HospitalInspections.org

Based on interview and document review the facility failed to obtain consent for blood administration in 3 (#1, 32, 34) of 4 patients receiving blood products and failed to assess vital signs per accepted standards of practice resulting in the potential to transfuse a patient with blood products against the patient's consent and the potential for failure to recognize blood product adverse reactions. Findings include:

On 10/10/2017 at 1400 during the document review of patient #1's medical record it was revealed patient #1 received a transfusion of platelets (a blood component) on 10/7/2017. Further review of the medical record revealed the patient's medical record failed to include a consent for the transfusion of blood products or blood components.

On 10/10/2017 at 1430 review of documentation of the transfusion revealed a failure to assess patient #1's vital signs per standards of practice. The vital signs documented during the transfusion listed the beginning time of transfusion as 1725, the fifteen minute vitals documented as 1750, and the sixty minute vitals documented as 1630. The one hour post transfusion failed to have vital sign documentation listed. Staff B the Director of Nursing confirmed vital sign documentation for patient #1 transfusion of platelets was out of chronological order and post one hour vital sign documentation was absent from the record.

On 10/10/2017 at 1430 during an interview with Staff B the Director of Nursing a request was made to obtain patient #1's consent for the transfusion of platelets. On 10/10/2017 at 1530 Staff B confirmed a consent for patient #1 to receive platelets "could not be found." Staff B was queried if all patients receiving blood or a blood component were required to sign a consent. Staff B responded "yes."

On 10/11/2017 at 1045 during the document review of patient #33 medical record it was revealed patient #32 received a transfusion of two units of red blood cells (a blood component) on 9/27/2017. Further review of the medical record for patient #32 revealed the patient's medical record failed to include a consent for the transfusion of blood products or blood components.

On 10/11/2017 at 1100 during the document review of patient #34 medical record it was revealed patient #34 received a transfusion of one unit of platelets (a blood component) on 9/26/2017. Further review of the medical record for patient #34 revealed the patient's medical record failed to include a consent for the transfusion of blood products or blood components.

On 10/11/2017 at 1340 during an interview with Staff B the Director of Nursing a request was made to obtain patient #32 and patient #34 consents for the transfusion of blood components. On 10/11/2017 at 1430 Staff B confirmed a consent for patient #32 and patient #34 to receive blood components "could not be found." Staff B was queried if all patients receiving blood or a blood component were required to sign a consent. Staff B responded "yes."

On 10/11/2017 at 1500 a review of the policy titled "Blood Component Transfusion" with a revision date of 7/21/2017 was reviewed. According to the policy "A signed Blood Consent is required for all transfusion of all blood and blood components."