HospitalInspections.org

Based on record review and interview, the facility failed to ensure nursing staff completed required monitoring and documentation of 2 of 2 sampled patients (#6 & 7) receiving blood or blood products as required by policy.

Findings:

1. Medical record review for patient #6 showed he was admitted on 1/07/14 for severe anemia. The medical record documented a physician order for the patient to receive 3 units of blood during dialysis on 1/08/14. On 1/08/14, the patient received a total of three units of packed red blood cells between 1:20 p.m. and 3:15 p.m. The medical record documented blood pressures, pulse and O2 saturation percentages. However, the temperature was only taken at 12 noon.

During an interview on 1/09/14 at 2:48 p.m., the registered nurse (RN) assigned to the patient said the vital signs should include the temperature, blood pressure, pulse, and O2 saturations. The documentation showed no temperatures taken except 1 hour and 20 minutes prior to the blood administration, with none taken at the beginning or at a 15 minute interval.

During record review on 1/09/14 at 2:45 p.m., the RN manager confirmed the lack of the temperature documentation in the medical record.

2. Medical record review for patient #7 showed he was admitted on 12/30/13 for acute myelogenous leukemia. The medical record documented a physician order for 1 unit of platelets on 1/08/14 based on the patient's low platelet count of 8 (140-440 is normal value). Review of the medical record documentation showed there were no vital signs taken prior to, at 15 minutes, or at the completion of the platelets on 1/08/14. The platelets were started at 10:05 a.m. and completed at 10:53 a.m. The earliest vital signs documented were at 12 noon on 1/08/14.

The patient also received 1 unit of platelets on 1/09/14 for a platelet count of 14. Review of the medical record showed there were no vital signs taken prior to, at 15 minutes, or at the completion of the platelets on 1/08/14. The platelets were started at 1:15 p.m. and completed at 3 p.m. The earliest vital signs documented were at 3:15 p.m.

The risk manager and the nursing unit manager were present during the review of the medical record and confirmed the lack of vital signs present on the medical record. The nursing manager even called (on the phone) the RN responsible for giving the platelets to the patient and asked her if she had taken the patient's vital signs (blood pressure, pulse, and temperature) prior to beginning, and she responded "no."

Review of the hospital policy "Blood and Blood Products Administration", dated as last reviewed 4/01/2013, read the procedure in part, "#5. Assess the patient's pre-transfusion vital signs and temperature and document in the patient's medical record ....#7c. Obtain 15-minutes vitals 15 minutes after the start of the transfusion and document in the patient's chart.