MERCY FITZGERALD HOSPITAL
Health Inspection Results For:
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Initial Comments:
This report is the result of an unannounced special monitoring survey completed on March 28, 2024, at Mercy Fitzgerald Hospital. It was determined there was non-compliance with 107.51(a)(1). Medical staff responsibilities: In order for the medical staff to take reasonable steps to ensure clinical practice of the highest quality, each staff member should endeavor to: Provide his patients with the best quality of care consistent with the circumstances of each case on February 3, 2024. The hospital identified and took effective corrective action prior to the investigation to include: Education completed to nursing and providers as it relates to retype and screen if greater than 72 hours for transfusion per FDA guidelines; Review for nursing, laboratory, and providers on the Massive Transfusion Policy (MTP) with establish roles and reoccurring education at minimum annually; Implementation of MTP drills quarterly; Process improved to ensure consistent bedside shift report for all operating room to intensive care unit transfers and announcing MTP activation overhead to ensure timely escalation. Audits were added to review the MTP activations and drills to identify opportunities for improvement and the results will be reported to Nurse Leadership Council, Quality Council, Medical Executive Committee and Community Board. The Department of Health verified the hospital implemented corrective actions during the onsite investigation.
At the time of the investigation, the facility was in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
Plan of Correction:
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