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Based on record review and interview the facility failed to have written data, performance improvements, and reported opportunities for improvement, changes, measures, and performance tracking for the following:

A. identify and process blood transfusions involving a patient death.
B. identify, process and report physician orders not implemented for patient telemetry monitoring involving a patient death.
C. Identify and reporting incomplete nursing assessments for telemetry patients and blood transfusions that resulted in a death.


Review of the patient's chart, Rebecca Marshall, revealed the patient was admitted to Post Acute Medical Specialty Hospital on 3/1/18 for Acute Respiratory Failure, Acute CHF, uncontrolled DM. Patient had pneumonia and was transferred to the LTAC for care.

Review of the patient's orders revealed there was no order for a Foley catheter or catheter care. Nurses notes revealed the patient had a Foley catheter and a physician order was written to discontinue the catheter on 3/13/18 at 1800 (6:00PM). This was not found or addressed during the root cause analysis performed by the PAM staff.

Review of the complaint stated that the patient was ordered telemetry and was never put on telemetry. Review of the chart revealed the patient had a physician order dated 3/1/18 at 1330 (1:30PM) for telemetry. The nurse signed at 1920 (7:20PM) that she had checked all the orders but the telemetry was not carried out.
Review of the nurse's notes dated 3/1/18 and 3/2/18 revealed the nurse had charted the patient had on telemetry. The nurses note from 3/3/18-3/18/18 showed the patient was not on telemetry. The nurse and physicians failed to monitor the patient's heart.

Review of the laboratory results revealed the patient had a critical Hemoglobin of 6.2 (10.9-14.3) and a critical platelet of 11 (130-400 x (10) 3). The critical lab values were called into Alton Williams LVN at 8:01AM. Documentation was found in the nursing note that the MD was aware of the critical lab value dated 3-18-18 at 9:00AM.

Review of the lab reports for 3-18-18 revealed the patient had blood drawn again at 8:20AM and sent to the lab for another CBC. The patient's hemoglobin was low at 7.2 and platelets were low at 83 but no longer critical. On 3-18-18 at 10:10AM a physician order stated to type and screen and ordered to give 2 units of packed red blood cells.

Review of the chart revealed the patient was started on the first unit on 3-18-18 at 18:00. There was no documentation on why the blood was delayed for 8 hours. Review of the patient's transfusion record revealed the patient had pre vital signs of T-99.6, Pulse 80, Respirations 18 and blood pressure of 98/55. The patient's vital signs upon completion of the blood was T- 100.4, Pulse 116, Respirations 22 and a blood pressure of 126/69. The patient also complained of nausea and was given a dose of Zofran. The nurse administering the blood (staff #5) failed to call the doctor and inform him of the elevated vital signs and nausea before continuing on to the second unit. The transfusion record clearly stated that nausea could be a sign and symptom of a transfusion reaction.

The second unit of blood was started at 2345 (11:45PM). The patient's pre-vital signs were T-98.0 Pulse 124, respirations 20 and a blood pressure of 117/57. Review of the nurse's notes dated 3/18/18 at 2200 (10:00PM) staff #5 documented, "Lasix given after transfusion. Zosyn hung waiting for 2nd unit of RBC's. 2345 2nd RBC hung. Pt awakes to verbal stimuli. Educated on transfusion reactions verbalizing understanding. 0100 VSS. Pulse slightly elevated. Pt denies needs, appears agitated. Says "leave me alone." Will monitor closely. 0155 Arrived in room and pt is unresponsive, pale, cool, and unable to find a pulse. Code blue called."

During the transfusion the patients pulse went from 80 to 116 and finally to 124.

According to the MAYO clinic, "Tachycardia is a common type of heart rhythm disorder (arrhythmia) in which the heart beats faster than normal while at rest.

It's normal for your heart rate to rise during exercise or as a physiological response to stress, trauma or illness (sinus tachycardia). But in tachycardia (tak-ih-KAHR-dee-uh), the heart beats faster than normal in the upper or lower chambers of the heart or both while at rest.

Your heart rate is controlled by electrical signals sent across heart tissues. Tachycardia occurs when an abnormality in the heart produces rapid electrical signals that quicken the heart rate, which is normally about 60 to 100 beats a minute at rest.

In some cases, tachycardia may cause no symptoms or complications. But if left untreated, tachycardia can disrupt normal heart function and lead to serious complications, including:

Heart failure
Stroke
Sudden cardiac arrest or death.

Treatments, such as drugs, medical procedures or surgery, may help control a rapid heartbeat or manage other conditions contributing to tachycardia."



Staff #15 failed to document any assessment of the patient heart rhythm, failed to note the patient was not being monitored by telemetry as ordered, and failed to notify the physician of a possible impending cardiac event and possible transfusion reaction. The time of patient's death was 3:05AM. Review of the nurses notes for 3/19/18 at 3:05 AM revealed the staff #5 had pre-charted on the patients flow sheet. The nurse charted she had visually observed the patient position herself in the bed, that head of bed was elevated, that the patient voided, side rails were up, call light in reach, and side rails up from 3:00AM to 6:00AM. The nurse went back to the paper chart and marked through her documentation from 3:00AM to 6:00AM and wrote error.

Review of an incident report dated 8/21/18 revealed the patient did have a portable heart monitor on but was not being monitored at the nurse's desk. The blood bank was not notified of the patient's death.

An interview was conducted with staff #2 on 8-13-18 concerning patient #1. Staff #2 stated he was aware of the incident and showed the surveyor a root cause analysis (RCA) performed on March of 2018. The RCA revealed, "According to documentation, the patient had a change in condition. Patients HR was noted to be evaluated during transfusion of 2nd unit of PRBC. I see no documentation in nurses notes of a reassessment by the nurse. The patient had an order for telemetry. It is noted that the patient had a telemetry box attached, but was not on the monitor at the nurse's station."

Review of the RCA revealed an action plan was put into place. Risk Reduction Strategies,
"Action #1 Education will be provided to all clinical staff on March 29th regarding blood transfusion administration, assessment, and documentation.

Action item #2 A process will be developed to ensure all patients with orders for telemetry are carried out. This process will be developed by March 29th.

Action #3 Education will be provided to all clinical staff on proper procedures to follow for reaction or death during a blood transfusion on March 29th."

Review of the Clinical Staff Meeting held on March 29th 2018 revealed the staff was educated on the blood transfusion policy, administration on blood, documentation on pre and post transfusion. A focus was done on Congestive Heart Failure patients, patient assessments during blood transfusions, signs and symptoms of reactions during a transfusion. Lengthy education was done on telemetry, process, and proper chart checks.

Review of Staff #5's training revealed the RN had extensive training over her blood administration and patient assessment. Staff #5 was observed by the nurse manager in giving blood to another patient after her education and was observed and marked off on proper administration.

Staff #2 had documented his Performance Improvement PI on the blood administration, telemetry, and nursing assessments. Staff #2 stated that they have been performing 100% chart audits on all blood administration. The nurse managers have been auditing the charts.

Review of the Quality Assessment Performance Improvement (QAPI) revealed there was no documentation of the PI processes in QAPI or reported to the Medical Executive Committee or Governing Board.

An interview with staff # 3 on 8-13-18 revealed that the PI processes and implementations have been discussed in the meetings, and talked about, but there was nothing in writing through QAPI on the blood transfusions, telemetry, and nursing assessments. Staff # 3 stated that she had just started in this position on 6/4/18 and no prior Quality experience. Staff # 3 stated that she was not sure what she needed to do to implement all this data into the QAPI report at this time.