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BON SECOURS ST FRANCIS MEDICAL CENTER
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on interview and document review, it was determined the facility failed to administer blood products in accordance with provider orders for four (4) of four (4) blood transfusions reviewed.
The findings include:
On July 29, at 12:08 PM, the surveyor initiated the medical record review of four (4) selected patients who had received blood transfusions since June 2024.
With the assistance of Staff Member #4, the surveyor identified the following transfusions of Packed Red Blood Cells (PRBs) not administered as ordered:
Patient #4:
One (1) unit of PRBs administered on July 20, 2024, between 7:49 PM through 10:46 PM.
The signed provider order released on July 20, 2024, at 7:49 PM stated, "Start infusion at 60 ml/hr x 15 minutes [60 milliliters per hour for fifteen minutes]" [sic].
The surveyor confirmed with Staff Member #4 that the initial infusion rate exceeded the ordered rate at "65 mL/hr" until 8:04 PM.
Patient #5:
Two (2) units of PRBs administered on June 4, 2024, between 11:59 AM through 3:15 PM and 6:03 PM through 9:01 PM, respectively.
The signed provider order released on July 4, 2024, at 6:02 PM stated, "Start infusion at 60 ml/hr x 15 minutes [60 milliliters per hour for fifteen minutes]" [sic].
The surveyor confirmed with Staff Member #4 that the initial infusion rate for the first transfusion exceeded the ordered rate at "75 mL/hr" until 12:14 PM.
The surveyor confirmed with Staff Member #4 that the second infusion rate exceeded the ordered rate at "75 mL/hr" until 6:16 PM.
Patient #6:
One (1) unit of PRBs administered on June 30, 2024, between 10:34 AM through 1:00 PM.
The signed provider order released on July 30, 2024, at 10:32 AM stated, "Start infusion at 60 ml/hr x 15 minutes [60 milliliters per hour for fifteen minutes]" [sic].
The surveyor confirmed with Staff Member #4 that the initial infusion rate exceeded the ordered rate at "75 mL/hr" until 10:45 PM.
In the afternoon of July 29, 2024, the surveyor received the facility policy titled, "Transfusion of Blood Products" (with last effective date of 07/03/24), which stated the importance of nurse monitoring for the first fifteen (15) minutes from the start of the transfusion in order to assess for signs and symptoms of a transfusion reaction or other complication.
The surveyor reviewed the Lippincott Nursing Procedures for the transfusion of blood products provided by Staff Member #4 on July 29, 2024, at 1:40 PM. Under "Nursing considerations" of PRBs section, the procedure stated to initiate the blood transfusion "at a slow rate as prescribed".
On July 29, at 1:33 PM, the surveyor met with Staff Member #1 and Staff Member #4 for interview regarding the aforementioned orders not followed as prescribed. The surveyor received confirmation that nursing staff are expected to follow provider orders as prescribed to include the administration of blood products.