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Based on record review and interview, the facility failed to follow policy and procedure for incident reporting when oxygen (SPO2) alarms were found not functioning properly. This had the potential to affect all patients admitted to the facility. The active census was 53.

Findings include:

Staff A stated in an interview on 09/17/18 at 10:30 AM there was a "rumor" within the facility that SPO2 alarms were being turned off on the high observation unit. At the same time an interview was conducted with Staff D whom stated a staff member reported finding the SPO2 alarms being turned off on the high observation unit. Staff D reported conducting an internal investigation and found no evidence of the alarms being turned off manually therefore it was found to be unsubstantiated.

On 09/18/18 Staff D provided documented evidence a former employee notified the Chief Executive Officer, Chief Nursing Officer, and Nurse Manager via email on 02/26/18 at 2:56 A.M. with a report that five SPO2 alarms were found turned off on 02/22/18 and 02/24/18. It was noted the alarms were not found to be suspended, and had to be manually turned back on at the monitor. The facility assigns monitor techs at a centralized station to monitor all telemetry monitors in use within the facility.

Further, Staff D stated in an interview on 09/18/18 at 1:34 PM he/she made an unannounced visit (s) to the unit and found all 9 patients had appropriate alarms on and active. Staff D conducted interviews with all five staff members and none were aware of how to disable the SPO2 alarms. Staff communications were sent out via email of the alarms possibly being turned off at some point during the day/night and to continue to monitor. It was unknown if a staff member was disabling alarms as there was no evidence of alarms being unplugged, suspended, and/or disabled by a staff member. Staff D stated he/she verified with the charge nurse on the high observation unit the employee discussed concerns of patient safety with alarms not functioning properly. The charge nurse reported to Staff D the SPO2 alarms are possibly being silenced in the centralized telemetry room which would silence the activated alarm in the nurses station (s). Staff D stated there was no credible evidence alarms were being disabled manually from the room or by unplugging.

Staff D reported signage was posted in the centralized telemetry room to not silence the alarms from the centralized telemetry station. A tour was conducted on 09/18/18 at 1:54 PM where signage was found in the centralized station to not silence any patient monitoring alarms. An interview was conducted with a monitor tech who reported any abnormal findings are called to the unit and the alarms are not to be suspended.

Staff S stated during tour/observation on 09/18/18 that respiratory rounds are completed every three to four hours for patients on ventilators and with a tracheostomy in place. Observations at the time of the tour confirmed call lights were in reach, and several alarms were randomly tested during the tour with no evidence of being turned off. The ventilators were noted to have an external alarm connected to the call light. When the alarm was activated it would display colored lights above the entrance to the door and was heard in the nurses station.

Tours were conducted on all four nursing units and of the ten staff members interviewed none reported finding alarms turned off. There was no evidence of alarms being suspended and/or disabled.

Review of the Complaint/Grievance Summary report dated 03/17/18 through 06/08/18 revealed two complaints of alarms not being answered timely. Both incidents included corrective actions and staff were re-educated on the importance and expectation of timely response to all alarms. According to policy and procedure no one may suspend an alarm for any reason, except for transports or showers.

Staff C stated when the nurse reported finding five SPO2 alarms not working properly, an incident report should have been completed by the end of the shift as per policy. Upon request, the facility was unable to to provide evidence an incident report was documented as per policy.

Review of the Administration Manual -Risk Management Manual and Policy and Procedure for Incident Reporting Number: R03-A (1) states the purpose of the incident report is to provide a mechanism whereby incidents are identified, rated by severity, and addressed in an efficient and effective manner. A confidential incident report will be completed promptly and accurately by any employee involved in or discovering an incident or having an incident reported to him/her by a patient or visitor. A confidential incident report will be completed electronically prior to the end of the shift by the staff member that witnessed the incident.

Based on record review and interview, the nursing staff failed to ensure the blood transfusion stop time and post-transfusion vital signs were documented. This affected one (Patient #7) of ten medical records reviewed. The active census was 53.

Findings include:

Review of the medical record for Patient #7 revealed and admission date of 08/06/18 for a diagnosis including acute to chronic hypoxemic respiratory failure. Per physicians orders, the patient was to receive one unit of packed red blood cells.

Review of the nursing flow sheets confirmed the one unit of packed red blood cells was administered on 09/13/18 beginning at 3:05 P.M. at a flow rate of 50 ml/hour. Review of the nursing documentation revealed vital signs were obtained at the start of the transfusion of blood and and intermittently while receiving the transfusion. The medical record lacked evidence the nurse documented the time the blood transfusion stopped and post transfusion vital signs. This finding was confirmed with Staff C on 09/19/18 at 3:49 PM.

Review of the policy titled "Clinical Services Policy and Procedure for Blood/Blood Components Administration ( Packed Red Blood Cells, Plasma, Platelets, Cryoprecipitate) Number: B04-N" stated the purpose of the policy is to establish procedures for safe administration of blood and/or blood components at hospitals. Record immediate post transfusion vital signs, including temperature.