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Based on medical record review and administrative nursing staff interview the hospital failed to ensure the medical record was accurate and complete for 4 of 4 records reviewed (#1, 3, 5 and 6).

Findings include:

The hospital policy entitled "Blood/Blood Products/Blood Derivatives Administration" states under Procedure C. 17. "Take and record the vital signs after the first 15 minutes, and the end of the transfusion as well as PRN (as needed) during transfusion as indicated by patient's condition."

1. Closed medical record review of patient #1, indicated this 83 year old male was admitted on 12/29/2009, with diagnosis of abdominal pain, and discharged 1/19/2010. During his admission he received several units of FFP (Fresh Frozen Platelets) and PRBC Packed Red Blood Cells. On 12/30/2009 at 1915 a unit of FFP was given with vital signs documented but no times posted. On 12/31/2009 at 1755 a unit of PRBC was given with no time documented for the end set of vital signs. On 1/2/2010 at 0013 a unit of FFP was given with the start, 15 minute and end vital signs all documented as being done at 0013, and on 1/2/2010 another unit of FFP was given with no documented time for the set of 15 minute vital signs. Interview with administrative nursing staff on 3/10/2010 at 1330 confirmed the times were not documented appropriately due to a computer system glitch.

2. Closed medical record review of patient #3, indicated this 45 year old male was admitted on 2/3/2010, with diagnoses of Fever and AIDS, and discharged 2/11/2010 to another hospital. During his admission he received 2 units of PRBC (Packed Red Blood Cells) On 2/7/2010 at 0415 the first unit of PRBC was administered however the vital signs posted had no time documentedfor the 15 minuted vitals and for the second unit of PRBC the start, 15 minute, and post vitals were all documented as given at 0818. Interview with administrative nursing staff on 3/10/2010 confirmed the times were not an accurate depiction of the events due to problems with how the computer system was set up.

3. Closed medical record review of patient #5, indicated this 66 year old male was admitted on 1/17/2010, with diagnosis of Digitoxicity, and discharged 1/21/2010. During his admission he received 6 units of PRBC (Packed Red Blood Cells) and/or Platelets. On 1/20/2010 at 1735 a unit of Platelets was given with both the starting and 15 minute vital sign being documented as done at 1735. On 1/21/2010 a unit of PRBC was given with all the starting, 15 minute, and post vital signs documented as done at 1230. On 1/21/2010 another unit of PRBC was given with both the starting and 15 minute vital signs being documented as done at 1530. Interview with administrative nursing staff on 3/11/2010 at 1000 confirmed the times were not documented appropriately due to a computer system glitch.

4. Closed medical record review of patient #6, indicated this 78 year old male was admitted on 1/1/2010, with diagnoses of GI Bleed. and discharged 1/3/2010. During his admission he received 9 units of FFP (Fresh Frozen Platelets) and /or PRBC (Packed Red Blood Cells). On 1/1/2010 a unit of FFP was given with the time for the 15 minutes vitals not documented and another unit of, type of product not documented. There was a time for post set of vitals documented, but no time of start or 15 minute vitals documented. Interview with administrative nursing staff on 3/11/2010 at 1000 confirmed the times were not documented appropriately due to a computer system glitch.

NC00062390