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Based on policy reviews, medical record reviews and staff interviews, the hospital staff failed to obtain blood transfusion vital signs in accordance with approved policy and procedure for a non-emergent transfusion for 1 of 2 patients (Patient #10).

Findings included:

Review of the hospital policy titled, "Blood and Blood Product Administration" revised/reviewed 10/2016 revealed, ...H. Blood Administration Monitoring 1. Monitor vital signs, patient's tolerance, and observe for possible transfusion reaction. Monitor vitals (at a minimum): within 60 minutes prior to administration, within 5-15 minutes of beginning the transfusion, within 45-75 minutes of beginning the transfusion, within 15 minutes of completed transfusion, within 47-75 minutes of the completed transfusion.

Open medical record review on 07/11/2018 revealed Patient #10 was a 77 year old male admitted on 06/26/2018 to the hospital with a chief complaint of blood in his stool. Patient #10 had a hemoglobin of 7.4 (low). A Physician order was entered for Red Blood Cells (RBC's) transfusion. The transfusion began at 2139 and ended at 2316 (one hour and 37 minutes). At 2206, during the transfusion, the nursing staff failed to obtain temperature and respirations within 5-15 minutes of transfusion initiation and at 2341 and at 0041, the nursing staff failed to obtain temperature and respirations within 45-75 minutes of transfusion completion. Review revealed the hospital staff failed to obtain vital signs at the required intervals. On 07/01/2018, a Physician order was entered for platelet transfusion. The transfusion began at 1425 and ended at 1744 (three hours and 19 minutes). At 1436, during the transfusion, the nursing staff failed to obtain a pulse within 5-15 minutes transfusion initiation; at 1623, the nursing staff failed to obtain a temperature and respirations within 45-75 minutes of beginning transfusion and at 1911, the nursing staff failed to obtain vital signs within 45-75 minutes of transfusion completion. Review revealed the hospital staff failed to obtain vital signs at the required intervals. On 07/02/2018, a Physician order was entered for platelet transfusion. The transfusion began at 0501 and ended at 0649 (one hour and 48 minutes). At 0741, during the transfusion, the nursing staff failed to obtain a temperature and respirations within 45-75 minutes of completion of the transfusion. Continued review revealed another Physician order was entered for a platelet transfusion. The transfusion began at 1442 and ended at 1750 (three hours and eight minutes). At 1555, during the transfusion, the nursing staff failed to obtain a temperature and respiration within 5-15 minutes of transfusion initiation; at 1610, the nursing staff failed to obtain the temperature and respirations within 45-75 minutes of the beginning of transfusion and at 1750, the nursing staff failed to obtain temperature, pulse, respirations and blood pressure of transfusion completion. Review revealed the hospital staff failed to obtain vital signs at the required intervals. On 07/05/2018, a Physician order was entered for RBC transfusion. The transfusion began at 1442 and ended at 1755 (three hours and 13 minutes). At 1634, during the transfusion, the nursing staff failed to obtain a temperature and respirations within 45-75 minutes of the transfusion start time; at 1755, the nursing staff failed to obtain a temperature, pulse, respiration and blood pressure at the completion of the transfusion; at 1811, the nursing staff failed to obtain a temperature and respirations within 15 minutes of completion of the transfusion and at 1858, the nursing staff failed to obtain a temperature within 45-75 minutes of completion of the transfusion. Review revealed the hospital staff failed to obtain vital signs at the required intervals.

Interview on 07/11/2018 at 1142 with RN #1 (Registered Nurse) who was assigned to direct patient care for Patient #10 during the blood transfusion revealed an understanding of the requirements for complete T (temperature), P (pulse), R (respirations), and BP (blood pressure) at the required timeframes as per policy. However, RN #1 cared for the Patient during the transfusion on 07/05/2018 - 07/06/2018 which revealed a failure to obtain complete vital signs within the required timeframe. RN #1 acknowledged the rationale of obtaining complete vital signs to be abreast of the development of any transfusion reaction in a swift manner as part of the nursing care during a blood transfusion.

Interview on 07/11/2018 at 1210 with RN #2 revealed, the nursing staff were expected to obtain and document complete vital signs as T, P, R and BP during a blood transfusion were necessary at specific times to be alert for transfusion reactions.

Interview on 07/11/2018 at 1230 with RN #3 revealed, the nursing staff were expected to obtain and document complete vital signs as T, P, R and BP during a blood transfusion within the appropriate timeframes.

Interview on 07/12/2018 at 1155 with the CE#1(Clinical Educator) revealed, during the transfusion of blood in a non-emergent setting the nursing staff were required to obtain complete vital signs as T, P, R and BP at each timeframe as stated in the policy. The explanation of the requirements of complete vital signs were explained to the staff during [electronic documentation training] in orientation and were part of the annual competencies.