiratory rate, and blood pressure were blank. Review of the 2nd unit of blood, the documentation on the record tubing changed, yes or no. The information was left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The post blood assessment transfusion form was left blank.

Review of patient #4's closed transfusion record revealed, on the 1st unit of blood the IV (intravenous) size and type were left blank and the post transfusion vital signs to be documented, the temperature was left blank. The blood tubing was to be changed after 1st unit of blood, the documentation on the record- tubing changed yes or no; the information was left blank. The post blood assessment transfusion form has assessment about lungs, skin, urinary output, and if the patient has had a blood reaction. On the 1st unit of blood the post blood assessment transfusion documentation concerning the urinary output and the blood reaction was left blank.

Review of the 2nd unit of blood, the type of blood product to be given was left blank. The blood tubing was to be changed after 2nd unit of blood, the documentation on the record- tubing changed yes or no; the information was left blank.

Review of the 3rd unit of blood the blood tubing was to be changed, the documentation on the record- tubing changed yes or no; the information was left blank.

Review of the 4th unit of blood permit obtained yes or no; the documentation was covered by a blood sticker with no documentation if a permit was obtained for the blood transfusion. The transfusion record revealed documentation for the type of blood product to be given was left blank. There was no documented date of when the 4th unit of blood was given. The blood tubing was to be changed after 4th unit of blood, the documentation on the record-tubing changed yes or no; the information was left blank.

Review of patient #5's closed transfusion record of the 1st and 2nd unit of blood given revealed, blood tubing changed yes or no; this information was left blank. The policy requires "administration sets that are used for blood and blood components shall be changed after administration of each unit or at the end of 4 hours, whichever comes first."

Review of patient #6's closed transfusion record of the 1st unit of blood given revealed, the IV (intravenous) site, size and type was left blank. The pre-transfusion documentation requires Hb (hemoglobin) date, and time. The date and time were left blank. The post transfusion vital signs were scratched out and the time and temperature were missing. The 2nd unit of blood the permit for transfusing blood was not documented, the record requires permit obtained yes or no; this information was left blank. The IV (intravenous) site, size, and type were left blank. The pre transfusion documentation requires Hb (hemoglobin) date, and time; the date and time were left blank. The 3rd unit of blood the permit for transfusing blood was not documented, the record requires permit obtained yes or no; this information was left blank. The record requires documentation that blood tubing is changed, yes or no; the documentation was left blank.

Review of patient #7's closed transfusion record revealed, on the 1st unit of blood, the record requires documentation that blood tubing is changed; yes or no. The documentation was left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The post blood assessment transfusion form was left blank.

Review of the 2nd unit of blood, the Registered Nurse failed to sign the pre-assessment form before the transfusion of blood was started. Also on the 2nd unit of blood the pre-transfusion documentation requires Hb (hemoglobin), date, and time. The time documentation was left blank. The Registered Nurse failed to sign the assessment form during the transfusion of blood. The post transfusion vital signs were left blank, when the transfusion was completed. The record requires documentation that blood tubing is changed, yes or no; the documentation was left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The post blood assessment transfusion form was left blank.

The 4th unit of blood documentation was missing the pre transfusion documentation which requires Hb (hemoglobin), date, and time. The record requires documentation that blood tubing is changed, yes or no. The documentation was left blank. The policy requires "administration sets that are used for blood and blood components shall be changed after administration of each unit or at the end of 4 hours, whichever comes first."

After the 6th unit of blood the record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

On the 7th unit of blood the unit number of the blood was not documented prior to giving the blood. Again the record requires documentation that blood tubing is changed, yes or no; the documentation was left blank.

On the 8th unit of blood the permit for transfusing blood was not documented, the record requires permit obtained yes or no; the documentation was left blank.

During the 9th unit of blood the permit for transfusing blood was not documented, the record requires permit obtained yes or no; the documentation was left blank.

On the 10th unit of blood the permit for transfusing blood was not documented, the record requires permit obtained, yes or no. The documentation was left blank. The facility policy for blood transfusions requires two signatures, one being a registered nurse. The one signature does not identify the type of staff member, and the other signature is missing. Again the record requires documentation that blood tubing is changed yes or no; the documentation was left blank.

On the 11th unit of blood being giving the permit for transfusing blood was not documented, the record requires permit obtained yes or no; the documentation was left blank. The facility policy for blood transfusions requires two signatures, one being a registered nurse. The record only had one staff member signature before the unit of blood was started.

On the 12th unit of blood being given the permit for transfusing blood was not documented, the record requires permit obtained, yes or no; the documentation was left blank, and the IV (intravenous) site, size, and type was left blank.

Review of patient #9's current transfusion record revealed, at the start of 1st unit of blood, the facility policy for blood transfusions requires two signatures, one being a registered nurse. The record only had one staff member signature before the unit of blood was started. The pre-transfusion documentation requires Hb (hemoglobin), date, and time prior to starting transfusion, all the documentation was left blank. Also the record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

On the 2nd unit of blood, the record only had one staff member signature before the unit of blood was started.

The 3rd unit of blood was missing documentation on the IV (intravenous) size and type. In the blood pre-assessment the urinary output was left blank. The record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

On the 4th unit of blood the vital signs (temperature, pulse, respiratory rate, and blood pressure) were not documented post transfusion, and the record requires documentation that blood tubing be changed, yes or no. The documentation was left blank.

Review of patient #10's current transfusion record revealed, the pre transfusion documentation requires Hb (hemoglobin), date, and time to be documented. The Hb (hemoglobin) was left blank. The post transfusion vital signs (temperature, pulse, respiratory rate, and blood pressure) were not documented.

On the 2nd unit of blood product being given, the post transfusion vital signs were not documented.

The documentation on the 5th unit of blood was missing the Hb (hemoglobin) and the post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank.

On the 6th unit of blood the permit for transfusing blood was not documented. The record requires permit obtained, yes or no. The documentation was left blank. The post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank, and the record requires documentation that blood tubing be changed, yes or no This documentation was left blank.

On the 7th unit of blood the permit for transfusing blood was not documented. The record requires permit obtained, yes or no. The documentation was left blank. The pre-transfusion documentation requires Hb (hemoglobin), date, and time. The documentation was left blank. The vital signs (temperature, pulse, respiratory rate, and blood pressure) were not documented. On the 8th, 9th, 10th, and 11th units of blood being given, the pre-transfusion, vital signs pre and post transfusion, vital signs after the first 50ml or 15 minutes of the blood being infused, tubing changed between the blood units, the post blood assessment transfusion was missing documentation on these units being given.

Review of patient #11's current transfusion record revealed, the permit obtained, yes or no; the information was left blank. Review of the transfusion record requires the staff to document the type of blood product. This information was left blank. Review of the record where the nurse documents the pre-transfusion information, the Hb (hemoglobin), date, and time were blank, and the post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank.

Review of patient #12's closed transfusion record of the 1st unit of blood given revealed the type of blood product the patient was receiving was not documented. Review of the 3rd unit of blood the record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

Review of patient #13's closed transfusion record of the 2nd unit of blood given revealed, the permit for transfusing blood was not documented. The record requires permit obtained, yes or no, and this information was left blank.

Review of patient #14's closed transfusion record revealed on the 1st unit of blood the facility policy for blood transfusions requires two signatures, one being a registered nurse. The record only had one staff member signature before the unit of blood was started. During the transfusion the patient's temperature was never documented. On the record it is documented see anesthesia record. The nurse's signature is missing from record during the transfusion of the unit of blood. The record requires documentation that blood tubing is changed, yes or no, but the documentation was left blank.

On the 2nd unit of blood the blood sticker was covering the signatures required by the facility policy before the blood is started. The unit of blood was started without staff members documenting the unit of blood was checked. The record requires documentation that blood tubing is changed, yes or no, but the documentation was left blank.

On the 3rd unit of blood the record requires documentation that blood tubing be changed, yes or no. The documentation was left blank.

On the 4th unit of blood, the IV (intravenous) site, size, and type was left blank and the nurses' signature is not documented on the pre-blood transfusion assessment. The pre-transfusion documentation requires Hb (hemoglobin), date, and time but the documentation was left blank. The record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

Review of patient #17's closed transfusion record revealed the pre transfusion part of the form on the 1st unit of blood, the time was left blank.

Review of the 2nd unit of blood the transfusion record requires the staff to document the type of blood product but the information was left blank. Review of the 2nd unit of blood on the pre transfusion part of the form the time is blank where the Hb, date, and time is to be documented. Review of the record where staff documents after 50ml or 15 minutes after the blood transfusion is started, the time, temperature, pulse, respiratory rate, blood pressure was left blank. The blood tubing was to be changed between 1st and 2nd units of blood, the documentation on the record- tubing changed yes or no; the information was left blank.

Review of the 3rd unit of blood, the time was blank on the pre transfusion part of the form where the Hb, date, and time is to be documented. The blood tubing was to be changed between 2nd and 3rd units of blood as indicated by the documentation on the record- tubing changed, yes or no. The information was left blank.

On the 4th unit of blood the transfusion record requires the staff to document two nurses check the unit of blood and there was a blood sticker covering the signature area. The 4th unit of blood was not checked by two nurses as required by the facility policy. The IV (intravenous) size and type was left blank. The blood tubing was to be changed between 3rd and 4th units of blood. The documentation on the record -tubing changed, yes or no, was left blank.

On the 5th unit of blood given to the patient the record revealed the permit obtained, yes or no; but the information was left blank. The IV (intravenous) size and type was left blank. The date of the 5th unit of blood to be administered is blank. The blood tubing was to be changed between 4th and 5th units of blood as indicated by the documentation on the record-tubing changed, yes or no, but the information was left blank. Review of patient #17's documentation of changing blood tubing revealed the tubing was not changed after receiving 5 units of blood. The policy requires "administration sets that are used for blood and blood components shall be changed after administration of each unit or at the end of 4 hours, whichever comes first."

Review of patient #18's closed transfusion record of the 2nd unit of blood given revealed the documentation that the permit was obtained was left blank. The blood unit number was not documented. The post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank. The blood tubing was to be changed between 1st and 2nd units of blood; the documentation of blood tubing change was left blank. Review of the 3rd unit of blood given to the patient, the patient's blood pressure is missing on the post transfusion record. Review of the 4th unit of blood the pre transfusion documentation requires Hb (hemoglobin), date, and time the documentation was left blank. Review of the 5th unit of blood the date of the transfusion is missing. The pre transfusion documentation requires Hb (hemoglobin), date, and time the documentation was left blank and the documentation of the blood tubing between the units of blood given was not marked as changed per the facility policy.

An interview with staff #25 and #29 on 09/19/2012 at approximately 3:00 PM in the conference room confirmed, the facility failed to administer and document blood and blood products according to the facility policy and the clinical records reviewed on blood transfusions had missing documentation.

B. follow physicians' order for transfusion of blood on 2 (#1 and #18) of 15 (#2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 17,and 18) clinical transfusion records.

A review of patient #1's clinical record revealed an order written by the physician on 02/28/12 at 2030 (8:30 PM) for a blood transfusion was not decipherable. The patient was transfused by nursing staff for a total of 5 units of blood without the physician's order being clarified. The 1st unit of blood was given on 2/28/12 at 2210 (10:25 PM) hemoglobin count 7.3, 2nd unit on 2/29/12 at 0200 (2:00 AM) hemoglobin count 9.8, 3rd unit on date unknown at 2200 (10:00 PM) hemoglobin count 8.7, 4th unit on 3/2/12 at 2340 (11:40 PM) hemoglobin count 9.0, and 5th unit on 3/3/12 at 2215 (10:15 PM) hemoglobin count 9.2. Review of the physician's order revealed there was no order to give the 3rd, 4th, and 5th units of blood. In reviewing further orders on the record the physician's order was to do H&H (hemoglobin & hematocrit) every 8 hours, the order was written on 2/28/12 at 2030 (8:20 PM). A review of the clinical record revealed the first hemoglobin documented after the order for H&H every 8 hours was 2/29/12 at 12:07 PM, which was 14 hours and 22 minutes later. The nursing staff failed to follow the physician's order for completing H&H every 8 hours.

A review of patient #18's clinical record revealed an order written by the physician on date unknown due to physician did not time or date order, but order is noted and signed by the nursing staff at 5/10/12 at 11:10 AM. The order reads to transfuse 1 unit of PRBC (packed red blood cells) over 4 hours. A review of the transfusion record revealed the unit of blood was started at 1450 (2:50 PM) and completed at 1750 (5:50 PM) which is a 3 hour transfusion. The nursing staff failed to follow the physicians' order for transfusing the unit of blood over a 4 hour period.

An interview with staff #25 and #29 on 09/19/2012 at approximately 3:00 PM in the conference room confirmed, the facility's nursing staff failed to follow physician's orders for the transfusion of blood products.





C. Follow physician's orders for the increasing and decreasing TPN rate for 10 of 10 ( patient #1, #14, #15, #16, #17, #18, #19, #20, #21 and #22) patients.
A review of (ASPEN)American Society for Perenteral and Entereal Nutrition's guidelines and recommendations revealed:
"These items, although not mandatory, are strongly recommended for inclusion on the PN order form (or back of the form):
? Guidelines for stopping or tapering of PN, to avoid rebound [DIAGNOSES REDACTED] and to provide patient safety in the event of this complication."

A review of the policy titled, "Total Parenteral Nutrition (TPN), If a delay occurs between TPN bag changes, a D10%W solution will be used as a substitute until TPN is obtained. (Infuse D10%W at same rate as TPN). The next bag of TPN will be requested from Pharmacy as soon as possible."
A review of the pre- printed order titled, "Standard" Adult Hyperalimentation (IVH) Order (TPN)" revealed, "Rate: Initiate IVH at 30 ml an hour for 8 hours, then titrate to 42 ml an hour for 8 hours then titrate to 84 ml an hour-Final rate."

A review of the pre- printed order titled, "Modified" Adult Hyperalimentation (IVH) Order (TPN)" revealed, "Rate: 63 ml/hr times 12 hours then 83 ml/hr".
A review of 10 of 10 ( patient #1, #14, #15, #16, #17, #18, #19, #20, #21 and #22) patients' medical record and the document titled "Medication Administration Report (MAR)" revealed, that patient #1, #15, #18 and #21 should have received a TPN rate at 63 ml/hr for 12 hours then the rate should have been increased to 83 ml/hr. Patients #1, #15, #18 and #21 TPN rate was started at 83 ml/hr. Patients #14, #16, #17, #19, #20 and #22 should have received a TPN rate at 30 ml/hr for 8 hrs then the rate should have been increased to 42 ml/hr for 8 hours then increase to 84 ml/hr for the final rate. Patients #14, #16, #17, #19, #20 and #22 TPN was started at a rate of 84 ml/hr.

D. Follow physician orders for 1 of 10 (#1) patients for the administration of intravenous fluids (D51/2NS at 70 ml/hr). The patient received a continuous intravenous (IV) rate at 50ml/hr.
A review of the admission orders "Admission: General Medical-Surgical and Intermediate Care," for patient #1. The document revealed an order for the IV Solution of D51/2NS at 70 ml/hr.
A review of the document titled "Physician's Order" for patient #1, dated 02/21/2012 and timed, 1130 revealed, "increase IV to 90ml/hr".
A review of the document titled "Physician's Order" for patient #1, dated 02/23/2012 and timed, 7:00AM revealed, "When TPN starts, Decrease other IV to 50 ml/hr times 12 hours then discontinue".
A review of the document titled "Medication Administration Report (MAR)" from patient #1 medical record revealed, the patient received the IV fluid, D5?NS at 50 ml/hr from the date of 02/21/2012 until the date 02/23/2012. The last documented bag of D5?NS was started by the nurse on 02/23/2012 at 6:04 PM by the nurse. The document (MAR) does not indicated what time the fluid, D5?NS, was discontinued by the nurse.
On 09/18/2012 at 10:00 AM in the Quality Conference Room, staff #29 confirmed the MAR reflects that patient #1 received a continuous IV rate of 50ml/hr. Staff # 29 confirmed the MAR reflects the physician's order were not followed.
E. Administer medication (TPN) to 1 of 10 (#1) patients in a timely manner.
A review of the document titled, "Modified" Adult Hyperalimentation (IVH) Order (TPN) for patient #1 revealed the order was written on 02/23/2012 at 7:00 AM.
A review of the document titled "Medication Administration Report (MAR)" from patient #1 medical record revealed, the TPN was started on 02/24/2012 at 6:46 PM. The evidence indicates there was a 35 hour and 46 minutes delay in the patient receiving the TPN.
A review of the document titled, "Modified" Adult Hyperalimentation (IVH) Order (TPN) for patient #1 revealed the order was written on 02/25/2012 at 7:56 PM.
A review of the document titled "Medication Administration Report (MAR)" from patient #1 medical record revealed, the TPN was started on 02/25/2012 at 12:24 AM. The evidence indicates there was a 4 hours and 20 minutes delay in the patient receiving the TPN.
A review of the document titled, "Modified" Adult Hyperalimentation (IVH) Order (TPN) for patient #1 revealed the order was written on 02/26/2012 at 7:50 AM.
A review of the document titled "Medication Administration Report (MAR)" from patient #1 medical record revealed no administration was electronically documented for this order. The evidence indicates the patient did not receive the ordered TPN.
F. Follow physician orders for 1 of 10 (#15) patients for the administration of a substitute IV fluid (D10W) while Total Parenteral Nutrition (TPN) was delayed.
A review of the document titled, "Modified" Adult Hyperalimentation (IVH) Order (TPN)" for patient #15, dated 05/09/2012 and timed at 12:30 PM revealed, "Dextrose 10% will be hung for TPN orders written outside of this time frame until the following evening."
A review of the document titled, "Total Parenteral Nutrition (TPN), If a delay occurs between TPN bag changes, a D10%W solution will be used as a substitute until TPN is obtained. (Infuse D10%W at same rate as TPN). The next bag of TPN will be requested from Pharmacy as soon as possible."
A review of the document titled "Medication Administration Report (MAR)" from patient #15 medical record revealed on 05/09/2012 no TPN was administered and no D10%W solution was substituted.
On 09/19/2012 at 09:00AM in the Quality Conference Room, staff #29 confirmed the MAR reflects that patient #15 did not receive TPN on 05/09/2012. Staff # 29 confirmed the MAR reflects the physician's order wasot followed.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview the facility failed to
A. Follow physician orders for the increasing and decreasing TPN rate for 10 of 10 ( patient #1, #14, #15, #16, #17, #18, #19, #20, #21 and #22) patients.
Refer to Tag 405 and 144
B. Follow physician orders for 1 of 10 (#1) patients for the administration of intravenous fluids (D51/2 NS at 70 ml/hr). The patient received a continuous intravenous (IV) rate at 50ml/hr.
Refer to Tag 405 and 144

C. Administer medication (TPN) to 1 of 10 (#15) patients in a timely manner.
Refer to Tag 405 and 144

D. Follow physician orders for 1 of 10(#1) patients for the administration of a substitute IV fluid (D10) while Total Parenteral Nutrition (TPN) was delayed.
Refer to Tag 405 and 144




E. failed to administer and document blood and blood products according to the facility policy. Based on clinical transfusion records reviewed 15 of 15 (#1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 17, and 18) patient records had missing documentation according to the facility policy on administration of blood and blood products. The facility also failed to follow the physicians' orders for transfusion of blood on 2 (#1 and #18) of 15 (#2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 17, and 18) records.

Refer to Tag A405 and A409
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
A. Follow physician orders for the increasing and decreasing TPN rate for 10 of 10 patients.
A review of (ASPEN)American Society for Perenteral and Entereal Nutrition ' s guidelines and recommendations revealed:
"These items, although not mandatory, are strongly recommended for inclusion on the PN order form (or back of the form):
? Guidelines for stopping or tapering of PN, to avoid rebound [DIAGNOSES REDACTED] and to provide patient safety in the event of this complication."

A review of the policy titled, "Total Parenteral Nutrition" (TPN), If a delay occurs between TPN bag changes, a D10%W solution will be used as a substitute until TPN is obtained. (Infuse D10%W at same rate as TPN). The next bag of TPN will be requested from Pharmacy as soon as possible."
A review of the pre- printed order titled, "Standard Adult Hyperalimentation (IVH) Order (TPN)" revealed, "Rate: Initiate IVH at 30 ml an hour for 8 hours, then titrate to 42 ml an hour for 8 hours then titrate to 84 ml an hour-Final rate."

A review of the pre-printed order titled, "Modified Adult Hyperalimentation (IVH) Order (TPN)" revealed, "Rate: 63 ml/hr times 12 hours then 83 ml/hr."
A review of 10 of 10 ( patient #1, #14, #15, #16, #17, #18, #19, #20, #21 and #22) patient medical records and the document titled "Medication Administration Report (MAR)" revealed, that patient #1, #15, #18 and #21 should have received a TPN rate at 63 ml/hr for 12 hours then the rate should have been increased to 83 ml/hr. Patients #1, #15, #18 and #21 TPN rate was started at 83 ml/hr. Patients #14, #16, #17, #19, #20 and #22 should have received a TPN rate at 30 ml/hr for 8 hrs then the rate should have been increased to 42 ml/hr for 8 hours then increase to 84 ml/hr for the final rate. Patients #14, #16, #17, #19, #20 and #22 TPN was started at a rate of 84 ml/hr.
B. Follow physician orders for 1 of 10 patients for the administration of intravenous fluids (D51/2NS at 70 ml/hr). The patient received a continuous intravenous (IV) rate at 50ml/hr.
A review of the admission orders "Admission: General Medical-Surgical and Intermediate Care," for patient #1. The document revealed an order for the IV Solution of D51/2NS at 70 ml/hr.
A review of the document titled "Physician Order," for patient #1, date, 02/21/2012 and timed, 1130 revealed, "increase IV to 90ml/hr."
A review of the document titled "Physician Order," for patient #1, date, 02/23/2012 and timed, 7:00AM revealed, "When TPN starts, Decrease other IV to 50 ml/hr times 12 hours then discontinue."
A review of the document titled "Medication Administration Report (MAR)" from patient #1 medical record revealed, the patient received the IV fluid, D5?NS at 50 ml/hr from the date of 02/21/2012 until the date 02/23/2012. The last documented bag of D5?NS was started by the nurse on 02/23/2012 at 6:04 PM by the nurse. The document (MAR) does not indicated what time the fluid, D5?NS, was discontinued by the nurse.
On 09/18/2012 at 10:00 AM in the Quality Conference Room, staff #29 confirmed the MAR reflects that patient #1 received a continuous IV rate of 50ml/hr. Staff # 29 confirmed the MAR reflects the physician's order were not followed.
C. Administer medication (TPN) in a timely manner.
A review of the document titled, "Modified Adult Hyperalimentation (IVH) Order (TPN)" for patient #1 revealed the order was written on 02/23/2012 at 7:00 AM.
A review of the document titled "Medication Administration Report (MAR)" from patient #1 medical record revealed, the TPN was started on 02/24/2012 at 6:46 PM. The evidence indicates there was a 35 hours and 46 minutes delay in the patient receiving the TPN.
A review of the document titled, "Modified Adult Hyperalimentation (IVH) Order (TPN)" for patient #1 revealed the order was written on 02/25/2012 at 7:56 PM.
A review of the document titled "Medication Administration Report (MAR)" from patient #1 medical record revealed, the TPN was started on 02/25/2012 at 12:24 AM. The evidence indicates there was a 4 hours and 20 minutes delay in the patient receiving the TPN.
A review of the document titled, "Modified Adult Hyperalimentation (IVH) Order (TPN)" for patient #1 revealed the order was written on 02/26/2012 at 7:50 AM.
A review of the document titled "Medication Administration Report (MAR)" from patient #1 medical record revealed, no administration were electronically documented for this order. The evidence indicates the patient did not receive the ordered TPN.
D. Follow physician orders for 1 of 10 patients for the administration of a substitute IV fluid (D10W) while Total Parenteral Nutrition (TPN) was delayed.
A review of the document titled, "Modified Adult Hyperalimentation (IVH) Order (TPN) " for patient #15, dated 05/09/2012 and timed at 12:30 PM revealed, "Dextrose10% will be hung for TPN orders written outside of this time frame until the following evening."
A review of the document titled, "Total Parenteral Nutrition (TPN)" revealed, "If a delay occurs between TPN bag changes, a D10% W solution will be used as a substitute until TPN is obtained. (Infuse D10% W at same rate as TPN). The next bag of TPN will be requested from Pharmacy as soon as possible."
A review of the document titled "Medication Administration Report (MAR)" from patient #15 medical record revealed on 05/09/2012 no TPN was administered and no D10%W solution was substituted.
On 09/19/2012 at 09:00AM in the Quality Conference Room, staff #29 confirmed the MAR reflects that patient #15 did not receive TPN on 05/09/2012. Staff # 29 confirmed the MAR reflects the physician ' s order were not followed.




E. follow the physcians' orders for transfusion of blood on 2 (#1 and #18) of 15 (#2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 17, and 18) records.

A review of patient #1's clinical record revealed an order written by the physician on 02/28/12 at 2030 (8:30 PM) for a blood transfusion is not decipherable. The patient was transfused by nursing staff for a total of 5 units of blood without the physician's order being clarified.

The 1st unit of blood was given on 2/28/12 at 2210 (10:25 PM) hemoglobin count 7.3, 2nd unit on 2/29/12 at 0200 (2:00 AM) hemoglobin count 9.8, 3rd unit on date unknown at 2200 (10:00 PM) hemoglobin count 8.7, 4th unit on 3/2/12 at 2340 (11:40 PM) hemoglobin count 9.0, and 5th unit on 3/3/12 at 2215 (10:15 PM) hemoglobin count 9.2.

There was no physician's order found to give the units of blood for units 3, 4, and 5. In reviewing the physician's order, the order was to obtain H&H (hemoglobin) every 8 hours, the order was written on 2/28/12 at 2030 (8:20 PM). A review of the clinical record revealed the next hemoglobin completed after the order had been prescribed was 2/29/12 at 12:07 PM and the last hemoglobin recorded in the record was 2/28/12 at 21:45(9:45 PM) the results is a 10 hour and 38 minute delay in obtaining a hemoglobin for the patient receiving blood.

A review of patient #18's clinical record revealed an order written by the physician on date unknown due to physician did not time or date order, but order is signed by the nursing staff at 5/10/12 at 11:10 AM to transfuse 1 unit of PRBC (packed red blood cells) over 4 hours. A review of the transfusion record revealed the unit of blood was started at 1450 (2:50 PM) and completed at 1750 (5:50 PM) which is a 3 hour transfusion.

An interview with staff #25 and #29 on 09/19/2012 at approximately 3:00 PM in the conference room confirmed, the facility failed to follow physician orders for the transfusion of blood products.
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview the facility failed to

A .administer and document the blood and blood products according to the facility policy. Review of transfusion clinical records 15 of 15 (#1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 17, and 18) revealed patient records had missing documentation according to the facility policy on administration of blood and blood products.

Review of policy titled: "ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS (WHOLE. PACKED CELLS/LEUKOCYTE POOR RED CELLS, PLASMA. FRESH FROZEN PLASMA. CRYOPRECIPITATE) Date Adopted: 06/05 Date Reviewed: 08/06 Date Revised: 01/12"

POLICY:
1. Blood and blood products will be administered according to physician order. Obtain
consent prior to administration [with the exception of emergency situations (life/death)].
2. Blood and blood components may be administered by peripheral route, central line,
(umbilical artery catheter. and an umbilical vein catheter in pediatrics).
3. Two licensed personnel (RN. LVN, pump technician and/or physician) with one being a RN must identify blood products prior to administration.

PROCEDURE:
1. Obtain permit or have patient sign refusal of blood permit.
7. At patient bedside, two nurses (one being an RN) must check the name, medical record
number, physician order, blood bank bracelet number, unit number, unit ABO/Rh, patient
ABORh checked, patient arm I.D. band, unit labels, and unit crossmatch tag, including
expiration dates. Sign transfusion record (STE/STM). The unit bag tag should remain
attached to the bag at all times. If a discrepancy exists, contact the Blood Bank.
10. Take patient ' s blood pressure, pulse, temperature, and respirations. RN to obtain pre
transfusion information to include: IV site, lungs, skin (hives/rash) and urinary output.
RN should record vital signs and physical data before initiation of transfusion.
Assessment by the RN must be done before and after each unit is administered.
12. Insert blood tubing spike into the blood bag. Administration sets that are used for blood
and blood components shall be changed after administration of each unit or at the end of
4 hours, whichever comes first.
14. Open clamp to allow blood to infuse at a slow rate the first 5 minutes. If no reaction,
increase flow rate.
15. If the rate not ordered, infuse over 2 to 4 hours but no longer than 4 hours, with the
exception of specialty areas (ie. E.R, ICU's, Surgery, recovery, Dialysis) where infusion
rate can be faster, based on patient condition. Infusion should be completed 4 hours from
the time of issue from the Blood Bank. Blood should never infuse longer than 4 hours
due to bacterial growth and red cell hemolysis.
16. Blood and components must be completed by expiration date and time, as indicated on
the label.
17. The RN will observe the patient closely for adverse reactions for the first 50m1 or
approximately 15 minutes since most [DIAGNOSES REDACTED] transfusion reactions occur in this initial
time. In pediatric patients, observe approximately 15 minutes.
a. Monitor patient throughout transfusion therapy for symptoms or signs:
? For a temperature increases of 2 degrees notify the MD and lab (most common reaction being fever and chills).
? Other transfusion reaction symptoms as noted but not limited to: Oliguria, hemoglobinuria, shock, [DIAGNOSES REDACTED], Jaundice, emboli, allergic reactions, circulatory overload, hypothermia, hyperkalemia, urticaria/hives, chest pain, respiratory distress.
b. Temperature, pulse, respirations, blood pressure, will be recorded
preadministration and at approximately 15 minutes and/or 50 m1 and at completion
of the transfusion.
18. If transfusion reaction occurs, stop transfusion immediately, maintain patent IV. Send
blood and saline tubing and urine sample to Lab with a completed transfusion reaction
form (obtain form from the lab). Notify physician and Blood Bank of reaction.
19. If no reaction is present: After completion of unit of blood, flush intravenous line with
normal saline, discontinue the IV unless further therapy is indicated. If the IV is to be
continued, remove empty blood container and tubing and hang appropriate solution with
new tubing. RN to reassess after completed.

DOCUMENTATION:
A. Obtain permit.
B. Transfusion Record /Documentation in Patient's Medical Record:
1. unit number
2. signatures of individuals verifying correctness (one must be a RN).
3. vital signs
4. physical assessment of IV site, lungs, urine output, presence or absence of
rash/hives before and after each unit.
5. Tubing change
6. Presence or absence of transfusion reaction
7. Size of IV catheter
8. type and amount of blood product
9. patient's response

There were 3 (#9,#10 and #11) current clinical records of blood transfusions reviewed and 12 (#1, 2, 3, 4, 5, 6, 7, 12, 13, 14, 17, and 18) closed transfusion records reviewed. The clinical records reviewed covered dates from 02/21/2012 through 09/20/2012.

Review of patient #1's closed record revealed, on the 4th and 5th units of blood, the permit for transfusing blood was not documented. The record requires permit obtained yes or no; the documentation was left blank. On the 3rd, 4th, and 5th units of blood the blood tubing change was not documented. The policy requires "administration sets that are used for blood and blood components shall be changed after administration of each unit or at the end of 4 hours, whichever comes first." The pre-transfusion documentation requires Hb (hemoglobin), date, and time to be documented. The date and time documentation was left blank on both units. On the 5th unit the vital signs (temperature, pulse, respiratory rate, and blood pressure) after 50ml or 15 minutes after the blood transfusion was started were not documented and the nurses' signature was left blank. Also the post transfusion vital signs (temperature, pulse, respiratory rate, and blood pressure) were not documented. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction and the documentation for the post blood assessment transfusion form was left blank.

Review of patient #2's closed transfusion record revealed, on the 1st unit of blood, the permit for transfusing blood was not documented. The record requires permit obtained yes or no, the documentation was left blank. The post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The post blood assessment transfusion form was left blank.

Review of 2nd unit of blood revealed the record requires vital signs after 50cc or 15 minutes after the blood has been started, the time, temperature, pulse, respiratory rate, blood pressure, and observed by the registered nurse signature is to be documented. This information was left blank. The post transfusion patient temperature was left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The urinary output was left blank. Review of patient #2's records of transfused units of blood (which was a total of eleven units), revealed the transfusion record requires documentation the blood tubing is changed yes or no; there was no documentation in the record of 5th, 6th, 7th, 8th, 9th, 10th, and 11th units of blood, that the blood tubing was changed.

Review of 10th unit of blood, the permit for transfusing blood was not documented, this area was left blank. The IV (intravenous) site, size, and type were left blank. The pre- transfusion assessment requires assessment of the lungs, skin (hives/rash), and urinary output. This documentation was left blank. The pre-transfusion documentation requires Hb (hemoglobin) date, and time to be documented and the information was left blank.

Review of 11th unit of blood, the permit for transfusing blood was not documented on the transfusion form. The IV (intravenous) site, size, and type were left blank. The pre-transfusion assessment requires assessment of the lungs, skin (hives/rash), and urinary output, this documentation was left blank. The pre-transfusion documentation requires Hb (hemoglobin) date, and time to be documented and the information was left blank. The post transfusion temperature, pulse, respiratory rate, and blood pressure were left blank.

Review of patient #3's closed transfusion record revealed, on the 2nd unit of blood transfused the post transfusion time, temperature, pulse, respiratory rate, and blood pressure were blank. Review of the 2nd unit of blood, the documentation on the record tubing changed, yes or no. The information was left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The post blood assessment transfusion form was left blank.

Review of patient #4's closed transfusion record revealed, on the 1st unit of blood the IV (intravenous) size and type was left blank and the post transfusion vital signs to be documented, the temperature was left blank. The blood tubing was to be changed after 1st unit of blood, the documentation on the record-tubing changed yes or no; the information was left blank. The post blood assessment transfusion form has assessment about lungs, skin, urinary output, and if the patient has had a blood reaction. On the 1st unit of blood the post blood assessment transfusion documentation concerning the urinary output and the blood reaction was left blank.

Review of the 2nd unit of blood, the type of blood product to be given was left blank. The blood tubing was to be changed after 2nd unit of blood, the documentation on the record-tubing changed yes or no; the information was left blank.

Review of the 3rd unit of blood the blood tubing was to be changed, the documentation on the record-tubing changed yes or no; the information was left blank.

Review of the 4th unit of blood permit obtained yes or no; the documentation was covered by a blood sticker with no documentation if a permit was obtained for the blood transfusion. The transfusion record revealed documentation for the type of blood product to be given was left blank. There was no documented date of when the 4th unit of blood was given. The blood tubing was to be changed after 4th unit of blood, the documentation on the record-tubing changed yes or no; the information was left blank.

Review of patient #5's closed transfusion record of the 1st and 2nd unit of blood given revealed, blood tubing changed yes or no; this information was left blank. The policy requires "administration sets that are used for blood and blood components shall be changed after administration of each unit or at the end of 4 hours, whichever comes first."

Review of patient #6's closed transfusion record of the 1st unit of blood given revealed, the IV (intravenous) site, size and type was left blank. The-transfusion documentation requires Hb (hemoglobin) date, and time. The date and time were left blank. The post transfusion vital signs were scratched out and the time and temperature were missing.

The 2nd unit of blood the permit for transfusing blood was not documented, the record requires permit obtained yes or no; this information was left blank. The IV (intravenous) site, size, and type were left blank. The pre transfusion documentation requires Hb (hemoglobin) date, and time; the date and time were left blank.

The 3rd unit of blood the permit for transfusing blood was not documented, the record requires permit obtained yes or no; this information was left blank. The record requires documentation that blood tubing is changed, yes or no; the documentation was left blank.

Review of patient #7's closed transfusion record revealed, on the 1st unit of blood, the record requires documentation that blood tubing is changed; yes or no. The documentation was left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The post blood assessment transfusion form was left blank.

Review of the 2nd unit of blood, the Registered Nurse failed to sign the pre- assessment form before the transfusion of blood was started. Also on the 2nd unit of blood the pre transfusion documentation requires Hb (hemoglobin), date, and time. The time documentation was left blank. The Registered Nurse failed to sign the assessment form during the transfusion of blood. The post transfusion vital signs were left blank, when the transfusion was completed. The record requires documentation that blood tubing is changed, yes or no; the documentation was left blank. The post blood assessment transfusion form requires assessment of the lungs, skin, urinary output, and if the patient has had a blood reaction. The post blood assessment transfusion form was left blank.

The 4th unit of blood documentation was missing the pre transfusion documentation which requires Hb (hemoglobin), date, and time. The record requires documentation that blood tubing is changed, yes or no. The documentation was left blank. The policy requires "administration sets that are used for blood and blood components shall be changed after administration of each unit or at the end of 4 hours, whichever comes first."

After the 6th unit of blood the record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

On the 7th unit of blood the unit number of the blood was not documented prior to giving the blood. Again the record requires documentation that blood tubing is changed, yes or no; the documentation was left blank.

On the 8th unit of blood the permit for transfusing blood was not documented, the record requires permit obtained yes or no; the documentation was left blank.

During the 9th unit of blood the permit for transfusing blood was not documented, the record requires permit obtained yes or no; the documentation was left blank.

On the 10th unit of blood the permit for transfusing blood was not documented, the record requires permit obtained, yes or no. The documentation was left blank. The facility policy for blood transfusions requires two signatures, one being a registered nurse. The one signature does not identify the type of staff member, and the other signature is missing. Again the record requires documentation that blood tubing is changed yes or no; the documentation was left blank.

On the 11th unit of blood being giving the permit for transfusing blood was not documented, the record requires permit obtained yes or no; the documentation was left blank. The facility policy for blood transfusions requires two signatures, one being a registered nurse. The record only had one staff member signature before the unit of blood was started.

On the 12th unit of blood being given the permit for transfusing blood was not documented, the record requires permit obtained, yes or no; the documentation was left blank, and the IV (intravenous) site, size, and type was left blank.

Review of patient #9's current transfusion record revealed, at the start of 1st unit of blood, the facility policy for blood transfusions requires two signatures, one being a registered nurse. The record only had one staff member signature before the unit of blood was started. The pre-transfusion documentation requires Hb (hemoglobin), date, and time prior to starting transfusion, all the documentation was left blank. Also the record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

On the 2nd unit of blood, the record only had one staff member signature before the unit of blood was started.

The 3rd unit of blood was missing documentation on the IV (intravenous) size and type. In the pre-transfusion assessment the urinary output was left blank. The record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

On the 4th unit of blood the vital signs (temperature, pulse, respiratory rate, and blood pressure) were not documented post transfusion, and the record requires documentation that blood tubing be changed, yes or no. The documentation was left blank.

Review of patient #10's current transfusion record revealed, the pre transfusion documentation requires Hb (hemoglobin), date, and time to be documented. The Hb (hemoglobin) was left blank. The post transfusion vital signs (temperature, pulse, respiratory rate, and blood pressure) were not documented.

On the 2nd unit of blood product being given, the post transfusion vital signs were not documented.

The documentation on the 5th unit of blood was missing the Hb (hemoglobin) and the post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank.

On the 6th unit of blood the permit for transfusing blood was not documented. The record requires permit obtained, yes or no. The documentation was left blank. The post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank, and the record requires documentation that blood tubing be changed, yes or no This documentation was left blank.

On the 7th unit of blood the permit for transfusing blood was not documented. The record requires permit obtained, yes or no. The documentation was left blank. The pre-transfusion documentation requires Hb (hemoglobin), date, and time. The documentation was left blank. The vital signs (temperature, pulse, respiratory rate, and blood pressure) were not documented.

On the 8th, 9th, 10th, and 11th units of blood being given, the pre-transfusion, vital signs pre and post transfusion, vital signs after the first 50cc or 15 minutes of the blood being infused, tubing changed between the blood units, the post blood assessment transfusion were missing documentation on these units being given.

Review of patient #11's current transfusion record revealed, the permit obtained, yes or no; the information was left blank. Review of the transfusion record requires the staff to document the type of blood product. This information was left blank. Review of the record where the nurse documents the pre-transfusion information, the Hb (hemoglobin), date, and time were blank, and the post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank.

Review of patient #12's closed transfusion record of the 1st unit of blood given revealed the type of blood product the patient was receiving was not documented. Review of the 3rd unit of blood the record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

Review of patient #13's closed transfusion record of the 2nd unit of blood given revealed, the permit for transfusing blood was not documented. The record requires permit obtained, yes or no, and this information was left blank.

Review of patient #14's closed transfusion record revealed on the 1st unit of blood the facility policy for blood transfusions requires two signatures, one being a registered nurse. The record only had one staff member signature before the unit of blood was started. During the transfusion the patient's temperature was never documented. On the record it is documented see anesthesia record. The nurse's signature is missing from record during the transfusion of the unit of blood. The record requires documentation that blood tubing is changed, yes or no, but the documentation was left blank.

On the 2nd unit of blood the blood sticker was covering the signatures required by the facility policy before the blood is started. The unit of blood was started without staff members' documenting the unit of blood was checked. The record requires documentation that blood tubing is changed, yes or no, but the documentation was left blank.

On the 3rd unit of blood the record requires documentation that blood tubing be changed, yes or no. The documentation was left blank.

On the 4th unit of blood, the IV (intravenous) site, size, and type was left blank and the nurses' signature is not documented on the pre-blood transfusion assessment. The pre-transfusion documentation requires Hb (hemoglobin), date, and time but the documentation was left blank. The record requires documentation that blood tubing is changed, yes or no. The documentation was left blank.

Review of patient #17's closed transfusion record revealed the pre transfusion part of the form on the 1st unit of blood, the time was left blank.

Review of the 2nd unit of blood the transfusion record requires the staff to document the type of blood product but the information was left blank. Review of the 2nd unit of blood on the pre transfusion part of the form the time is blank where the Hb, date, and time is to be documented. Review of the record where staff documents after 50cc or 15 minutes after the blood transfusion is started, the time, temperature, pulse, respiratory rate, blood pressure was left blank. The blood tubing was to be changed between 1st and 2nd units of blood, the documentation on the record- tubing changed yes or no; the information was left blank.

Review of the 3rd unit of blood, the time was blank on the pre-transfusion part of the form where the Hb, date, and time is to be documented. The blood tubing was to be changed between 2nd and 3rd units of blood as indicated by the documentation on the record-tubing changed, yes or no. The information was left blank.

On the 4th unit of blood the transfusion record requires the staff to document two nurses check the unit of blood and there was a blood sticker covering the signature area. The 4th unit of blood was not checked by two nurses as required by the facility policy. The IV (intravenous) size and type was left blank. The blood tubing was to be changed between 3rd and 4th units of blood. The documentation on the record -tubing changed, yes or no, was left blank.

On the 5th unit of blood given to the patient the record revealed the permit obtained, yes or no; but the information was left blank. The IV (intravenous) size and type was left blank. The date of the 5th unit of blood to be administered is blank. The blood tubing was to be changed between 4th and 5th units of blood as indicated by the documentation on the record-tubing changed, yes or no, but the information was left blank. Review of patient #17's documentation of changing blood tubing revealed the tubing was not changed after receiving 5 units of blood. The policy requires "administration sets that are used for blood and blood components shall be changed after administration of each unit or at the end of 4 hours, whichever comes first."

Review of patient #18's closed transfusion record of the 2nd unit of blood given revealed the documentation that the permit was obtained was left blank. The blood unit number was not documented. The post transfusion time, temperature, pulse, respiratory rate, and blood pressure were left blank. The blood tubing was to be changed between 1st and 2nd units of blood; the documentation of blood tubing change was left blank.

Review of the 3rd unit of blood given to the patient, the patient's blood pressure is missing on the post transfusion record.

Review of the 4th unit of blood the pre transfusion documentation requires Hb (hemoglobin), date, and time the documentation was left blank.

Review of the 5th unit of blood the date of the transfusion is missing. The pre-transfusion documentation requires Hb (hemoglobin), date, and time the documentation was left blank and the documentation of the blood tubing between the units of blood given was not marked as changed per the facility policy.

An interview with staff #25 and #29 on 09/19/2012 at approximately 3:00 PM in the conference room confirmed, the facility failed to administer and document blood and blood products according to the facility policy and the clinical records reviewed on blood transfusions had missing documentation.

B. follow physicians' order for transfusion of blood on 2 (#1 and #18) of 15 (#2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 17, and 18) clinical transfusion records.

A review of patient #1's clinical record revealed an order written by the physician on 02/28/12 at 2030 (8:30 PM) for a blood transfusion was not decipherable. The patient was transfused by nursing staff for a total of 5 units of blood without the physician's order being clarified. The 1st unit of blood was given on 2/28/12 at 2210 (10:25 PM) hemoglobin count 7.3, 2nd unit on 2/29/12 at 0200 (2:00 AM) hemoglobin count 9.8, 3rd unit on date unknown at 2200 (10:00 PM) hemoglobin count 8.7, 4th unit on 3/2/12 at 2340 (11:40 PM) hemoglobin count 9.0, and 5th unit on 3/3/12 at 2215 (10:15 PM) hemoglobin count 9.2.

Review of the physician's order revealed there was no order to give the 3rd, 4th, and 5th units of blood. In reviewing further orders on the record the physician's order was to do H&H (hemoglobin) every 8 hours, the order was written on 2/28/12 at 2030 (8:20 PM). A review of the clinical record revealed the first hemoglobin documented after the order for H&H every 8 hours was 2/29/12 at 12:07 PM, which was 14 hours and 22 minutes later. The nursing staff failed to follow the physician's order for completing H&H every 8 hours.

A review of patient #18's clinical record revealed an order written by the physician on date unknown due to physician did not time or date order, but order is noted and signed by the nursing staff at 5/10/12 at 11:10 AM. The order reads to transfuse 1 unit of PRBC (packed red blood cells) over 4 hours. A review of the transfusion record revealed the unit of blood was started at 1450 (2:50 PM) and completed at 1750 (5:50 PM) which is a 3 hour transfusion. The nursing staff failed to follow the physicians' order for transfusing the unit of blood over a 4 hour period.

An interview with staff #25 and #29 on 09/19/2012 at approximately 3:00 PM in the conference room confirmed, the facility's nursing staff failed to follow physician's orders for the transfusion of blood products.