HospitalInspections.org

Based on interview and record review the facility failed to maintain all physician orders of the clinical records to assist staff involved in the patients care in 1(#1) of 3(#1-3) blood charts reviewed.Blood administered without a physician's order may result in harm or possible death.

Review of the policy and procedure "Blood Administration" stated, "1. Physician must write the order for the blood transfusion."
Review of patient #1's chart revealed 4 blood administration records. Review of physician orders revealed four units of blood were administered on the following;
#1- 7/18/2014 at 4:30PM
#2- 7/18/2014 at 9:32PM
#3- 7/19/2014 at 6:30AM
#4- 7/20/2014 at 11:36AM
Review of the physician orders revealed hand written orders and computer orders. There were no written or computerized orders found for unit #2 and #3 in patient #1's chart.
An interview with staff #7 and staff #3 on 8/4/2014 at 4:20PM confirmed there were no orders found in the chart for units 2 and 3.
An interview with staff #13 on 8/4/2014 at 4:40PM reported she remembers the order to be hand written but does not know why the order is not in the chart.
Interview with staff #3 on 8/5/2014 at 9:00AM reported that he had talked with the nurses involved with the blood administration and staff #3 reported the staff #12 had a written order to administer the blood. Staff #3 reported the order was missing and was not able to produce the order.