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Based on staff interview and document review, it was determined the hospital failed to ensure blood transfusions were administered in accordance with hospital policies and procedures in two (2) of two (2) applicable records reviewed in the survey sample. Specifically, the hospital failed to obtain consent for a blood transfusion in one record (#5) and failed to appropriately monitor a patient receiving an infusion of packed red blood cells in one record (#6).

Findings:

Two (2) records of patients receiving blood products were reviewed on 01/08/24.

The medical record for patient #5 contained documentation that the patient was ordered and received four (4) units of fresh frozen plasma on 12/12/23. The medical record contained no consent for blood products. The medical record contained no documentation that the physician explained the risk and benefits of the transfusion to the patient or to the patient's spouse who was documented to be at the patient's bedside at the time the blood product was ordered and administered. The facility's policy, Blood Transfusion of Blood Products was reviewed and reads in part: Informed Consent: Consent for blood products given outside of the perioperative setting will be documented on the Consent for the Administration of Blood or Blood Products (FR-138-MWHC)...The attending or consulting physician will be responsible for discussing appropriate information regarding informed consent for blood or blood products with the patient or surrogate decision maker. The physician will discuss the risks, benefits, and alternatives for treatment with the patient (or the patient's legally designated decision-maker)...The physician will enter the appropriate documentation in the patient's medical record regarding discussions with the patient or surrogate about risks, benefits, and alternatives to treatment. During record review staff member's # 4 and #6 confirmed the lack of informed consent documentation in the patient's medical record.

The medical record for patient #6 contained an order to infuse four (4) units of packed red blood cells (PRBCs) on 12/09/23. The first unit was initiated at 1:06 PM on 12/09/23 and vital signs were obtained. Vital signs were again obtained 15 minutes into the transfusion per hospital policy. Vital signs were again obtained at 2:30 PM and 2.25 PM to include blood pressure, pulse and respirations, but no temperatures were recorded. No vital signs were collected at 3:30 PM.

The second unit of PRBCs started at 4:00 PM on 12/09/23. Vital signs were obtained at initiation and after 15 minutes of starting the transfusion. Vital signs were then taken at 4:45 PM but did not include a temperature. Vital signs were obtained at 5:30 PM. No vital signs were obtained after 5:30 PM to the end of the transfusion at 7:40 PM. No vital signs were collected 15 minutes after the end of the transfusion per facility policy.

The third unit of PRBC was started at 9:27 PM on 12/09/23 and vital signs obtained. No further vital signs were taken until the end of the transfusion at 11:05 PM.

The fourth (4th) unit of PRBCs was started at 11:17 PM on 12/09/23. Vital signs were obtained at initiation and 15 minutes into the transfusion. the infusion was completed at 1:00 AM on 12/10/23. No vital signs were taken after the 15 minute vitals. Vital signs were not again documented in the record until 4:33 AM, approximately 3.5 hours after the transfusion ended.

The facility's policy, Blood Transfusion of Blood Products was reviewed and reads in part: Assessment:...A licensed nurse (RN or LPN) will obtain a baseline temperature, pulse respirations (TPR) and blood pressure (BP) no longer than 30 minutes prior to obtained blood from the blood bank...An RN or LPN will check the initial set of vital signs (TPR and BP) no more than 30 minutes prior to incitation of the transfusion. The RN or LPN will remain with the patient during the first 15 minutes, starting when the blood product actually enters the patient's body, not including saline, if not purged or discarded. This is typically when most transfusion reactions occur. The next set of vital signs is 15 minutes after the blood product enters the patient's body...Thereafter vital signs will be taken by licensed or unlicensed staff at a minimum of every hour after start of the transfusion and a set of vital signs 15 minutes post transfusion.

Staff member #6 confirmed the absence of required monitoring and vital signs per facility policy for patient #6's transfusions during record review on 01/08/24.

An interview was conducted with an RN (staff member #8) at 1:00 PM on 01/08/24. Staff member #8 confirmed before initiating a blood transfusion, the nurse assists in obtaining informed consent from the patient. The paper form is later scanned into the patient's chart after discharge. Vital signs should be taken prior to beginning the infusion, after 15 minutes, and every 30-60 minutes while receiving the transfusion. Another set of vitals are taken after the transfusion is complete.