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3535 SOUTHERN BOULEVARD

KETTERING, OH 45429

BLOOD TRANSFUSIONS AND IV MEDICATIONS

Tag No.: A0410

Based on record review, interview and policy review, the facility failed to ensure post transfusion vital signs were documented at the proper intervals. This affected two (Patients #4 and #5) of three patients reviewed for blood transfusions.

Findings include:

1. Medical record review revealed Patient #4 was admitted through the Emergency Department (Ed) on 07/25/20 with a complaint of shortness of breath. The patient received and blood transfusion in the ED and a second transfusion after transfer to the nursing unit.

Review of the blood transfusion documentation revealed the second transfusion was started on 07/26/20 at 2:08 AM and ended at 4:54 AM. There was no documentation the patient's vital signs were checked one hour after the completion of the transfusion as required. Vital signs were not documented as being obtained until 8:15 A.M.

2. Medical record review revealed Patient #5 was admitted through the ED on 07/31/20 with loss of consciousness. The patient had a low hemoglobin and hematocrit and received several blood transfusions during his/her hospitalization.

The fourth blood transfusion was started on 08/02/20 at 12:02 AM and the transfusion ended at 2:30 AM. The post vital signs were completed 30 minutes post transfusion but not one hour after transfusion as required.

These findings were confirmed during interview with Staff C on 08/05/20 at 10:00 AM.

Review of the hospital policy and procedure titled "Blood Product Administration: Red Blood Cells and Whole Blood", undated, documented vital signs to be taken every 15 minutes until the first 50 milliliter (ml) is infused, every hour following the first 50 ml; and one hour post transfusion.