HospitalInspections.org

Based on review of hospital policy and procedures, medical record reviews and staff interviews, the hospital's nursing staff failed to monitor patients' vital signs per policy for 3 of 3 patients receiving blood transfusions (Patient # 9, 7 and 6).

The findings include:

Review of the hospital's policy, "Administration of Whole Blood/PRBC (Packed Red Blood Cells)", revised 07/2013, revealed, "PURPOSE: To deliver blood and blood products to the patient in a safe and timely manner. ...IV. ADMINISTRATION ...6. Observe the patient closely throughout the transfusion and record the vital signs every 15 minutes for the first hour, then every hour thereafter until the blood has infused. Assess any changes in clinical condition. ...".

1. Open medical record review on 11/13/2013 of Patient #9 revealed a 74 year-old male, admitted on 11/12/2013 with acute coronary syndrome and anemia. Record review revealed a physician's order, dated 11/12/2013 at 1710, to transfuse 2 units of packed red blood cells. Record review revealed the first unit of packed red blood cells was started on 11/12/2013 at 2156, ending at 0100. Record review revealed Patient #9's vital signs, including temperature, pulse rate, respiratory rate and blood pressure was assessed at 2156 and 2211. Record review revealed Patient #9's temperature was not reassessed until 0003 (1 hour, 52 minutes later). Record review revealed the second unit of packed red blood cells was started on 11/13/2013 at 0352, ending at 0745. Record review revealed Patient #9's vital signs, including temperature, pulse rate, respiratory rate and blood pressure was assessed at 0352 and 0407. Record review revealed Patient #9's temperature was not reassessed until 0745 (3 hours, 38 minutes later).

Interview on 11/13/2013 at 0940 with the nurse manager of Patient #9's patient care unit revealed, "the first sign of a blood reaction is increased temperature". Interview revealed the patient's temperature should be monitored every 15 minutes for the first hour of transfusion. Interview confirmed Patient #9 received the first unit of packed red blood cells on 11/12/2013, starting at 2156, ending at 0100. Interview confirmed Patient #9's vital signs, including temperature, pulse rate, respiratory rate and blood pressure was assessed at 2156 and 2211. Interview confirmed Patient #9's temperature was not reassessed until 0003 (1 hour, 52 minutes later). Interview confirmed the second unit of packed red blood cells was started on 11/13/2013 at 0352, ended at 0745. Interview confirmed Patient #9's vital signs, including temperature, pulse rate, respiratory rate and blood pressure was assessed at 0352 and 0407. Interview confirmed Patient #9's temperature was not reassessed until 0745 (3 hours, 38 minutes later). Interview revealed the nursing staff failed to follow the hospital's policy for monitoring a patient during a blood transfusion.

2. Closed medical record review revealed Patient #7, a 90 year-old female, admitted on 08/29/2013 with pulmonary edema and anemia. Record review revealed a physician's telephone order, dated 09/01/2013 at 1542 to transfuse 2 units of packed red blood cells. Record review revealed the first unit of packed red blood cells was started on 09/01/2013 at 1640, ended at 2030, by RN (Registered Nurse) #1. Record review revealed Patient #7's vital signs including temperature, pulse rate, respiratory rate and blood pressure was assessed at 1625, 1700 and 1715. Record review revealed Patient #7's temperature was not reassessed until 2000 (2 hours, 45 minutes later). Record review revealed the second unit of packed red blood cells was started on 09/01/2013 at 2245, ended at 0200. Record review revealed Patient #7's vital signs, including temperature, pulse rate, respiratory rate and blood pressure was assessed at 2245. Record review revealed Patient #7's temperature was not reassessed until 2359 (1 hour, 14 minutes later).

Telephone interview on 11/13/2013 at 0900 with RN #1 revealed vital signs should be checked every 15 minutes for the first hour for a patient receiving blood. Interview revealed "this includes checking the patient's temperature since one of the first signs of a blood reaction is elevated temperature".

Interview on 11/13/2013 at 0915 with administrative nursing staff confirmed. Interview confirmed Patient #7 received the first unit of packed red blood cells on 09/01/2013 starting at 1640, ending at 2030. Interview confirmed Patient #7's vital signs, including temperature, pulse rate, respiratory rate and blood pressure was assessed at 1625, 1700 and 1715. Interview confirmed Patient #7's temperature was not reassessed until 2000 (2 hours, 45 minutes later). Interview confirmed the second unit of packed red blood cells was started on 09/01/2013 at 2245, ended at 0200. Interview confirmed Patient #7's vital signs, including temperature, pulse rate, respiratory rate and blood pressure was assessed at 2245. Interview confirmed Patient #7's temperature was not reassessed until 2359 (1 hour, 14 minutes later). Interview revealed the nursing staff failed to follow the hospital's policy for monitoring a patient during a blood transfusion.

3. Closed medical record review of Patient #6 revealed a 62 year-old male, admitted on 09/20/2013 with osteomyelitis of the left great toe, peripheral vascular disease and end-stage renal disease. Record review revealed a physician's order dated 09/24/2013 to transfuse two units of packed red blood cells. Record review revealed the first unit was started on 09/24/2013 at 0915 while the patient was on the hemodialysis machine. Record review revealed Patient #6's vital signs including temperature, pulse rate, respiratory rate and blood pressure was assessed at 0915. Record review revealed Patient #6's temperature was not reassessed until 1000 (45 minutes later). Record review revealed the second unit of packed red blood cells was started on 09/24/2013 at 1000. Record review revealed Patient #6's vital signs, including temperature, pulse rate, respiratory rate and blood pressure was assessed at 1000. Record review revealed Patient #6's temperature was not reassessed. Record review revealed the transfusion was stopped at 1025 and the blood was returned to the blood bank for a possible transfusion reaction due to Patient #6 complaining of urticaria (itching).

Interview on 11/13/2013 at 0900 with RN #2, a dialysis nurse, revealed Patient #6's temperature should have been assessed every 15 minutes for the first hour during blood administration. Interview confirmed the first unit of blood started on 09/24/2013 at 0915 and Patient #6's temperature was not checked until 45 minutes later. Interview further revealed the second unit of blood was started at 1000 and Patient #6's temperature was not reassessed prior to the discontinuation of the blood for a possible transfusion reaction. Interview revealed the nursing staff failed to follow the hospital's policy for monitoring a patient during a blood transfusion.


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