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Based on medical record review, facility documentation, staff interview, and facility policy review, the facility failed to ensure staff properly verified patients' identities at the bedside prior to blood transfusions. (A-0410).

Based on medical record review and staff interview, the facility failed to ensure restraint use was in accordance with the physician's order. This affected one (Patient #3) of two patients reviewed for restraints. The facility's census was 68.

Findings include:

Review of the medical record for Patient #3 revealed orders dated 11/06/24 at 10:33 AM for bilateral soft wrist restraints. The medical record documentation on 11/06/24 at 2:29 PM revealed bilateral secured mittens were in use until 8:00 PM when the restraints changed to a left secured mitten and a right soft wrist restraint. On 11/25/24 at 6:57 AM bilateral unsecured mittens were ordered. The medical record contained documentation of a left unsecured mitten only on 11/25/24 at 6:58 AM. On 11/28/24 at 7:59 AM bilateral unsecured mittens were ordered. The medical record contained documentation of bilateral soft wrist restraints on 11/28/24 from 6:00 AM until discontinued at 8:00 PM. The medical record lacked additional restraint orders on these dates.


Interview on 02/06/25 at 3:05 PM, Staff E verified the above findings.

Based on medical record review, facility documentation, staff interview, and facility policy review, the facility failed to ensure staff properly verified patients' identities at the bedside prior to blood transfusions. This affected two patients (Patient #1 and Patient #2) in a sample of nine patients reviewed for blood administration. This deficient practice had the potential to affect any patient who required blood administration at the facility. The facility census was 68.

Findings include:

Review of the medical record revealed Patient (Pt) #1 was admitted to the facility's West campus on 01/18/25. Diagnoses included history of a motor vehicle accident with traumatic chest injury, multiple rib and sternal fractures, respiratory failure which required intubation, anemia, thoracic and lumbar spine fractures, liver injury, and multiple abdominal injuries. The physician's progress note dated 01/23/25 documented the patient's red blood cell count (RBC) was normal at 2.2 cells/microliter (c/mcL) (normal 4.7 to 6.1 c/mcL), hemoglobin was 7.0 grams/decliter (g/dL) (normal was 13.5 to 17.5 g/dL), and hematocrit was 22.5% (normal 38% to 48%). The progress note documented the hemoglobin was borderline at 7.0 g/dL and transfuse if it goes lower. The laboratory tests dated 01/24/25 documented Pt #1's hemoglobin was 6.6 g/dL and the physician ordered the patient to have a blood transfusion. The patient was blood typed and screened and found to have ABO blood group type O positive blood. The medical record documented on 01/24/25 at approximately 7:00 PM Pt #1's unit of O positive blood arrived at the facility. Pt #1's blood transfusion was initiated at approximately 7:19 PM. The Single Transfusion Record form documented Supervisory Staff Nurse F and Staff Nurse H both attested on 01/24/25 the following: "I am currently at the bedside with the nurse who will complete Dual Signoff and we have validated the patient's identity with two forms of identification." The nurses' notes dated 01/24/25 at 11:18 PM documented the patient received wrong unit of blood which was mixed up with neighbor's blood. Transfusion started at 7:14 PM and was stopped at 7:42 PM after receiving 41 milliliters (ml). The physician was notified, ordered a bolus of normal saline (NS) intravenous (IV), and to follow up with blood bank protocol. Suggested to be transported to the nearest hospital. The patient was transported to the hospital at 8:55 PM for further observation. Review of the acute care hospital's post transfusion laboratory analysis by the acute care hospital pathologist documented impressions included there was an evidence of mild acute hemolytic transfusion reaction. No further blood transfusions are recommended for this patient.


Review of the medical record revealed Pt #2 was admitted to the facility's West campus on 01/20/25. Diagnoses included respiratory failure, circulatory shock, gastrointestinal (GI) bleeding, large B-cell lymphoma with mediastinal lymphadenopathy, history of deep vein thrombus, pulmonary emboli, and history of tumor lysis syndrome. The patient has aggressive B-cell lymphoma with metastasis and hemorrhagic effusion. Review of the patient's 01/24/25 complete blood count (CBC) documented the patient with a RBC count of 2.32 c/mcL, hemoglobin of 6.9 g/dL, and a hematocrit of 22.8%. The medical record documented the patient was ordered a blood transfusion on 01/23/25. The patient was typed and screened and found to have ABO blood group type A negative blood. The medical record documented on 01/24/25 at approximately 6:59 PM Pt #2's A negative unit of blood arrived at the facility. Pt #2's blood transfusion was initiated at approximately 7:20 PM. The Single Transfusion Record form documented Supervisory Nurse G and Staff Nurse I both attested on 01/24/25 the following: "I am currently at the bedside with the nurse who will complete Dual Signoff and we have validated the patient's identity with two forms of identification." Review of the PT #2's physician's Significant Event Progress note dated 01/24/25 at 11:19 PM documented the physician was contacted by the charge nurse regarding Pt #2 was supposed to receive blood this evening. Instead of getting the blood intended for him (A negative) he received the blood intended for his neighbor. Patient received what was reported to be roughly 50 mls of Type O positive blood. Upon discovery of the mismatch the blood transfusion was stopped immediately. The physician advised the charge nurse to contact the blood bank and to follow the protocols they outline for incorrect transfusion as well as hospital policies of contacting family and leadership, all while monitoring patient for reaction and maintaining stable vitals.


Review of the facility's adverse event documentation revealed the facility's West campus administrative staff received a report that on the evening of 01/24/25 two patients (Pt #1 and Pt #2) received the wrong ABO type blood. The adverse event report documented "Found the nurses failed to follow the facility's Blood Administration Policy (B04-N) by ensuring the use of two patient identifiers which resulted in the incorrect blood administered to two patients." The investigation documentation revealed there were multiple deviations from the policy which included two units of blood were verified at the nurses' station against the paperwork and physician orders. The two units of blood were never checked at the bedside against the patients' wrist bands thereby Pt #1 received Pt #2's intended unit of blood and Pt #2 received Pt #1's intended unit of blood. Four nurses failed to verify the patients with their names on the units of blood and the patients' wrist identification bracelets at the bedside. This adverse event was documented as having the potential to affect all patients.


Review of the West campus Patient Safety Huddle forms used during nursing shift report documented immediate re-education of Staff F, Staff G, Staff H and Staff I was initiated on 01/25/25. The re-education directed nurses must complete the mandatory verification using two nursing staff and two patient identifiers with the verification performed at the bedside. Documentation revealed Staff F, Staff G, Staff H and Staff I received written disciplinary action.


Review of the facility's policy and procedure titled "Blood/Blood Components Administration (Packed Cells, Plasma, Platelets Cryoprecipitate)," revised 07/01/24, revealed the purpose was to establish a policy and procedures for the safe administration of blood and/or blood components. Under the heading of Procedure Item 5 states Perform dual verification of blood products at the bedside as follows: a. Two registered nurses (RN), one of whom must be the Chief Nursing Officer (CNO), House Supervisor (HS), Nurse Manager (NM) or Clinical Coordinator (CC), and the other must be the RN initiating the transfusion and h. Spell aloud and verify the patient's name and hospital number on crossmatch tag and match the patient's ID bracelet. NOTE: Patient Identifiers and labeling requirements must match that of the issuing blood bank. NOTE: If there are any discrepancies, do not start the transfusion and immediately contact the contracted blood bank.


Interview with Director of Quality Management, Nurse C, on 02/05/25 at 11:31 AM revealed there had been an adverse event on 01/24/25 in regard to blood administration. The facility had conducted a Root Cause Analysis (RCA). The RCA had identified multiple errors related to the adverse event on 01/24/25 related to the administration of the wrong blood to two patients. Staff C verbalized blood transfusions were currently being administered by facility nursing staff per physician orders. Staff C verbalized each facility campus was responsible for re-educating their own nursing staff. Staff C verbalized staff had until 02/08/25 to complete the facility's blood administration re-education.


Interview on 02/12/25 at 11:23 AM Staff A confirmed East campus nurses had administered blood transfusions to four patients (Patient #11, Patient #12, Patient #13, and Patient #14) after 01/24/25 and prior to nurse's re-education for blood product patient verification at the bedside.