HospitalInspections.org

Based on policy review, clinical record review and interview the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care for 3 of 5 sampled patients (Patient #2, #4 and #11) as evidenced by failure to monitor vital signs during blood transfusions as specified per facility policy.


The Findings include:


Facility Policy titled Blood Product Administration last revised 02/2014 documents Baseline vital signs must be taken before within 30 minutes of transfusion.
During transfusion: Repeat vital signs at 15 minutes and as patient condition requires and compare to baseline. If there are no signs of transfusion complications, adjust flow to the prescribed rate. The patient is to be reassessed every 30 minutes thereafter for possible signs of transfusion reaction. Refer to Nursing procedure.
1. The pre transfusion temperature will be used as a baseline for determining if there is a transfusion reaction. Any temperature increase of 2 degrees Fahrenheit above the baseline will be reported.
2. Marked change in other vital signs
3. Chills
4. Pain
5. Itching
6. Skin rash
7. Facial swelling
8. Nausea
9. Tingling
10. Muscle cramps
11. Respiratory distress


Clinical record review conducted on 03/26/15 through 03/27/15 revealed the following:
Transfusion Record for Patient # 11 documents blood transfusion was administered on 02/24/15. Further review of the record failed to provide evidence the patient was reassessed as specified per facility policy for signs of transfusion reaction. The clinical record provides no evidence a complete set of vital signs was done every thirty minutes during the transfusion.
Transfusion Record for Patient # 2 documents blood transfusion was administered on 03/26/15. Further review of the record failed to provide evidence the patient was reassessed as specified per facility policy for signs of transfusion reaction. The clinical record provides no evidence a complete set of vital signs done every thirty minutes during the transfusion.
Transfusion Record for Patient # 4 documents blood transfusion was administered on 03/26/15. Further review of the record failed to provide evidence the patient was reassessed as specified per facility policy for signs of transfusion reaction. The clinical record provides no evidence a complete set of vital signs was done every thirty minutes during the transfusion.

Interview with The Chief Nursing Officer (CNO) conducted on 03/27/15 at 4:10 PM revealed the CNO reviewed the facility policy and verified patient reassessments are to be completed every 30 minutes and the reassessment should include vital signs, specifically temperature readings as the policy describes signs of transfusion reaction as an increase of 2 degrees or marked changes in other vital signs.

Interview with The Director of Patient Safety conducted on 03/27/15 at 4:45 PM revealed the Risk Managers and The Director of the Unit are researching the records for Patient # 2, # 4 and # 11 for further evidence of monitoring during the blood transfusion. The facility was not able to locate additional documentation to validate monitoring was provided to the patients as specified per policy.