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Based on record review and interview the hospital failed to follow their policy and procedure for complaints and grievances and implement as evidenced by: 1) failing to initiate a complaint form when a family member reported the rudeness of a nurse by making inappropriate remarks about the condition of her family member; 2) failed to identify and initiate the grievance process as evidenced by no documented evidence of action taken concerning the expressed displeasure by Patient #5's son concerning the discharge process for his mother for 1 of 6 sampled medical records. Findings:

1) failing to initiate a complaint form when a family member reported the rudeness of a nurse for making inappropriate remarks about the condition of a family member;

In a face to face interview on 02/21/11 at 11:45am RN S2 Director of Nursing (DON) when asked for documentation of complaints and grievances for the last six months indicated the hospital had not received any complaints or grievances since the last time the State visited.

During record review of the personnel file of RN S6 revealed she was counseled related to a complaint from a family member for rudeness.

In a face to face interview on 02/23/11 at 3:00pm RN S2 DON indicated RN S6 was questioned about the incident and S6 indicated the comment that was made "if she makes it out of here" was a joke about getting back to work made to another staff member. RN S2 indicated he did not feel this was a complaint because it was a comment made between the staff and verified no further action was taken. RN S2 added that complaints are supposed to be in reference to patient care and this had nothing to do with the care the family member was receiving.

Review of policy # I-A.1.11 titled "Patient/Family Grievance", effective 04/09 and submitted by the hospital as the one currently in use, revealed....B. The individual receiving the complaint will initiate the Complaint Form and take any steps available to resolve the complaint....... F. The completed Complaint form will be logged into the Patient/Family database".

In a face to face interview on 02/22/11 at RN S2 DON indicated Patient #5's son was very difficult to deal with from the day his mother was admitted because he was unhappy about the condition his mother was in and blamed Hospital "A" for the poor care she received. Further S2 indicated for the first three weeks after #5 was admitted, whenever her son started complaining, S2 went to the room to discuss the problem. When the surveyor asked S2 DON why these complaints had not been documented, S2 responded that when he went into the room the son would then say LTAC of Slidell was giving good care that he was speaking about Hospital "A". S2 indicated Patient #5's son became upset when it was determined that his mom would not be able to weaned off the ventilator and decisions needed to be made for care after discharge. S2 indicated Patient #5's son became very angry at the Case Manager when she suggested nursing home care and refused to speak to her again; however discharge planning continued with trying to find placement in a home which accepted ventilator patients.
Further S2 indicated he did not consider Patient #5's son's poor behavior and displeasure with having to deal with moving his mother a grievance toward the hospital because Administration and staff had done everything in their power to provide good care to the patient and that was what was important. S2 indicated after Patient #5 was transferred her son came to the hospital, very agitated and started screaming obscenities at the staff and himself and at that point S2 told him to leave the hospital and not return.

2) failed to identify and initiate the grievance process as evidenced by no documented evidence of
In a face to face interview on 02/22/11 at 6:00 pm RN S2 DON indicated Patient #5's son was very difficult to deal with from the day his mother was admitted because he was unhappy about the condition his mother was in and blamed Hospital "A" for the poor care she received. Further S2 indicated for the first three weeks after #5 was admitted, whenever her son started complaining, S2 went to the room to discuss the problem. When the surveyor asked S2 DON why these complaints had not been documented, S2 responded that when he went into the room the son would then say LTAC of Slidell was giving good care that he was speaking about Hospital "A". S2 indicated Patient #5's son became upset when it was determined that his mom would not be able to weaned off the ventilator and decisions needed to be made for care after discharge. S2 indicated Patient #5's son became very angry at the Case Manager when she suggested nursing home care and refused to speak to her again; however discharge planning continued with trying to find placement in a home which accepted ventilator patients.

S2 indicated he did not consider Patient #5's son's poor behavior and displeasure with having to deal with moving his mother a grievance toward the hospital because Administration and staff had done everything in their power to provide good care to the patient and that was what was important. S2 indicated after Patient #5 was transferred her son came to the hospital, very agitated and started screaming obscenities at the staff and himself and at that point S2 told him to leave the hospital and not return. Further S2 indicated he had told the complainant that because of his (the complainant ' s) behavior, he had burned all of his bridges and that is why his mother could not get into any nursing homes in the area. S2 emphasized that at no time did Patient #5 make a formal complaint or grievance against the hospital and that is why nothing was documented. S2 indicated it was not possible to document every time the complainant was not happy about something.

Based on record review and interview, the hospital failed to ensure all informed consents were properly executed as evidenced by: 1) failing to ensure all blood consents were completed with all required information (the reason/condition warranting the transfusion, alternative therapeutic interventions, reason why someone other than patient signed consent)), authenticated (time of all signatures and telephone consents witnessed by two people) (#3, #5, #6, R1, R2, R3, R4, R5) for 8 of 8 patient with orders for blood administration out of 6 sampled medical records and 5 random medical records; 2) failing to follow hospital policy and procedure for obtaining DNRs (Do Not Resuscitate) as evidenced by no documentation of a discussion with the patient and/or family concerning the basis for and consequences of the DNR, persons present, date/time of the discussion and the decision made by the patient/family (#1, #2, #4, #6) for 4 of 4 patients with an order for Do Not Resuscitate out of 6 sampled patients. Findings:

1) Failing to ensure all blood consents were completed with all required information (the reason/condition warranting the transfusion, alternative therapeutic interventions, reason why someone other than patient signed consent), authenticated (time of all signatures and telephone consents witnessed by two people):

Patient #3
Review of the "Consent for Transfusion of Blood and Blood Components" dated 02/11/11 for Patient #3 revealed no documented evidence the condition or diagnosis of the patient which indicates/recommends the blood transfusion, reasonable alternatives and risks associated with such alternatives was discussed with the patient. Further review revealed no documented time the patient, physician or witness signed the blood transfusion consent or the name of the physician or physician group authorized to administer the medical treatment.

Patient #5
Review of the "Consent for Transfusion of Blood and Blood Components" dated 01/06/11 for Patient #5 revealed no documented evidence the condition or diagnosis of the patient which indicates/recommends the blood transfusion, reasonable alternatives and risks associated with such alternatives was discussed with the patient. Further review revealed no documented time the physician signed the blood transfusion consent or the name of the physician or physician group authorized to administer the medical treatment.

Patient #6
Review of the "Consent for Transfusion of Blood and Blood Components" dated 01/20/11 for Patient #6 revealed no documented evidence the condition or diagnosis of the patient which indicated/recommended the blood transfusion and reasonable alternatives and risks associated with such alternatives was discussed with the patient. Further review revealed the consent was signed by Patient #6's caregiver with no documented evidence of the reason why someone other than the patient signed the consent. Further review revealed no documented evidence of the date and time the witness signed the consent. Review of the "Consent for Transfusion of Blood and Blood Components" dated 02/20/11 revealed no documented evidence the condition or diagnosis of the patient which indicated/recommended the blood transfusion and reasonable alternatives and risks associated with such alternatives was discussed with the patient. Further review revealed the consent was signed by Patient #6's power of attorney with no documented evidence of the reason why someone other than the patient signed the consent. Further review revealed no documented evidence of the patient's identification on the consent form.

Random Patient R1
Review of the "Consent for Transfusion of Blood and Blood Components" dated 11/30/10 for Random Patient R1 revealed no documented evidence the condition or diagnosis of the patient which indicates/recommends the blood transfusion, reasonable alternatives and risks associated with such alternatives was discussed with the patient.

Random Patient R2
Review of the "Consent for Transfusion of Blood and Blood Components" dated 12/29/10 for Random Patient R2 revealed no documented evidence the condition or diagnosis of the patient which indicated/recommended the blood transfusion and reasonable alternatives and risks associated with such alternatives was discussed with the patient. Further review revealed the consent was obtained from R2's daughter by telephone with no documented evidence of the time it was received. Further review revealed no documented evidence of a second witness to the telephone consent and the reason why someone other than the patient signed the consent.

Random Patient R3
Review of the "Consent for Transfusion of Blood and Blood Components" dated 12/04/10 for Random Patient R3 revealed no documented evidence reasonable alternatives and risks associated with such alternatives was discussed with the patient. Further review revealed no documented evidence of the time the physician signed the consent and the date and time R3's wife signed the consent. Review of the "Consent for Transfusion of Blood and Blood Components" dated 01/10/11 revealed no documented evidence the condition or diagnosis of the patient which indicated/recommended the blood transfusion and reasonable alternatives and risks associated with such alternatives was discussed with the patient. Further review revealed no documented evidence of the time the physician signed the consent and the reason why someone other than the patient (patient's wife) signed the consent.

Random Patient R4
Review of the "Consent for Transfusion of Blood and Blood Components" dated 12/13/10 for Random Patient R4 revealed no documented evidence the condition or diagnosis of the patient which indicates/recommends the blood transfusion, reasonable alternatives and risks associated with such alternatives was discussed with the patient. Further review revealed no documentation of the name of the physician or physician group authorized to administer the medical treatment.

Random Patient R5
Review of the "Consent for Transfusion of Blood and Blood Components" dated 12/01/10 for Random Patient R5 revealed no documented evidence the condition or diagnosis of the patient which indicates/recommends the blood transfusion, reasonable alternatives and risks associated with such alternatives was discussed with the patient. Further review revealed no documentation of the name of the physician or physician group authorized to administer the medical treatment.

In a face-to-face interview on 02/23/11 at 4:00pm, neither DON (director of nursing) S2 or ADON (assistant director of nursing) S4 could offer an explanation for the consents for blood administration being incomplete. S2 indicated blood utilization reviews were being done, but S2 didn't think review of the process of administration, including the completion of the consent, was a part of the review.

Review of the hospital policy titled "Informed Consents", policy number I.-A.1.27, effective 09/10 and submitted by ADON S4 as the current policy for informed consent for blood administration, revealed, in part, "...The hospital's informed consent process shall assure patient's or their representatives are given the information and disclosures needed to make an informed decision about whether to consent to a procedure, intervention, or type of care that requires consent. Procedure: ...2. Invasive Procedures and/or Treatments, Blood Administration requires an "Informed Consent"... 4. Prior to obtaining an informed consent, the hospital clinical team must acknowledge if the patient is able to make his or her own decisions. ... 5. If patient is unable to make his or her own decisions, the hospital must consult the patient's advance directives, medical power of attorney or patient representative, if any of these are available. 6. If a Power of Attorney (POA) Durable POA or Medical POA is acknowledged, the clinical team must document the name of the individual designated as the POA in the medical record and a copy of the executed POA document must be placed in the patient's medical record". Further review revealed no documented evidence of the process to be taken when an informed consent is received by telephone.

2) Failing to follow hospital policy and procedure for obtaining DNRs (Do Not Resuscitate):
Patient #1
Review of Patient #1's medical record revealed she was a 74 year old female admitted on 02/04/11 for Sepsis with a history of diabetes, hypertension, and anemia of chronic renal disease. Further review revealed she was a "Full Code Status".

Review of the "Resuscitation Orders" dated 02/09/11, with no documented evidence of the time, revealed an order to "Do Not Resuscitate: No Code Blue (documentation and confirmation of communication with patient and/or family/responsible party must be written in the physicians' progress notes)". Review of the "Physician's Progress Note Do Not Resuscitate" signed by Patient #1 on 02/07/11 at 11:20am and by Medical Director S12 on 02/09/11 at 1:00pm revealed no documented evidence of the discussion concerning the basis for and consequences of the DNR and the decision made by the patient. Review of the "Physician Orders" revealed an order on 02/17/11 at 9:30am revealed an order by Medical Director S12 to "do not resuscitate per pt (patient) request".

Patient #2
Review of the medical record revealed Patient #2, a 78 year old male, was admitted to the hospital on 01/21/11 for Sepsis and Dehydration with a history of Dementia and HTN (Hypertension) and was a "Full Code Status".

Review of the Resuscitation Orders dated 01/27/11 (no time documented) for Patient #2 revealed an order to "Resuscitate with Modifications" with a check mark indicating emergency medications only and basic life support.

Review of the Physician's Progress Notes dated 01/27/11 for Patient #2 revealed no documented evidence a discussion with the patient and/or family concerning the basis for and consequences of the modification in resuscitation had taken place before the order was written.

In a face-to-face interview on 02/22/11 at 4:55 pm, MD S12 Medical Director indicated the new forms (Resuscitation Order Form) were developed in response to the last survey to improve compliance in documentation. Further she indicated that even with the use of the order form, documentation is still required in the chart concerning discussion with the patient and/or family. After review of Patient #1's medical record S12 confirmed she did not document her discussion with Patient #1.

Patient #4
Review of Patient #4's medical record revealed she was an 86 year old female admitted on 02/17/11 with diagnoses of decubitus ulcers right and left heels, atrial fibrillation, esophageal reflux, hypothyroidism, hyperlipidemia, anemia, depression, psychosis, edema, and hypertension.

Review of the "Resuscitation Orders" dated 02/17/11 at 2200 (10:00pm) and signed by Physician S 11 revealed an order for "Do Not Resuscitate: No Code Blue (documentation and confirmation of communication with patient and/or family/responsible party must be written in the physicians' progress notes)".

Review of the "Physician's Progress Note Do Not Resuscitate" signed by Physician S11 on 02/18/11 at 1600 (4:00pm) revealed the following: the DNR status is based on one or more of the following: family's request; family aware of code status; name of 2 sons, and no power of attorney. Further review revealed no documented evidence of the discussion concerning the basis for and consequences of the DNR.

In a face-to-face interview on 02/23/11 at 12:10pm, Physician S11 indicated Patient #4 was a long-time patient of his at the nursing home, and he had a face-to-face discussion concerning DNR with her son there. S11 confirmed he did not document a discussion with Patient #4's son at the time he wrote orders to make her a DNR for this hospitalization.

Patient #6
Review of Patient #6's medical record revealed she was an 81 year old female admitted on 01/19/11 for respiratory failure and strep pneumonia. Review of the "Resuscitation" orders revealed an order signed by Physician S11 on 01/20/11 at 2048 (8:48pm) for "Do Not Resuscitate: No Code Blue (documentation and confirmation of communication with patient and/or family/responsible party must be written in the physicians' progress notes)". Review of the entire medical record revealed no documented evidence of S11's discussion with Patient #6 or her caregivers concerning the basis for and consequences of the DNR.

In a face-to-face interview on 02/23/11 at 12:10pm, Physician S11 confirmed he did not document a discussion with Patient #6 or her caregivers prior to writing an order for DNR.

Review of the hospital policy titled "Do Not Resuscitate", policy number I-A.1.13, effective 04/09 and submitted by ADON S4 as the hospital's current policy for Do Not Resuscitate, revealed, in part, "...Procedure: A. The patient's attending physician and a consulting physician (optional) must determine if a DNR or a Terminal Care Order is medically appropriate, based on the patient's underlying terminal illness or irreversible medical condition. B. If the attending physician and the consulting physician determine that a DNR or a Terminal Care Order is medically appropriate, the physician must then discuss the matter with the patient, explaining the basis for and the consequences of, a DNR or a Terminal Care Order. If the patient is incompetent, this discussion must be held with the patient's family or legal guardian. All such discussions must be noted on the patient's medical record. The notation of such discussions shall include at least the following information: persons present, information conveyed by physician, date / time of conference with family / patient, and decision of family and legal guardian. C. If the patient is competent, the patient must consent to the entry of a DNR or Terminal Care Order. ... In any case where the declaration is made by other than a court-appointed guardian, the decision must be an unanimous one on the part of those members of the class reasonably available for consultation. Furthermore, at least two witnesses... must be present at the time the declaration is made...".

Based on record review and interview, the hospital failed to ensure the least restrictive intervention was implemented as an alternative to restraints as evidenced by placing a patient into restraints and then removing the restraints while the patient's family was at the patient's bedside for 1 of 1 who had restraints applied out of a total of 6 sampled patients (R5). Findings:

Review of the medical record revealed Patient R5, a 69 year old male, was admitted to the hospital on 12/01/10 with Pneumonia, Anemia, Renal Sufficiency, CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease) and Diabetes Mellitus.

Review of the Physicians' Orders for Patient R5 dated/timed 12/02/10 at 1545 (3:45pm) revealed a telephone order from MD S 21 for, "OK to restrain pt (patient) - soft wrist".

Review of the Restraint Management Documentation Form dated 12/02/10 through 12/03/10 for Patient R5 revealed soft wrist restraints were applied on 12/02/10 at 1600. Further review revealed the following boxes under the "High-Risk Criteria/Behaviors Present" had been checked: History of falls; Unsteady gait/balance; Uncorrected hearing/vision defects; Confusion/inability to follow directions; Bowel/bladder frequency or incontinence; Verbalizes/demonstrates dizziness or lightheadedness; Medication administration for purpose of altering LOC )Level of Consciousness; Receiving laxatives; Climbing over siderails; Combative; Uncooperative; and Wandering. Review of the revealed the following boxes under the "Alternatives to Restraints Tried" had been checked: Patient/Family/Significant Other education; Re-orientation to environment; Family/Significant other/sitter at bedside; Increased observation; Diversional activities; Siderails that include the entire length of the bed; Other environmental modifications (space left blank for those implemented); Re-taping/changing location of line or device; Concealing line/device; Repositioning patient; Bed Alarm; Medication as ordered by physician; and Other - Family notified.

Review of the Nurse's Narrative Notes dated 12/02/10 for Patient R5 revealed no documentation of behaviors requiring the use of restraints. Further review revealed that at 1400 (2:00pm) R5 climbed over the side of his bed and sat in a chair. The nursing staff returned him to bed and R5 was given Hydrocodone. 1600 (4:00pm) R5 Pt. continued to climb over the bed with the bed alarm going off. Assisted back to bed. No signs or symptoms of discomfort. Further review of the Nursing Narrative Notes revealed no documented evidence of any continued behavior which would indicate the need for restraints nor any documented evidence of any of the less restrictive methods such as a family member, significant other or sitter at the bedside had been tried before soft wrist restraints were applied at 1600 (4:00pm). At 1830 (6:30pm) 2 hours and 30 minutes after soft wrist restraints had been applied to R5, the restraints were removed while the family was at the bedside.

In a face-to-face interview on 02/23/11 at 4:00pm, DON (director of nursing) S2, when informed of the above findings, offered no explanation.

Review of the hospital's policy titled "Restraints", policy number II-C.3.20, effective 12/09 and submitted by ADON (assistant director of nursing) S4 as the current policy for restraints, revealed, in part, "...A. Alternatives To Restraints i. Restraints should be a temporary solution to a situation. Preventative strategies must be implemented prior to utilizing restraint unless an immediate safety risk is present for the patient, staff, or others. Alternatives to restraints are to be exhausted prior to the application of restraints. ii. When less restrictive alternatives are not effective or if the patient requires medical intervention, the physician should be notified... Documentation in the medical record will reflect patient care activities documenting which restraint was applied. This includes the following: ... B. Alternative measures tried. ... Alternatives to restraints include, but are not limited to the following: A. Physical Measures ... B. Psychological Measures... C. Physiological Measures... D. Spiritual Needs... E. Environmental Modification Measures... j. Organize (schedule) family and friends to remain with patient...".

Based on record review and interview, the hospital failed to ensure restraint orders were written according to policy and procedure as evidenced by a telephone order written "Soft wrist restraints if okay with family" for 2 of 3 patients with orders for restraints (#2, R1) out of 6 sampled and 5 random medical records. Findings:

Patient #2
Review of the medical record revealed Patient #2, a 78 year old male, was admitted to the hospital on 01/21/11 for Sepsis and Dehydration with a history of Dementia and HTN (Hypertension).

Review of the Physicians' Orders for Patient #2 dated/timed 01/24/11 at 2100 (9:00pm) revealed a telephone order from MD S12 Medical Director for, "Soft restraints if okay with family".

Patient R5
Review of the medical record revealed Patient R5, a 69 year old male, was admitted to the hospital on 12/01/10 with Pneumonia, Anemia, Renal Sufficiency, CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease) and Diabetes Mellitus.

Review of the Physicians' Orders for Patient R5 dated/timed 12/02/10 at 1545 (3:45pm) revealed a telephone order from MD S 21 for, "OK to restrain pt (patient) - soft wrist".

In a face-to-face interview on 02/23/11 at 3:00pm RN (registered nurse) S2, DON indicated any order for a restraint must be time-limited.

Review of the hospital's policy titled "Restraints", policy number II-C.3.20, effective 12/09 and submitted by ADON (assistant director of nursing) S4 as the current policy for restraints, revealed, in part, "...If indicated, the order for use of restraints will be obtained. In an emergency, the RN may apply restraints when the patient is dangerous to self and/or others. Orders for restraints are valid for no more than the specified time frame and must be renewed to be continued (see below). "PRN" (as needed) restraint orders are not acceptable and cannot be transcribed or carried out. ... Each order must: a. Specify a time limitation... c. Be written for a specific episode...".

Based on record review and interview, the hospital failed to develop and implement a policy for restraints which included documentation of the date, time, condition and discipline responsible for removing the restraint resulting in restraints being removed without appropriate assessment and documentation of the patient for 2 of 2 patients who had restraints applied and removed (#6, R5) from a total of 6 sampled patients and 5 random patients. Findings:

Patient #6
Review of Patient #6's medical record revealed she was admitted on 01/19/11 at 10:00am with diagnoses of respiratory failure and strep pneumonia. Review of Patient #6's "History & Physical" revealed her past medical history included asthma, hypertension, hyperlipidemia, history of stroke, depression, acute renal failure, and dementia.

Review of the "Restraint Order Sheet" dated 02/15/11 at 2130 (9:30pm) revealed soft wrist restraints were ordered due to Patient #6 pulling off the trach collar.

Review of the "Restraint Management Documentation Form" dated 02/15/11 through 02/16/11 revealed wrist restraints were applied on 02/15/11 at 2100 (9:00pm), and Patient #6 was assessed at 11:00pm, 1:00am (02/16/11), 3:00am, and 5:00am. Further review of the form revealed "*document time restraint discontinued in the nurses note". Review of the nurse's note revealed no documented evidence the restraints were removed.

In a face-to-face interview on 02/21/100 at 4:25pm, LPN (licensed practical nurse) S3 indicated she was the nurse caring for Patient #6 on 02/16/11. She further indicated Patient #6 did not have restraints in place when S3 began her shift at 6:00am on 02/16/11.

In a face-to-face interview on 02/22/11 at 6:20pm, LPN S22 indicated she passed on in report on 02/16/11 to LPN S3 that Patient #6 had to be assessed for removal of the restraints. When told by the surveyor that LPN S3 reported that Patient #6 did not have restraints on when she assessed #6 the morning of 02/16/11, LPN S22 indicated Patient #6 was still in restraints when she reported to the day shift. She further indicated "maybe the CNA (certified nursing assistant) removed them.

Patient R5
Review of the medical record revealed Patient R5, a 69 year old male, was admitted to the hospital on 12/01/10 with Pneumonia, Anemia, Renal Sufficiency, CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease) and Diabetes Mellitus.

Review of the Physicians' Orders for Patient R5 dated/timed 12/02/10 at 1545 (3:45pm) revealed a telephone order from MD S 21 for, "OK to restrain pt (patient) - soft wrist".

Review of the Restraint Management Documentation Form dated 12/02/10 through 12/03/10 for Patient R5 revealed soft wrist restraints were applied on 12/02/10 at 1600. The next entry was dated/timed 1800 (6:00pm) that the restraint was off. Further review revealed no documented evidence of the time and name of the person removing the restraint.

In a face-to-face interview on 02/23/11 at 4:00pm, DON (director of nursing) S2 offered no explanation for the failure to have documentation in the medical record of the assessment and removal of a patient's restraints.

Review of the hospital's policy titled "Restraints", policy number II-C.3.20, effective 12/09 and submitted by ADON (assistant director of nursing) S4 as the current policy for restraints, revealed, in part, "...B. Requisites To Restraints... vi. If a restraint is applied the patient must be assessed for the possibility of discontinuance of the restraint at least every two hours. ... Reassessment For Continued Need For Restraints A. While in restraints, the patient will be observed a minimum of every two hours. The nurse may assess the patient for his/her continued need for restraints based on the patient's behavior the state of their environment, and their response to the restraint... Documentation in the medical record will reflect patient care activities documenting which restraint applied. This includes the following: ... J. Time restraint discontinued...".

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care of each patient as evidenced by failure to: 1) assess a patient's blood pressure after administration of Clonidine for blood pressure for 2 of 2 patients receiving Clonidine from a total of 6 sampled patients (#1, #3); 2) assess a patient's pulse prior to administration of Digoxin for 1 of 1 patient reviewed who had Digoxin ordered from a total of 6 sampled patients (#4); 3) assess a patient's vital signs per hospital protocol during and after administration of blood for 4 of 8 patients reviewed who received blood (#6, R1, R2, R3); 4) assess a patient's wound at admission according to hospital policy for 1 of 5 patients reviewed with a wound from a total of 6 sampled patients (#4); and 5) assess a patient upon the patient's return from treatment in the emergency department (ED) for 1 of 1 patient reviewed with a transfer to the ED from a total of 6 sampled patients (#6). Findings:

1) Assess a patient's blood pressure after administration of Clonidine for blood pressure:
Patient #1
Review of Patient #1's "LTAC (long term acute care) Admit Physician Orders" revealed she was admitted on 02/04/11 at 5:55pm with a diagnosis of Sepsis. Review of the "History and Physical" revealed Patient #1 had a history of diabetes accompanied by diabetic retinopathy, nephropathy, and neuropathy, morbid obesity, chronic venous ulcerations of the lower extremities with severe hyperpigmentation of the lower aspect of both lower extremities with occasional ulcerations and intermittent infections.

Review of Patient #1's medical record revealed a physician's order on 02/06/11 at 1:00PM Clonidine 0.1 mg (milligrams) by mouth every 8 hours prn (as needed) for systolic blood pressure greater than 170 or diastolic blood pressure greater than 100.

Review of Patient #1's MAR (medication administration record) revealed Clonidine 0.1 mg was administered orally on 02/15/11 at 6:45am for a blood pressure of 186/81. Further review revealed no documented evidence of a blood pressure reading at 7:45am, as evidenced by a line next to 7:45am on the MAR in the column titled "results/response".

In a face-to-face interview on 02/22/11 at 3:45pm, RN S6 confirmed she had not documented a reassessment of Patient #1's blood pressure after she administered Clonidine on 02/15/11.

Patient #3
Review of the medical record for Patient #3 revealed a 47 year old female admitted to the hospital on 01/25/11 for continued care after an ORIF (Open Reduction Internal Fixation) of the right hip. Further review revealed she had a history of renal failure (on dialysis) and anemia.

Review of the Physicians' Orders for Patient #3 dated 02/10/11 revealed an order for Clonidine HCL 0.1mg tablet one by mouth every 8 hours as needed for SBP (Systolic Blood Pressure) greater than 170 and DBP (Diastolic Blood Pressure) greater than 100.

Review of the MAR (Medication Administration Record) for Patient #3 dated 02/13/11 revealed Clonidine 0.1 mg was administered at 0700 (7:00am) for a blood pressure of 175/86. Review of the Nurses' Notes, MAR and Vital Signs Record revealed no documented evidence Patient #3's blood pressure had been reassessed after the administration of the Clonidine.

Review of the hospital policy titled "Medication Management", policy # II-F.7.00, revised 04/09 and submitted as the hospital's current policy for medication administration by ADON (assistant director of nursing) S4, revealed, in part, "...G. Monitoring Each patient's response to their medication is monitored according to the clinical needs and addresses the patient's response to the prescribed medication and actual or potential medication-related problems. Monitoring a medication's effect includes the following: Gathering the patient's own perceptions about side effects, Referring to information in the patient's medical record such as lab values, clinical response, and medication profile...". Further review revealed no documented evidence of the time interval at which effectiveness should be assessed.

2) Assess a patient's pulse prior to administration of Digoxin:
Review of Patient #4's "LTAC Admit Physician Orders" revealed she was admitted on 02/17/11 at 5:40pm with diagnoses of decubitus ulcers right and left heels, atrial fibrillation, esophageal reflux, hypothyroidism, hyperlipidemia, anemia, depression, psychosis, edema, and hypertension. Further review revealed an order for Digoxin 125 mcg (micrograms), 1 tablet orally every morning and to hold for heart rate less than 60.

Review of Patient #4's MARs revealed Digoxin was administered at 9:00am by LPN (licensed practical nurse) S9 with no documented evidence of the heart rate at the time of administration, and there was no documented evidence of the date of administration (the MAR was hand-written and not dated). Further review of the MARs revealed Digoxin was administered at 9:00am on 02/19/11 and 02/20/11 by LPN S9 and at 9:00am on 02/21/11 by LPN S10, all with no documented evidence of the heart rate at the time of administration.

In a face-to-face interview on 02/22/11 at 2:40pm, LPN S10 indicated she checked Patient #4's pulse before administering Digoxin, but she didn't document it on the MAR. She further indicated that she knew that "if it's not documented, it's not done".

In a face-to-face interview on 02/22/11 at 4:10pm, LPN S9 confirmed the MAR did not have the date on it, and she had not documented Patient #4's heart rate prior to administering Digoxin as ordered.

Review of the hospital policy titled "Medication Management", policy # II-F.7.00, revised 04/09 and submitted as the hospital's current policy for medication administration by ADON S4, revealed, in part, "...Specific Order Limitations ...Digitalis and derivatives - All patients receiving digitalis or any derivatives thereof shall have pulse check daily before administration and recorded on the medication sheet. If pulse is below 60 the drug shall be withheld and the physician shall be notified...".

3) Assess a patient's vital signs per hospital protocol during and after administration of blood:
Review of the "Blood/Blood Component Administration Record" revealed instructions of "Transfusion: Vital signs every 15 minutes x (times) 3, then 30 minutes x 2, then every 60 minutes until infused...". Further review revealed this instruction was not according to the hospital policy for vital signs assessment of every 15 minutes for the first hour.

Patient #6
Review of Patient #6's medical record revealed she was admitted on 01/19/11 at 10:00am with diagnoses of respiratory failure and strep pneumonia. Review of Patient #6's "History & Physical" revealed her past medical history included asthma, hypertension, hyperlipidemia, history of stroke, depression, acute renal failure, and dementia.

Review of Patient #6's medical record revealed an order on 01/20/11 at 11:20am to type and cross match for 2 units of packed red blood cells and transfuse each over 4 hours.

Review of the "Blood/Blood Component Administration Record" revealed no documented evidence of the date and time the first unit of blood was received and the date and time the transfusion was started. Review of the form received from the blood bank revealed the transfusion was started on 01/20/11 at 2130 (9:30pm) and stopped on 01/21/11 at 0100 (1:00am), for a total transfusion time of 3 hours 30 minutes, rather than 4 hours as ordered by the physician. Further review of the "Blood/Blood Component Administration Record" revealed vital signs were documented for 2130 (9:30pm), 2145 (9:45pm), 2200 (10:00pm), 2230 (10:30pm), 2300 (11:00pm), 0000 (12:00am), and 0100 (1:00am). Further review revealed vital signs were not documented for the third 15 minute check and post-transfusion.
Review of the "Blood/Blood Component Administration Record" revealed no documented evidence of the date and time the second unit of blood was received and the date and time the transfusion was started. Review of the form received from the blood bank revealed the transfusion was started on 01/21/11 at 1:45am and stopped on 01/21/11 at 4:15pm, for a total of 2 hours 30 minutes, rather than 4 hours as ordered. Further review of the "Blood/Blood Component Administration Record" revealed vital signs were documented for 0145 (1:45am), 0200 (2:00am), 0215 (2:15am), 0245 (2:45am), 0315 (3:15am), 0415 (4:15am), and 0515 (5:15am). Further review revealed vital signs were not documented every 15 minutes for the first hour as required by hospital policy.

Patient R1
Review of the medical record for Patient R1 revealed a 68 year old female admitted to the hospital on 11/18/10 with Fournier's gangrene to the groin, Diabetes mellitus, Obesity, CHF (Congestive Heart Failure) and HTN (Hypertension).

Review of the Blood/Blood Component Administration Record dated 12/28/10 for Patient R1 revealed one unit of PRBC (Packed Red Blood Cells) was hung at 10:00am and completed at 1400 (2:00pm). Further review revealed no documented evidence a blood pressure had been assessed on patient R1 after the blood had been completed.

Patient #R2
Review of Patient #R2's medical record revealed he was admitted on 12/08/10 with a diagnosis of resolving aspiration pneumonitis and MRSA (Methicillin-Resistant Staphylococcus Aureus) pneumonia. Review of his H&P revealed he had a history of chronic lymphocytic leukemia, acute kidney insufficiency with electrolyte abnormalities, status post pleural effusions with thoracentesis, atrial fibrillation, and chronic anemia.

Review of Patient #R2's physician orders revealed an order on 12/29/10 at 11:00am to type and cross match for 2 units of packed red blood cells and transfuse each over 4 hours.

Review of the "Blood/Blood Component Administration Record" revealed the first of unit of blood was started on 12/30/10 at 12:00am. Further review revealed the vital signs were taken at 12:15am, 12:30am, 1:00am, 1:30am, 2:30am, and 3:30am. Further review revealed vital signs were not documented every 15 minutes for the first hour as required by hospital policy. Further review revealed the second unit of blood was started at 4:00am on 12/30/10. Vital signs were taken at 4:15am, 4:30am, 4:45am, 5:15am, 5:45am, 6:45am, and 7:45am. Further review revealed vital signs were not documented every 15 minutes for the first hour as required by hospital policy.

Patient #R3
Review of Patient #R3's medical record revealed he was admitted on 12/03/10 with a diagnosis of infected sacral decubitus ulcer Stage III to IV. Further review revealed he had a history of diabetes mellitus type II, hypothyroidism, and chronic urinary tract infections.

Review of Patient #R3's physician orders revealed an order on 12/04/10 at 9:00am to type and cross match for 2 units of packed red blood cells and give each over 4 hours. Further review revealed an order on 01/10/11 at 9:00am to infuse 2 units of packed red blood cells each over 4 hours.

Review of the medical record revealed no documented evidence of the "Blood/Blood Component Administration Record" for the first of unit of blood that was begun on 12/05/10 at 12:45am. Thus, there was no documented evidence that vital signs were assessed according to hospital policy during the administration of blood.

Review of the "Blood/Blood Component Administration Record" for the second unit of blood administered on 12/05/10 revealed it was started at 4:15am, while the form sent to the blood bank revealed it was started at 4:30am. Further review revealed no documented evidence of the date and time the blood was completed on the "Blood/Blood Component Administration Record", and review of the blood bank form revealed the blood was stopped at 7:30am on 12/05/10. Due to the discrepancy in the start time of the blood administration, it could not be determined if vital signs were taken every 15 minutes for for the first hour as required by hospital policy.

Review of the "Blood/Blood Component Administration Record" for 01/11/11 revealed the first unit of blood was started at 12:30am. Further review revealed vital signs were taken at 12:45am, 1:00am, 1:30am, 2:00am, 3:00am, and 4:00am. There was no documented evidence vital signs were taken every 15 minutes for the first hour as required by hospital policy. Further review revealed the second unit of blood was started at 11:05am. Further review revealed vital signs were taken at 11:10am, 11:25am, 12:00pm, and 1:00pm. There was no documented evidence vital signs were taken every 15 minutes for the first hour as required by hospital policy.

In a face-to-face interview on 02/23/11 at 4:00pm, DON S2 could offer no explanation for the vital signs not being taken according to hospital policy for blood administration and for the policy and the instructions on the "Blood/Blood Component Administration Record" being different related to the monitoring of vital signs during the administration of blood.

Review of the hospital policy titled "Blood Administration", policy number II-C.3.15, effective 04/09 and submitted by ADON S4 as their current policy for blood administration, revealed, in part, "...All patients requiring administration of blood or blood products will be safely administered and documented by RN after informed consent. ...Procedure: ...6. Obtain pre-vital signs and document on blood transfusion Flow Sheet. ...16. Monitor vital signs every 15 minutes for the first hour and then every 30 minutes times 2 then every hour thereafter until unit is infused. 17. Adjust rate as prescribed but do not exceed 4 hours. ... 21. Document procedure in the patient record/document blood intake (250 ml [milliliter]/unit of PRBC's [packed red blood cells]) and on blood transfusion Flow Sheet...".

4) Assess a patient's wound at admission according to hospital policy:
Review of Patient #4's "LTAC Admit Physician Orders" revealed she was admitted on 02/17/11 at 5:40pm with diagnoses of decubitus ulcers right and left heels, atrial fibrillation, esophageal reflux, hypothyroidism, hyperlipidemia, anemia, depression, psychosis, edema, and hypertension.

Review of the "Admit/Weekly Photographic Wound Documentation Sheet" completed on 02/18/11 at 9:00am by RN S17 revealed a photograph and documentation of "L (left) dorsal foot". Further review revealed no documented evidence of completion of blanks labeled as: staples; length x width x depth; stage; drainage; odor; amount and color of drainage; wound bed color; slough; eschar; color and temperature of peri-wound skin; pain; tenderness; redness; swelling; length and location of tunneling or undermining; date of last CMP (complete metabolic profile), albumin, protein; and wound care. Review of the "Wound Assessment Flowsheet" revealed measurements of the wound to the left dorsal foot.

In a face-to-face interview on 02/22/11 at 3:00pm, RN S17 indicated she was the wound care RN who was at this hospital on Mondays, Wednesdays, and Fridays. She confirmed that she did the wound assessment and photograph of Patient #4's wounds on 02/18/11. S17 further confirmed she did not document an assessment of the left dorsal foot wound. S17 indicated "I guess that one slipped through".

Review of the hospital policy titled "Photographic Method of Wound Documentation", policy number II-D.5.12, revised 11/10 and submitted by ADON S4 as their current policy for documentation of wound assessments at admit, revealed, in part, "...Photo documentation of wounds will be obtained within 24 hours of admission, at onset of any new wound, weekly, and as needed until wound resolved or patient discharged. Procedure: ... 8. Attach the photo to a wound documentation form, documented written description and location of the wound will be obtained by nurse within 24 hrs. (hours) of admission or new onset of wound. Measurements of size and depth, color, odor, phase of healing, presence of necrotic and granulation tissue ... will be performed by RN Wound Care Specialist or RN Charge Nurse within 72 hours of admit or onset of new wound (policy statement has wound assessment will be obtained within 24 hours of admission). Note: When using photographic records of wounds, be aware that the dimensions of the wound will still have to be measured via some other method in order to accurately track changes in wound size. Suggested ways would be to use a tape measure or disposable transparent measuring device to measure length, width, and to use sterile Q-tips to measure depth and undermined areas...".

5) Assess a patient upon the patient's return from treatment in the ED:
Review of Patient #6's medical record revealed she was admitted on 01/19/11 at 10:00am with diagnoses of respiratory failure and strep pneumonia. Review of Patient #6's "History & Physical" revealed her past medical history included asthma, hypertension, hyperlipidemia, history of stroke, depression, acute renal failure, and dementia.

Review of the "Rapid Response Team Record" completed by RN S19 on 02/15/11 at 9:00am revealed Patient #6 was transferred to the ED at 8:50am due to bright red blood from the trach site and mouth. Further review revealed the followup report contained "returned @ (at) 1330 (1:30pm) from ... BP (blood pressure) ____ ... family @ bedside - no (circle with line through center) bleeding from site". There was no documented evidence of the author of of this note. Review of the nurse's notes for 02/15/11 revealed an entry by LPN S3 at 1:30pm of "pt (patient) returned to facility. stable condition. VS (vital signs) WNL (within normal limits)". There was no documented evidence of an assessment of Patient #6 by a RN for the remainder of the shift and the entire next 12 hour shift. There was no documented evidence that the attending physician had been called to obtain orders for care of Patient #6 upon her return from the ED.

In a face-to-face interview on 02/22/11 at 2:50pm, RN S19 confirmed she was the charge nurse on 02/15/11. She further confirmed she did not document an assessment of Patient #6 upon her return from the ED, and she did not call the physician to obtain orders upon the return of Patient #6 from the ED. She indicated it was a busy day, as they had two rapid response episodes that day.

Review of the hospital policy titled "Nursing Documentation Guidelines", policy number II-A.1/02, revised 11/10 and submitted by ADON S4 as their current policy for nursing documentation, revealed, in part, "...3. For changes in patient condition, the RN must be notified for assessment, physician notification (if applicable), and evaluation of interventions. This is to be documented in patient's daily record and communicated to the other disciplines involved in the patient's care...".

Based on record review and interviews, the hospital failed to ensure the plan of care was implemented as evidenced by: 1) failure to administer medications as ordered by the physician for 3 of 6 sampled patients (#1, #2, #3 ) and 2) failure to ensure blood was administered in a timely manner for 3 of 8 patients reviewed who received blood (#6, #R2, #R3) from a sample of 6 patients and 5 random patients. Findings:

1) Failure to administer medications as ordered by the physician:
Patient #1
Review of Patient #1's "LTAC (long term acute care) Admit Physician Orders" revealed she was admitted on 02/04/11 at 5:55pm with a diagnosis of Sepsis. Review of the "History and Physical" revealed Patient #1 had a history of diabetes accompanied by diabetic retinopathy, nephropathy, and neuropathy, morbid obesity, chronic venous ulcerations of the lower extremities with severe hyperpigmentation of the lower aspect of both lower extremities with occasional ulcerations and intermittent infections.

Review of Patient #1's medical record revealed a physician's order on 02/06/11 at 1:00PM Clonidine 0.1 mg (milligrams) by mouth every 8 hours prn (as needed) for systolic blood pressure greater than 170 or diastolic blood pressure greater than 100.

Review of Patient #1's "Vital Signs and Intake & (and) Output Records" revealed the following blood pressure and times:
02/08/11 at 6:00pm - 179/76;
02/18/11 at 6:00am - 171/87;
02/19/11 at 6:00am - 180/88; and
02/20/11 at 6:00am - 193/79.

Review of Patient #1's MARs (medication administration record) and nurse's notes revealed no documented evidence Clonidine was administered as ordered for systolic blood pressure greater than 170.

In a face-to-face interview on 02/22/11 at 3:45pm, RN (registered nurse) S6, after confirming there was no evidence that she had administered Clonidine on 02/18/11 for the blood pressure of 171/87, indicated she "probably retook the blood pressure manually and didn't write it down". She indicated if she retook it and it was below the ordered parameter, she would not have administered the Clonidine. S6 further confirmed there was no documented evidence why the Clonidine was not administered as ordered.

In a face-to-face interview on 02/22/11 at 4:30pm, DON (director of nursing) S2 indicated the hospital did not have a policy related to specific medications that require monitoring other than Digoxin.

Patient #2
Review of the medical record for Patient #2 revealed a 78 year old male admitted to the on hospital on 01/21/11 with Urosepsis and aspiration pneumonia.

Review of the Physicians' Orders for Patient #2 dated 01/26/11 revealed an order for Clonidine HCL 0.1mg tablet one by mouth every 8 hours as needed for SBP (Systolic Blood Pressure) greater than 160 and DBP (Diastolic Blood Pressure) greater than 100.

Review of the Vital Signs and Intake & Output Record for Patient #2 revealed the following recorded blood pressures:
01/31/11 at 0600 (6:00am)170/96;
02/08/11 at 1800 (6:00pm) 166/96;
02/14/11 at 1800 (6:00pm) 162/96;
02/16/11 at 0600 (6:00am) 164/88.

Review of the MAR (Medication Administration Record) for Patient #2 dated 01/31/11, 2/08/11, 02/14/11, and 02/16/11 revealed no documented evidence Clonidine had been administered as ordered.

Patient #3
Review of the medical record for Patient #3 revealed a 47 year old female admitted to the hospital on 01/25/11 for continued care after an ORIF (Open Reduction Internal Fixation) of the right hip. Further review revealed she had a history of renal failure (on dialysis) and anemia.

Review of the Physicians' Orders for Patient #3 dated 02/10/11 revealed an order for Clonidine HCL 0.1mg tablet one by mouth every 8 hours as needed for SBP (Systolic Blood Pressure) greater than 170 and DBP (Diastolic Blood Pressure) greater than 100.

Review of the Nursing Notes for Patient #3 dated/timed 02/13/11 at 1900 (7:00pm) revealed a blood pressure of 179/92.

Review of the MAR (Medication Administration Record) for Patient #3 dated 02/13/11 revealed no documented evidence Clonidine 0.1 mg was administered at 1900 (7:00pm) for a blood pressure of 179/92.

In a face-to-face interview on 02/22/11 at 4:55pm, Medical Director S12 offered no explanation when told that record reviews revealed Clonidine was not being administered as ordered for elevated blood pressures outside the acceptable parameters, and the blood pressure was not being reassessed after Clonidine had been administered.

Review of the hospital policy titled "Nursing Documentation Guidelines", policy number II-A.1/02, revised 11/10 and submitted by ADON (assistant director of nursing) S4 as their current policy for nursing documentation, revealed, in part, "...14. Medication Administration Record (MAR) documentation: ... B.) Any vital sign parameters for medications will be transcribed onto the MAR as part of the order. Vital signs required for medication administration will be documented on the MAR, along with the nurse's initials indicating the medication has been given, or held, per physician's order. C.) Pharmacy will be responsible for ensuring that all pre-printed MARs will have any required vital signs/parameters listed on the MAR. In the event there is no pre-printed MAR available, or a new medication order is received; the nurse will be responsible for documenting the entire order on the MAR, as written, including the vital sign parameters...".

2) Failure to ensure blood was administered in a timely manner:
Patient #6
Review of Patient #6's medical record revealed she was admitted on 01/19/11 at 10:00am with diagnoses of respiratory failure and strep pneumonia. Review of Patient #6's "History & Physical" revealed her past medical history included asthma, hypertension, hyperlipidemia, history of stroke, depression, acute renal failure, and dementia.

Review of Patient #6's medical record revealed an order on 01/20/11 at 11:20am to type and cross match for 2 units of packed red blood cells and transfuse each over 4 hours. Further review revealed an order on 02/20/11 at 10:30am to type and cross match one unit of packed red blood cells and give over 4 hours.

Review of the "Blood/Blood Component Administration Record" revealed no documented evidence of the date and time the first unit of blood was received and the date and time the transfusion was started. Review of the form received from the blood bank revealed the transfusion was started on 01/20/11 at 2130 (9:30pm). There was no documented evidence of a reason for the delay in administering blood for greater than 10 hours and that the physician was notified of the delay.

Review of the "Blood/Blood Component Administration Record" revealed the one unit of blood was received from the blood bank on 02/21/11 at 12:00am and begun at 3:00am, more than 16 hours after the order to transfuse was received.

In a face-to-face interview on 02/22/11 at 6:40pm, RN S13 indicated she was the charge nurse on the day shift (6:00am to 6:00pm) on 02/20/11. She further indicated she had a one-to-one patient to whom she was administering Dopamine and blood. She further indicated this required her to be in this patient's room almost all day. S13 indicated she was not aware of the order for blood for Patient #6, and no one had brought it to her attention. She further indicated she did not learn of the need for a type and cross match and administration of a unit of blood until 5:00pm that evening, and she reported the need for this to the oncoming RN. RN S13 indicated she did not notify the physician of the delay in administering blood.

Patient #R2
Review of Patient #R2's medical record revealed he was admitted on 12/08/10 with a diagnosis of resolving aspiration pneumonitis and MRSA (Methicillin-Resistant Staphylococcus Aureus) pneumonia. Review of his H&P revealed he had a history of chronic lymphocytic leukemia, acute kidney insufficiency with electrolyte abnormalities, status post pleural effusions with thoracentesis, atrial fibrillation, and chronic anemia.

Review of Patient #R2's physician orders revealed an order on 12/29/10 at 11:00am to type and cross match for 2 units of packed red blood cells and transfuse each over 4 hours.

Review of the "Blood/Blood Component Administration Record" revealed the first of unit of blood was received on 12/29/10 at 11:00pm and started at 12:00am on 12/30/10, 13 hours after the order was received to transfuse. Review of Patient #R2's medical record revealed no documented evidence of the reason for the delay in administering the blood and that the physician was notified of the delay.

Patient #R3
Review of Patient #R3's medical record revealed he was admitted on 12/03/10 with a diagnosis of infected sacral decubitus ulcer Stage III to IV. Further review revealed he had a history of diabetes mellitus type II, hypothyroidism, and chronic urinary tract infections.

Review of Patient #R3's physician orders revealed an order on 12/04/10 at 9:00am to type and cross match for 2 units of packed red blood cells and give each over 4 hours. Further review revealed an order on 01/10/11 at 9:00am to infuse 2 units of packed red blood cells each over 4 hours.

Review of the medical record revealed no documented evidence of the "Blood/Blood Component Administration Record" for the first of unit of blood that was begun on 12/05/10 at 12:45am, more than 15 hours after the order was received to transfuse. Further review the "Blood/Blood Component Administration Record" for the first of unit of blood on 01/10/11 revealed it was received at 9:00pm and started at 12:30am on 01/11/11, more than 15 hours after the order was received to transfuse. Further review revealed the second unit of blood was not started until 11:05am on 01/11/11, more than 6 1/2 hours after the first blood administration was completed. Review of the medical record revealed no documented evidence of the reason for the delay in administering the blood and that the physician was notified of the delays.

In a face-to-face interview on 02/23/100 at 4:00pm, DON S2 could offer no explanation for the delay in the administration of blood.

Review of the hospital policy titled "Blood Administration", policy number II-C.3.15, effective 04/09 and submitted by ADON S4 as their current policy for blood administration, revealed no documented evidence that the timeliness of blood administration in relation to the time the order was received to transfuse had been addressed.