Rho (D) - - immune globin (human) shall be administered to each Rh-negative patient at the time of any abortion, unless contraindicated. Evidence of compliance with this paragraph shall appear in the medical record of the patient. If for any reason the patient refuses the administration of Rh immune globulin when recommended, this refusal shall be noted in the clinical record of the patient.
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Observations:
Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to follow the facility's policy to ensure proper documentation of administration or refusal of Rho (D) Immunoglobulin injection for two of six Rh-negative patients reviewed (MR1 and MR4).
Findings include:
Review on May 16, 2024, of facility policy "Administrative Chapter 4: Consent, Informed Consent, and Patient Education" last revised February 2023, revealed "... Request and Consent for Services and Release Forms .... IV. Release When Test/Service/Consultation Will Not Be Obtained as Advised A. A new release must be signed or acknowledged electronically for online health care, once each time an advised test, service, or consultation is not obtained. B. The specific test, service, or consultation that will not be obtained must be checked off or written in ..."
Review of MR1 on May 16, 2024, revealed the patient was determined to be Rh-negative (a blood group that lacks the Rh antigen in the red blood cell). There was no documentation the patient received or refused the Rho (D) Immunoglobulin (a medication used to prevent antibodies from forming and to avoid complications with future pregnancies) injection.
Review of MR4 on May 16, 2024, revealed the patient was determined to be Rh-negative (a blood group that lacks the Rh antigen in the red blood cell). There was no documentation the patient received or refused the Rho (D) Immunoglobulin (a medication used to prevent antibodies from forming and to avoid complications with future pregnancies) injection.
Interview with EMP1 on May 16, 2024, at approximately 1:30 PM confirmed the above findings for MR1 and MR4.
| | Plan of Correction - To be completed: 06/30/2024
By 6/31/24, all facility staff will receive refresher training on the requirement to document the administration or refusal of Rho(D) Immunoglobulin injection for patients that test Rh-negative. The Director of Clinical Services and Lead RN for Training will present this training content at the facility staff meeting (scheduled 6/13/24) and via email for anyone not in attendance at the staff meeting.
The staff training will include review of medical guidelines (required Rh-testing, treatment, administration or refusal documentation), EHR workflow and clinic operations. Training records will be maintained in the facility RQM binder.
To monitor compliance following staff training, the center manager will conduct an audit of all RH negative patient charts will be conducted every two 2 weeks (first completed by 6/31/24) through end of July 2024 (3 audits). The manager in collaboration with the Lead RN for Training will address any findings with the team or individual staff as needed. For ongoing compliance, Rh-negative patient management will be audited as part of annual abortion care audits (at least twice a year) completed by the RQM Coordinator.
Audit activities, findings, and corrective actions (as needed) will be reported by the Center Manager or RQM Coordinator at the quarterly RQM Committee (scheduled 7/16/24). The Director of Patient Services is responsible for ensuring implementation and completion of this correction action plan.
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