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Based on interview, record review, and procedure review, the facility failed to follow hospital procedure during blood administration for two patients (#2 and #14) of two patients, whose medical records were reviewed for blood administration. This had the potential to prevent the identification of any type of negative reaction to blood or blood products, with any patient who received blood or blood products. The facility census was 26.

Findings included:

1. Review of facility's undated procedure titled, "Required Documentation for Transfusion of Blood (to administer blood into a vein) or Blood Products," showed the required monitoring during blood or blood product transfusions, and that vital signs are to be obtained and recorded:
- 30 minutes prior to initiation of any transfusion;
- 15 minutes after starting transfusion;
- 30 minutes after starting transfusion;
- 60 minutes after starting transfusion;
- Every hour during transfusion, and
- Within 30 minutes of completion of the transfusion.

Review of Patient #2's Blood Product Administration Record showed that:
- Baseline (what is considered normal for the patient, prior to illness, procedure, or medical treatment) vitals were obtained at 11:29 AM, prior to initiation of her transfusion.
- She received a blood transfusion of one unit of packed red blood cells (specific blood cells that have been separated from whole blood cells, for administration into a vein) on 04/02/19 at 11:36 AM.
- A second set of vitals were obtained at 11:45 AM, after the initiation of her transfusion.
- The blood transfusion was completed at 2:26 PM.
- A final set of vital signs were recorded at 4:29 PM, which was two hours and three minutes after the completion of the transfusion.

Per facility procedure, vital signs should have been taken again at 30 minutes, 60 minutes, and every hour after the start of the transfusion, and within 30 minutes of completion of the transfusion. There were no vital signs documented for a period of four hours and 44 minutes.

Review of Patient #14's Blood Product Administration Record showed that:
- He received a blood transfusion of two units of leukoreduced (a unit of whole blood that has had the white blood cells filtered out) red blood cells, on 12/23/18.
- Baseline vital signs were obtained on 12/23/18 at 4:24 PM, prior to initiation of his transfusion.
- The first unit of blood was initiated at 4:28 PM.
- The patient's first set of vital signs should have been recorded 15 minutes after initiation, at 4:43 PM, but were not documented until 4:50 PM, 22 minutes after initiation.
- The patient's second set of vital signs should have been recorded 30 minutes after initiation, at 4:58 PM, but were not documented until 5:23 PM, 55 minutes after initiation.
- The patient's third set of vital signs should have been recorded 60 minutes after initiation, at 5:28 PM, but were not documented until 6:35 PM, two hours and seven minutes after initiation.
- The transfusion of the first unit of blood was completed at 6:52 PM, and a full set of vital signs were documented at that time.
- The second unit of blood, was initiated at 7:06 PM.
- The patient's first set of vital signs should have been recorded 15 minutes after initiation, at 7:21 PM, but were not documented until 7:32 PM, 26 minutes after initiation.
- The patient's second set of vital signs should have been recorded 30 minutes after initiation, at 7:36 PM, but were not documented until 8:04 PM, 58 minutes after initiation.
- The patient's third set of vital signs should have been recorded 60 minutes after initiation, at 8:06 PM, but were not documented until 10:28 PM, three hours and 22 minutes after initiation.
- The transfusion of the second unit of blood was completed at 10:28 PM, vital signs should have been documented every hour after the third set of vital signs, until the unit was infused. There were no vitals documented for a period of two hours and 22 minutes.

During an interview on 04/09/19 at 10:25 AM, Staff Q, Clinical Coordinator, Registered Nurse (RN) for Two South Medical Surgical Unit, stated that vital signs should have been monitored as per protocol during the blood transfusions. Staff Q shared that they used more agency staff than she would like. She stated that agency staff were trained on their policies and procedures and that the vital signs monitoring was part of their training when agency staff were oriented to the hospital. For additional safety, she had hung a laminated copy of their hospital procedural document at the nurses station, which gave clear direction for vital sign monitoring during blood or blood product transfusion.

During an interview on 04/09/19 at 1:05 PM, Staff E, Chief Nursing Officer (CNO), stated that she expected a baseline set of vital signs be obtained prior to the initiation of blood products, and the patient continuously monitored during infusion as per protocol. She stated that vital signs monitoring was part of the continual assessment process during the transfusion of blood and blood products and that this was a standard level of care that should be adhered to as per their policy and procedure, unless otherwise indicated by a patient's physician.












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