HospitalInspections.org

Based on review of policy, medical records, incident report log, and interviews with staff, the facility staff failed to ensure tracking of patient safety events by failing to document, investigate and complete an incident report for 1 of 1 records (Patient #1) with a foley insertion with blood loss requiring a blood transfusion.

The findings include:

Review of policy titled "Risk Management (Incident) Reporting: Patients/Guests" with revision date of 01/01/2020, revealed "Purpose: To provide a mechanism whereby incidents are identified, rated by severity, and addressed in an efficient and effective manner. Policy: A confidential incident report will be completed promptly and accurately by any employee involved in or discovering an incident or having an incident reported to him/her by a patient or visitor. Procedure: 1. A confidential incident report will be completed electronically prior to the end of the shift by the staff member that witnessed the incident. 2. Information included in the incident report should be statements of observable facts...4. When the staff member has submitted the incident, the Director of Quality Management (DQM) will receive an email with a link to the incident. The DQM performs the initial review of the incident and assigns the severity level...."

Review of History and Physical for Patient #1 dated 11/14/2020 at 1959 revealed a 28 year old male who had a diving accident resulting in a near drowning cardiac arrest event resulting in quadriplegia. Patient #1 was admitted on 11/14/2020 for ventilator weaning and consultations with rehab therapy. Review of nurses notes dated 11/16/2020 at 0800 written by RN #2 revealed "...noted blood in urine c (with) clots. noted started CBI (continuous bladder irrigation) Dr. reviewed labs. ordered blood transfusion....1430 started 1 unit of PRBC (packed red blood cells)." Review of lab results dated 11/16/2020 at 1123 revealed Hemoglobin of 8.0 (normal range of 13.7-17.3) and Hematocrit of 25.4 (normal range of 39.0-49.1). Review of lab results dated 11/17/2020 at 0435 revealed Hemogloblin of 7.7 and Hematocrit 24.1. Review of lab results dated 11/18/2020 at 0559 revealed Hemogloblin of 6.7 and Hematocrit of 21.5. Review of Hospital Progress Note written on 11/16/2020 at 1900 by MD #1 revealed "Chief Complaint: Traumatic foley--bleed." Review of discharge summary dated 12/20/2020 at 1528 revealed "...18. Anemia. This was due to traumatic Foley. On November 16, he required 1 unit of PRBC's and again on November 18, 1 unit of PRBC." Review of blood transfusion documentation revealed Patient #1 received one unit of PRBC on 11/16/2020 from 1220 through 1800 and one unit on 11/18/2020 from 0925 through 1205.

Review of incident log dated 11/2020 through 12/2020 revealed no incident report on Patient #1 regarding difficult foley insertion or blood loss.

Interview on 03/03/2021 at 1355 with MD #3 revealed Patient #1 did have blood loss after insertion of catheter. Interview revealed CBI was started to clear urine and Patient #1 was given blood.

Interview for RN #4, night shift nurse who inserted the foley, was not obtained. RN #4 was not available for interview.

Interview on 03/4/2021 at 1035 with RN #2 revealed Patient #1 had orders for in and out catheters every 6 hours at the hours of 0600, 1200, 1800 and 2400. Interview revealed remembering blood clots in the foley upon shift change and CBI had to be started to clear up urine. Interview revealed incident report should have been written about blood loss.

Interview on 03/04/2021 at 1610 with CNO revealed an incident report should have been written noting the traumatic foley insertion.
Interview revealed the policy was not followed and an incident report should have been written.

NC00173328
NC00172170