HospitalInspections.org

Based on record review and staff interviews, the hospital's Quality Assurance and Performance Improvement (QAPI) Program failed to accurately report data on blood transfusions administered in February of 2025.

Findings include:

During a review of the hospital's 2025 Blood Transfusion Reporting in QAPI, the surveyor observed that the Quality Program had inaccurate data related to the number of blood transfusions given in the hospital. The hospital's Quality Program reported "0" transfusions administered in February 2025.

A review of medical records for Patient # 1 revealed the patient received 2 units of packed red blood cells on 02/25/2025.
This data was not reported to the Quality Program.

An interview was conducted with Staff # 7 on 03/17/2025 at 3:45 PM which confirmed the data reported in February of 2025 was incorrect.

Based on record review and staff interviews, the hospital's Quality Assurance and Performance Improvement (QAPI) Program failed to identify systemic problems with the creation, approval, and implementation of hospital policies.

Findings include:

During a review of the hospital's QAPI program with Staff # 7 (Director of Quality), the surveyor observed two policies with multiple active versions available for use by the hospital's staff members.

There were two active policies relating to the process of blood administration and transfusions.

Policy # 1 relating to blood product administration:

Policy Title: "Administration of Blood Products" with a policy ID of "16833737" and an effective date of "12/2024". The policy's owner was documented as Staff # 3 and the policy's status was "Active".
The policy's approval process was as follows: Board Approval: Staff # 7 (Director of Quality)
Medical Staff Approval: Staff # 7 (Director of Quality), Quality Committee Approval: Staff # 7 (Director of Quality).

Policy # 2 relating to blood product administration:

Policy Title: Transfusion of Blood and Blood Products with a policy ID of "17636224" and an effective date of "02/2025". The policy's owner was documented as Staff # 7 and the policy's status was "Active". The policy's approval process was as follows: Board Approval: Staff # 7 (Director of Quality)
Medical Staff Approval: Staff # 7 (Director of Quality), Quality Committee Approval: Staff # 7 (Director of Quality).

The two policies related to blood product administration gave staff members different processes to follow.

There were two active policies relating to nurse staffing.

Policy # 1 relating to Nurse Staffing:

Policy Title: "Nurse Staffing Plan" with a policy ID of "17556310" and an effective date of "02/2025". The policy's owner is listed as Staff # 3 and the policy's status was "Active". The policy's approval process was as follows: The policy's approval process was as follows: Board Approval: Staff # 7 (Director of Quality) Medical Staff Approval: Staff # 7 (Director of Quality), Quality Committee Approval: Staff # 7 (Director of Quality).

Policy # 2 relating to Nurse Staffing:

Policy Title "Nurse Staffing Plan" with a policy ID of "15663893" and an effective of "05/2024". The policy's owner is listed as Staff # 3 and the policy's status was "Active". The policy's approval process was as follows: The policy's approval process was as follows: Board Approval: Staff # 52, Medical Staff Approval: None. Quality Committee Approval: Staff # 7 (Director of Quality).

The two policies relating to Nurse Staffing gave staff members different processes and staffing matrices to follow.

An interview was conducted with Staff # 7 on 03/17/2025 at 3:30 PM. Staff # 7 acknowledged there were multiple policies with conflicting information. Staff # 7 stated, "We must have overlooked this with all the extra stuff I have on my plate. We will get this fixed".