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Based on interview, record review, and observation it was determined that the Governing Body failed to be effective based on deficiencies cited and the complaint investigation conducted on 09/04/13. This failure had the potential to affect all 108 patients evaluated and/or treated in the hospital's Emergency Department (ED) and 10 patients admitted to inpatient hospital care from 08/22/13 to 09/04/13 at 11:19 AM. See A115, A576, and A1100.

Based on records review, interviews, and observation, it was determined that the facility failed to protect the rights of patients and failed to provide care in a safe setting in that the hospital laboratory had zero (0) units of blood available for 13 consecutive days from 08/22/13 to 09/04/13 at 11:19 AM. See Tag A144.

Based on record reviews, interviews, and observation, it was determined that the facility failed to maintain or have available adequate laboratory services to meet the needs of its patients in that the laboratory had zero (0) units of blood available for 13 consecutive days from 08/22/13 to 09/04/13 at 11:19 AM. See A583.

Based on record reviews, interviews, and observation, the facility failed to meet the emergency needs of patient in accordance with acceptable standards of practice in that the the hospital leadership and ED personnel was unaware for 13 days that the laboratory had zero (0) units of blood available. See A1103.

Based on observation, interviews, and record review, it was determined that the facility failed to provide patient care in a safe setting in that the hospital laboratory had zero (0) units of blood available for 13 consecutive days from 08/22/13 to 09/04/13 at 11:19 AM.

Findings included:

Observations on 09/04/13 at 10:05 AM reflected no units of blood in the laboratory refrigerator.

During an interview on 09/03/13 at 14:25 PM Hospital Personnel #12 stated he knew the laboratory was supposed to have two units of blood but none was available.

On 09/04/13 at 10:05 AM Hospital Personnel #2 was asked about blood supply in the laboratory. Hospital Personnel #2 stated there had been "no blood units since 08/21[13] when the last unit expired." The contract with the blood bank supplier had been canceled.

Hospital Personnel #10 stated on 09/04/13 around 10:45 AM that he became aware of the lack of blood supply on 09/03/13.

Hospital Personnel #1 and Hospital Personnel #11 were interviewed in the hospital Emergency Department (ED) on 09/04/13 at 16:30 PM and stated they had been unaware that the laboratory had no blood supply.

Record review of the hospital ED log reflected 108 patient encounters dated 08/22/13 to 09/04/13.

Record review of the hospital's Transfusion Policy #3231 dated 06/01/04 noted "...it is the policy...that in order to support a patient with severe hypovolemia due to blood loss...a patient may need to receive blood from a universal donor..." and established the procedure for "...RNs may obtain blood from the lab."

Based on observation, interviews, and record review, it was determined that the facility did not have emergency laboratory services available to meet the emergency needs of its patients in that the laboratory had zero (0) units of blood available for 13 consecutive days from 08/22/13 to 11:19 AM on 09/04/13.

Findings included:

Observations on 09/04/13 at 10:05 AM reflected no units of blood in the laboratory refrigerator.

During an interview on 09/03/13 at 14:25 PM Hospital Personnel #12 stated he knew the laboratory was supposed to have two units of blood but none was available.

On 09/04/13 at 10:05 AM Hospital Personnel #2 was asked about blood supply in the laboratory. Hospital Personnel #2 stated there had been "no blood units since 08/21[13] when the last unit expired." The contract with the blood bank supplier had been canceled.

Hospital Personnel #10 stated on 09/04/13 around 10:45 AM that he became aware of the lack of blood supply on 09/03/13.

Record review of the hospital ED log reflected 108 patient encounters dated 08/22/13 to 09/04/13.

Record review of the hospital's Transfusion Policy #3231 dated 06/01/04 noted "...it is the policy...that in order to support a patient with severe hypovolemia due to blood loss...a patient may need to receive blood from a universal donor..." and established the procedure for "...RNs may obtain blood from the lab."

Based on observation, interviews, and record review, it was determined that the facility failed to integrate the Emergency Department Services with other departments in the hospital in hospital leadership and ED personnel was unaware for 13 days that the laboratory had zero (0) units of blood available for patient use from 08/22/13 to 09/04/13.

Findings included:

Observations on 09/04/13 at 10:05 AM reflected no units of blood in the laboratory refrigerator.

During an interview on 09/03/13 at 14:25 PM Hospital Personnel #12 stated he knew the laboratory was supposed to have two units of blood but none was available.

On 09/04/13 at 10:05 AM Hospital Personnel #2 was asked about blood supply in the laboratory. Hospital Personnel #2 stated there had been "no blood units since 08/21[13] when the last unit expired." The contract with the blood bank supplier had been canceled.

Hospital Personnel #10 stated on 09/04/13 around 10:45 AM that he became aware of the lack of blood supply on 09/03/13.

Hospital Personnel #1 and Hospital Personnel #11 were interviewed in the hospital Emergency Department (ED) on 09/04/13 at 16:30 PM and stated they had been unaware that the laboratory had no blood supply.

Record review of the hospital ED log reflected 108 patient encounters dated 08/22/13 to 09/04/13.

Record review of the hospital's Transfusion Policy #3231 dated 06/01/04 noted "...it is the policy...that in order to support a patient with severe hypovolemia due to blood loss...a patient may need to receive blood from a universal donor..." and established the procedure for "...RNs may obtain blood from the lab."