HospitalInspections.org

Based on document review and interview the facility failed to monitor and ensure blood products were being administered in a safe manner. The facility failed to enforce their policy/procedures for administering blood.
Refer to Tags; A0409 and A0410

Based on document review and interview the facility failed to follow their policy/ procedures for administering blood transfusions in a safe manner for 2 of 2 patients (#3 and #4).
Review of the policy and procedure "Blood Product Administration" states, "Ordering Blood and/or Blood products;
-A written order must be placed in the patients chart by the physician or the nurse acting on the part of the physician per telephone order.
-Lab personnel must carefully identify the patient using the facility identifiers to make absolutely sure there is no error in identification.
- The facility personnel will go to the hospital to obtain one unit of blood that has been allocated to the patient to be treated.
Receiving Blood and/or Blood Products;
A. Blood or Blood products will be checked in with the RN in charge of the transfusion process.
B. If more than one unit is to be transfused, each additional unit will be obtained at a later time. Only one unit will be brought back to the facility at a time.
C. The RN will then follow the Blood Administration Policy to infuse the product.
Blood Administration;
- Verify Physician order.
- Prepare the infusion set and IV of 0.9% normal saline.
- Compare name and birth date on the blood bag tag to those on the patient's lab bracelet, hospital ID bracelet and transfusion form. THEY MUST BE THE SAME!!!
Procedure;
- Start the infusion slowly (50ml/hour or less for the first 15 minutes). Observe closely throughout the transfusion.
- A blood transfusion will be delivered in a four hour time frame, from the time it is obtained from the blood bank.
- Monitor and record vital signs on Transfusion Record prior to start of the infusion, 15 minutes after the infusion starts, the hourly until the infusion is complete and the final vital signs 1 post transfusion. "
1. Review of patient #4's medical record revealed an order was written on 2/26/14 at 10:00AM. The order read, "Type and Cross match 2 Units PRBC (packed red blood cells)."
The nurses' notes for 2/26/14 revealed patient #4 received two units of packed red blood cells (PRBC). There was no evidence of an order to transfuse blood.
A review was done of two documents titled; Transfusion Sheet (Transfusion Sheet #1, #2). The documents revealed patient #4 received two units of packed red blood cells (PRBC), (The transfusion sheets documents the critical elements necessary to ensure the patient is receiving the correct blood and critical elements necessary to later track the blood if the patient were to have a reaction or contract and disease). The Transfusion Sheet did not contain the required critical elements.
- Transfusion Sheets #1 and #2 did not have the date or time when blood was picked up from the lab.
- Transfusion Sheets #1 and #2 did not have signatures of the technician issuing the blood or the messenger picking up the blood. Transfusion Sheets #1 and #2 contained initials. Interview with staff #5 on 3/5/14 at 2:30PM was unable to identify these individuals by their initials.
-The nurse's notes revealed that the blood was started at 2:45AM on Transfusion Sheets #1 and the blood was started at 5:45AM on Transfusion Sheets #2. Transfusion Sheets #1 and #2 revealed the blood was transfused in three hours, not the required four hours per the facility's policy.
-The time documented on the vital signs portion of the Transfusion Sheets #1 revealed the first vitals were taken at 2:35AM. The blood was started at 2:45AM Vital were taken 15 min later at 3:00AM, and again, post transfusion, at 5:00AM. Vital signs were not documented every hour after the first 15 minutes. Transfusion Sheets #1 revealed the blood was transfused in two hours and fifteen minutes, not the required four hours per the facility's policy.
-There was no documentation the blood was transfused with normal saline.
Interview with Staff #5 on 3/5/14 at 2:30PM confirmed there was not an order to administer blood.

2. Review of patient #3's medical record revealed an order written on 2/26/14 @10:25 AM. The order revealed:
1.) Type and cross for 2 units of PRBC (packed red blood cells).
2.) Give one unit now with post (after) H&H (hematocrit and hemoglobin) and with Lasix (diuretic) 40mg IV before transfusion.
3.) Hold 1 unit of PRBC. Notify nurse practitioner of H&H after first unit.

A review of the document dated 2/26/14 and titled; Transfusion Sheet revealed:
- no date or time when blood was picked up from the lab.
- no signatures of the technician issuing the blood or signature of the messenger picking up the blood. The Transfusion contained initials. Interview with staff #5 on 3/5/14 at 2:30PM was unable to identify these individuals by their initials.
- Patient / Family Instructions for Suspected Transfusion Reaction are blank.
-The time documented on the vital signs portion of the Transfusion Sheets revealed the first vitals were taken at 1:30PM. The blood was started at 1:35PM Vital were taken 15 min later at 1:50PM, and again, post transfusion, at 4:35PM. Vital signs were not documented every hour after the first 15 minutes as per facility policy. Transfusion Sheets revealed the blood was transfused in three hours, not the required four hours per the facility's policy.
- No documentation that the nurse practitioner or physician was notified of the post H&H as per order.
Interview with staff #5 on 3/5/14 at 2:30PM acknowledged that remedial and further instruction was needed for blood administration.

Based on document review and interviews the facility failed to report incidents on blood administration. Blood transfusions are not being followed and regularly monitored through the QAPI process. 2 of 2 patients (#3 and #4) reviewed had incidents identified while receiving blood.
There were no incident reports provided for patient #3 and #4 for review. There were no incident reports of blood being administered without a physician's order.
Interview with staff #5 on 3/5/14 confirmed that the blood charts have not been audited and monitored appropriately in the past. Staff #5 confirmed that the process has not been followed in the QAPI process.

Based on observation and interview, the facility failed to ensure supplies were protected from being soiled. Five (5) wire carts with patient supplies were found with no impermeable barrier on the bottom shelves. This practice failed to protect supplies stored on the bottom shelves from being contaminated from floor debris.

Findings include:

During a tour of the facility 3/4/14 at 9:30am, the following wire storage carts were found with no impermeable barrier on the bottom shelf:
-One supply storage cart in central supply;
-One linen storage cart in the linen supply room;
-One rolling supply cart in the linen supply room;
-One supply cart in the oxygen storage room (room 232);
-One linen cart in the nurses' station clean linen room.

During the tour, staff #14 confirmed these findings.