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Based on interview and documentation review it was determined the medical staff failed to identify/assess that blood ordered for transfusion needed to be JKb antigen negative.

1.) Review of the medical record indicated an order was written on 7/26/10 at 3:00 PM to type and cross for two units of packed red blood cells and to transfuse each unit over hours hours.

2.) Review of the transfusion record indicated the first unit of blood was started at 10:35 PM and was stopped at 11:20 PM

3.) Nurse #4 was interviewed by telephone on 8/12/10 at 11:00 AM. Nurse #4 said the blood was hung on the evening shift just an hour before she checked the transfusion. Nurse #4 recalled reading that if the Patient needed to receive blood transfusions the blood needed to be tested for the JKb antigen. Nurse #4 said she checked the ordered and called the blood bank and the blood bank reported to her that the blood was not tested for the JKb antigen. Nurse #4 said she stopped the blood and called the physician. Nurse #4 said the Patient remained stable and did not have a transfusion reaction.

4.) The Attending Physician was interviewed in person on 8/16/10 at 9:30 AM. The Attending Physician said it was his mistake that he did not order the blood to be tested for the JKb antigen.

Based on a tour of the Chronic Care Unit and staff interviews the Hospital failed to maintained the Chronic Care Unit in such a manner that the safety and well being of patients are assured. Findings include:

1) A tour of the Chronic Care Unit was performed on 8/12/10 at 8:20 AM with the Chief Clinical Officer. Observed during the tour, a patient who was on contact precautions walked out of his room and helped himself to linen from a facility laundry linen cart.

2.) Nurse #1 was interviewed by telephone on 8/16/10 at 10:40 AM. Nurse #1 admitted to placing soiled toilet paper into a trash barrel. Nurse #1 was asked by the Surveyor if she removed the trash that contained the soiled toilet paper from the Patient's room after assisting/providing care needs to the Patient and Nurse #1 said she did not remember.

3.) Nurse #2 was interviewed by telephone on 8/12/10 at 11:10 AM. Nurse #2 recalled the Patient and recalled starting an intravenous (IV) in the Patient's right lower arm. Nurse #2 said she felt for a vein and prepped the skin with alcohol without gloves on. Nurse #2 said she then put one glove on her right hand, the hand that placed the needle into the vein for the IV. Nurse #2 said her left hand, not gloved, was holding the Patient's skin.

Based on documentation review, it was determined the Rehabilitation Hospital had not (yet) fully implemented a Corrective Action Plan related to its Internal Investigation of the failure of the Patient to receive his morning medications before he left the facility for an appointment.

Findings included:

Review of the Rehabilitation Hospital's Internal Investigation indicated the facility reviewed the incident regarding the Patient leaving the facility on the morning of 7/29/10 without receiving morning medications and without the appropriate paper work..

A review of the Corrective Action Plan related to the Hospital's Internal Investigation of the Patient's leaving with receiving his medications and the appropriate paper work indicated a form was developed so that a patient will not be able to leave the facility until the form is completed by the patient's primary nurse. However, the staff education regarding the new form was underway, but not completed.

Based on documentation review of one of one applicable medical record it was determined the administration of the Patient's medications on 7/30/10 were not administered according to accepted standards of practice.

Finding include:

1.) Review of the Patient's medication administration records (MAR) dated 7/29/10 indicated that the Patient was scheduled to receive morning medication at 9:00 AM. The medications included Adair, Norvasc, colace, folic acid, magnesium oxide, mepron, lopressor, neoral , Prilosec, prednisone, valganciclovir. The MAR indicated Nurse #1 failed to administer medications as required by Hospital policy

2.) Review of Nursing Policy/Procedure for administering medications indicated the following: medications were to be administered at the right time and the nurse administering medications shall initial in the appropriate box on the MAR to indicate medications held.

3.) Review of the Patient's admission orders dated 7/17/10 indicated that the Patient had a follow-up appointment with an infectious disease physician at an acute care hospital in Boston on 7/29/10. The orders also included to arrange for transportation.

4.) The Case Manager was interviewed in person on 8/16/10 at 8:00 AM. The Case Manager said on 7/26/10 the Patient was scheduled for one appointment on 7/29/10 and she scheduled a second appointment for 7/29/10. The Case Manager said it was the Case Management Office that makes transportation arrangements for patients transportation.

5.) Review of the Log for transportation arrangements indicated that on 7/26/10 transportation was arranged for the Patient to be picked up at 10:30 AM on 7/29/10.

6.) Nurse #1 was interviewed by telephone on 8/16/10 at 10:40 AM. Nurse #1 said no one told her and it was not written on the white bord that the Patient was leaving at 10:00 AM as was the usual practice. Nurse #1 said she was told in report that the Patient was leaving at 1:00 PM.

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