HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that medical records were accurately documented for 1 (Patient #1) of 3 records reviewed.
Findings:

Review of the medical record for Patient #1 revealed an admission date of 02/16/2024. The patient had a diagnosis of anemia and the physician ordered the patient to have a blood transfusion on 02/16/2024.

Review of the Blood Bank Transfusion Form dated 02/16/2024 revealed that the PRBCs were spiked at 4:35 p.m. and stopped at 7:20 p.m. by S2RN (a time of 8:07 p.m. was also written as the time stopped but it was struck through and initialed by S2RN). Under the section titled Adverse Reaction, no was circled.

Review of the Transfusion Administration Record dated 02/16/2024 revealed that at 7:20 p.m., S2RN documented that the patient had a suspected blood transfusion reaction due to elevated systolic blood pressure of 170/66. The note further revealed the infusion was stopped, MD called and awaiting MD return call.

On 03/12/2024 at 3:00 p.m., interview with S3Lab Director revealed that she was aware that Patient #1 had a suspected blood transfusion reaction on 02/16/2024. At that time, S3Lab Director provided the surveyor with the patient's blood transfusion documentation. Review of this documentation revealed a Transfusion Administration Record dated 02/16/2024, which indicated that the patient's blood transfusion was completed at 8:07 p.m. Review of the nurses note dated 02/16/2024 at 8:07 p.m., completed by S2RN, revealed that 1st unit of PRBCs completed. No signs or symptoms of transfusion reaction. Vital signs noted in transfusion record. Patient denies pain. Call light in reach. Further review of the nurses notes written by S2RN on 02/16/2024 at 9:07 p.m. revealed no signs or symptoms of post blood transfusion reaction. Patient sitting up in bed. S2RN's nurses note at 9:32 p.m. revealed unable to reach patient's physician regarding elevated blood pressure at 7:20 p.m.

S3Lab Director further confirmed that there were two sets of nurses notes written by S2RN on 02/16/2024, one indicating the transfusion was stopped at 8:07 p.m. with no reaction and another note indicating the transfusion was stopped at 7:20 p.m. after a suspected transfusion reaction.

On 03/12/2024 at 4:00 p.m., S1CNO revealed that she was unaware of two different sets of nurses notes written by S2RN on 02/16/2024. At that time, the surveyor provided the original nurses note from 02/16/2024 for S1CNO to review. At that time, S1CNO confirmed the inaccurate documentation in Patient #1's medical record.