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SALINE MEMORIAL HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on policy and procedure review, clinical record review, and interview it was determined the facility failed to follow its own policy for blood transfusions in that three (#3, #6, and #7) of five (#3, #5 - #7, and #9) patients receiving blood transfusions did not have their vital signs assessed as stated in the Blood, Administration and Blood Products Policy. The failed practice did not allow the Registered Nurse (RN) to be informed of the patient's response to the blood transfusion for potential reactions or side effects. The failed practice affected patient #3, #6, and #7. Findings follow.
A. Review of policy and procedure titled "Blood, Administration and Blood Products" stated "the RN transfusing the blood must take patients T/P/R (temperature/pulse/respirations) and B/P (blood pressure) and record on Unit Issue/Transfusion Sheet just prior to the infusion. Take initial vital signs prior to start of transfusion, 15 minutes after blood transfusion started, and after completion; unless patient condition warrants more frequent monitoring.
B. Review of clinical records showed the following:
1) Review of Patient #3's clinical record showed blood unit #1 was started at 5:35 PM and ended at 8:30 PM with no evidence of post transfusion vital signs documented. Patient #3 blood unit #2 was started at 11:45 PM and ended at 3:30 AM with no evidence of vital signs documented post transfusion.
2) Review of Patient #6 clinical record showed blood unit #1 was started on 05/31/18 at 10:17 AM and ended at 2:15 PM. There was no evidence vital signs were documented for the 15 minutes after start of transfusion or post transfusion. Patient #6 blood unit #2 was started on 05/31/18 at 2:30 PM and stopped at 4:30 PM with no documentation of any vital signs.
3) Review of Patient #7's clinical record showed blood unit #1 was started on 07/19/18 at 3:34 AM and ended at 7:30 AM with no post transfusion vital signs documented.
C. The above findings in A and B were verified with the Director of Quality on 07/19/18 at 1:15 PM.