HospitalInspections.org

Based on review of hospital policy, medical record review and staff interviews, the nursing staff failed to monitor a patient receiving a blood transfusion per hospital policy for 2 of 3 patients reviewed (Patient #6 and 10).

The findings include:

Review of the hospital's policy #PC 210.78 - Blood/Blood Products/Blood Derivatives Administration, revised 8/6/14, revealed, "...B. Administration & Monitoring of Blood (Leukoreduced Red Blood Cells), Fresh Frozen Plasma (FFP) & HLA Products 1. Obtain baseline vital signs within one hour prior to hanging blood ....12. Monitor and record vital signs (TPR & BP) (temperature, pulse, respirations, and blood pressure) during the transfusion as follows: a. 15 minutes after starting the infusion, b. every hour, c. at discontinuation, d. one hour after completion ..."

1. Closed medical record for Patient #6 revealed an 86 year old female admitted 5/18/2015 with diagnosis of pneumonia. Record review revealed physician orders on 5/31/2015 to transfuse one unit of packed red blood cells. Review revealed the blood was started 5/31/15 at 1627. Record review revealed vital signs (temperature, pulse, respirations, and blood pressure) were taken at 1549, 1645, 1745, and at 1924 - when the transfusion was completed. Review revealed no vital signs taken between 1745 and 1924 (1 hour 39 minutes).

Interview on 06/24/2015 at 1630 with Administrative Nursing Staff #2 confirmed the nurse did not assess vital signs (temperature, pulse, respirations and blood pressure) every hour while administering blood to Patient #6 per the hospital's policy.

2. Closed medical record for Patient #10 revealed a 36 year old female admitted 5/13/15 with diagnosis of pregnancy at term and repeat cesarean section. Record review revealed physician orders on 5/14/15 to transfuse two units of packed red blood cells. Review revealed the patient's vital signs were documented 5/14/15 at 1138 and the first unit was started at 1305 (1 hour 27 minutes prior to initiating the transfusion).

Interview on 06/24/2015 at 1630 with Administrative Nursing Staff #1 confirmed the nurse did not assess vital signs (temperature, pulse, respirations and blood pressure) within one hour prior to administering blood to Patient #10 per the hospital's policy.