HospitalInspections.org

Based on document review and interview, nursing services failed to document blood administration, document fall risk assessments, and vital signs as ordered in 1 out of 10 patient medical records reviewed (Patient 5).

Findings Include:

1. Facility policy titled, Blood and Blood Component Administration, Publication Date 10/31/2023, indicated under VI. Procedures, D. Minimum Documentation Requirements, 2. Pre-transfusion vital signs: a. Between 1 and 60 minutes prior to initiating the transfusion ("Start time"), a trained clinical team member must take and record vital signs., 3. 15 Minutes vital signs: a. Between the first 10 and 20 minutes of the transfusion, the transfusionist must take and record vital signs; 6. For all transfusions being documented on the Transfusion Document., a. All the following blanks must be filled out to be considered complete: 3. Pre-transfusion vital signs, time, and first initial and last name of team member recording., 4 Start date and time, 5. Fifteen (15) minute vital signs, time, and first initial and last name of transfusionist/team member recording, 6. Signature with credentials of who performed mid-way assessment., 8. Stop date and time., 9. Amount of product transfused in mL (or indicate ALL if whole unit transfused); 10. Post-transfusion vital signs, time, and first initial and last name of team member recording.

2. Facility policy titled, Fall Prevention, Publication Date 10/17/2023, indicated under VI. Procedures, Assessment, A. Fall Risk assessment should be completed: b. once per shift.

3. Review of Patient 5's medical record indicated the following:
a. Provider order on 02/22/2024 indicated vital signs to be taken every 2 hours; medical record lacked 6 out 12 sets of vital signs on 03/01/2024, 5 out of 12 sets of vital signs on 03/02/2024, 7 out of 12 sets vital signs on 03/03/2024, and 3 out of 12 sets of vital signs on 03/04/2024.
b. Provider ordered transfusion of 1 unit of blood on 03/01/2024 at 8:18 a.m. MR indicated the start time for the blood infusion was 11:20 a.m. and medical record lacked documentation of pre-transfusion vitals.
c. Provider ordered transfusion of 1 unit of blood on 03/04/2024 at 10:12 a.m. Medical record indicated unit of blood was verified by two Registered Nurses at 10:41 a.m. and documented as transfused; medical record lacked documentation of the following: pre-transfusion, 15 minute, and post transfusion vital signs; start and stop times of the transfusion; mid-way assessment; and amount of product transfused.
d. Medical record lacked documentation of shift fall assessments on the following shifts: 03/01/2024 day and night shift, 03/02/2024 day and night shift, 03/03/2024 day and night shift, and 03/04/2024 day shift.

4. Interview with A2 (Clinical Nurse Specialist) and A3 (Manager of Accreditation and Regulatory) on 10/21/2024 at approximately 5:10 p.m. confirmed the following:
a. Provider order on 02/22/2024 indicated vital signs to be taken every 2 hours; medical record lacked 6 out 12 sets of vital signs on 03/01/2024, 5 out of 12 sets of vital signs on 03/02/2024, 7 out of 12 sets vital signs on 03/03/2024, and 3 out of 12 sets of vital signs on 03/04/2024.
b. Medical record lacked documentation of pre-transfusion vitals for blood administered on 03/01/2024.
c. Medical record lacked documentation of the following: pre-transfusion, 15 minute, and post transfusion vital signs; start and stop times of the transfusion; mid-way assessment; and amount of product transfused for the transfusion of 1 unit of blood on 03/04/2024 at 10:12 a.m.
d. Medical record lacked documentation of shift fall assessments on the following shifts: 03/01/2024 day and night shift, 03/02/2024 day and night shift, 03/03/2024 day and night shift, and 03/04/2024 day shift.