HospitalInspections.org

Based on clinical record review and facility document review, the facility staff failed to monitor two (2) of two (2) patients receiving a blood transfusion.

The findings include:

On 1/12/2021 the surveyor reviewed the clinical record for Patient #4. Patient #4 received a blood transfusion on 1/9/2021 and on 1/10/2021. The record contained documentation that on 1/9/2021 vital signs were taken at 1818 (6:18 p.m.) and the transfusion began at 1828 (6:28 p.m.). Vital signs were taken again at 1845 (6:45 p.m.), 1941 (7:41 p.m.), 2045 (8:45 p.m.), and 2203 (10:03 p.m.). The blood transfusion ended at 2205 (10:05 p.m.). On 1/10/2021 vital signs were taken at 1121 (11:21 a.m.) and the transfusion began at 1145 (11:45 a.m.). Vital signs were taken again at 1204 (12:04 p.m.) and 1456 (2:56 p.m.). The blood transfusion ended at 1508 (3:08 p.m.). The vital signs taken each time were temperature, pulse, respiratory rate, blood pressure, and oxygen saturation.

On 1/12/2021 the surveyor reviewed the clinical record for Patient #5. Patient #5 received a blood transfusion on 1/10/21. The record contained documentation that on 1/10/2021 vital signs were taken at 1539 (3:39 p.m.) and the transfusion began at 1541 (3:41 p.m.). Vital signs were taken again at 1556 (3:56 p.m.), 1634 (4:34 p.m.), and 1727 (5:27 p.m.). The blood transfusion ended at 1836 (6:36 p.m.). The vital signs taken each time were temperature, pulse, respiratory rate, blood pressure, and oxygen saturation.

On 1/12/2021, a review of the facility's document titled, "Blood/Blood Product Ordering and Administration", was conducted. The policy reads in part: "Patient monitoring & Documentation...B. Vital signs: blood pressure, temperature, pulse, respirations, pulse oximetry; 1. At initiation of transfusion (pre transfusion), 2. Every 15 minutes x2, then again in 30 minutes, 3. Hourly from the start of the transfusion until completion of transfusion..."

At the exit conference on 1/12/2021 at 3:15 p.m., the surveyor discussed the findings with Staff Members #1 (Chief Nursing Officer), #2 (Vice President, Quality), #3 (Infection Preventionist), #4 (Chief Executive Officer), and #8 (Chief Financial Officer).