HospitalInspections.org

Based on review of facility documents, staff interview (EMP), and review of medical records it was determined the facility failed to follow the blood infusion protocol as per policy by failing to assess the patient at required time intervals for three of three medical records reviewed (MR15, MR16 and MR17).

Review on October 30, 2019, of the facility's policy, "Blood Transfusions," no date, revealed, "... 6. Infusion protocols: ... i. Assess the patient 5 minutes after start of transfusion, then 15, 30 and 60 minutes and every 60 minutes thereafter until transfusion complete ... ."

Review on October 30, 2019, of MR15 revealed this patient received a blood transfusion on September 6, 2019 with start time at 0945 and end time at 1300. Further revealed Assessments were documented at 1235 and 1335. Further revealed no documentation that an assessment was completed at 950, 1000, 1015, 1045, 1145 and 1245 as required by policy.

Review on October 30, 2019, of MR16 revealed this patient received a blood transfusion on August 30, 2019 with start time at 1048 and end time at 1320. Further revealed Assessments were documented at 1103, 1116 and 1320. Further revealed no documentation that an assessment was completed at 1053, 1148 and 1248 as required by policy.

Review on October 30, 2019, of MR17 revealed this patient received a blood transfusion on August 25, 2019 with start time at 1800 and end time at 2100. Further revealed Assessments were documented at 1750, 2000, 2020 and 2100. Further revealed no documentation that an assessment was completed at 1805, 1815, 1830, 1900 and 2000 as required by policy.

Interview on October 30, 2019, at approximately 11:00 AM, with EMP1 confirmed facility failed to follow the blood infusion protocol, as per policy by failing to assess the patients at required time intervals for three of three medical records reviewed (MR15, MR16 and MR17).