HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure the physician documentation was obtained on the risks and benefits of blood transfusion to the patient while consenting for blood administration in 3 (#6, 7, and 9) of 3 charts reviewed.

A review of patient #7 revealed he was administered blood on 9/8/24 at 11:15 PM for a nosebleed in the emergency room. The blood consent was signed on 9/8/24 at 10:20 PM. The consent revealed there was no physician signature and no documentation that the patient was given his risk and benefits by the physician.

A review of patient # 9's chart revealed patient #9 was administered blood products due to intermittent nose bleeding on 9/13/24 at 11:20 am. The blood consent was signed on 9/13/24 at 10:40 am. The consent revealed there was no physician signature and no documentation that the patient was given his risk and benefits by the physician.

A review of patient #6's chart revealed patient #6 had a blood administration of packed red blood cells on 9/23/24 a review of the consent dated 9/23/24 revealed the patient had signed the consent with the nurse but there was no physician signature that the patient received information on the risk and benefits of blood administration.

An interview was conducted on 9/24/24 with Staff # 5 RN Women's Care Director. Staff #5 stated the physician documents the risks and benefits in the physician's history and physical or progress notes. A review of the chart revealed there was no physician documentation of the risks and benefits.

An interview was conducted on 9/24/24 with physician # 14. Physician #14 stated that patient #6 was her patient. Physician #14 stated that she did discuss the risks and benefits but had not been documenting the risks and benefits in the physician notes.

Based on reviews and interviews the facility failed to ensure the physician ordered an infusion rate for the administration of blood products in 2 of 2(patient #7 and #9) charts reviewed.

A review of patient #7 revealed he was administered blood on 9/8/24 at 11:15 PM for a nosebleed in the emergency room. The physician order stated "LPC (PRBC) priority Lab: stat." There was no number of units ordered or a rate. While nurses administer the transfusion, they must follow the physician's orders regarding the infusion rate. There was no documented rate of the blood that was infused in the nursing documentation.

A review of patient # 9's chart revealed patient #9 was administered blood products due to intermittent nose bleeding on 9/13/24 at 11:20 am. The physician order stated, "9-13-24 at 5:00 am "Transfuse 2 u of PRBC." There was no rate ordered. A review of the nurse's documentation revealed there was no documented rate at which blood was transfused.

An interview was conducted with Staff #6 on 9/24/24. Staff #6 stated the nurses set the rate by the pump. Staff #6 was asked if the pumps were set just for blood and at one specific rate and she stated no. Staff #6 confirmed the physicians were not writing orders and the nurses were setting their rates to administer blood.

A review of the policy and procedure of "Blood or Blood Component Therapy/Management of Transfusion Reaction" stated, "16. After the first 50mls (15 minutes for pediatric patients) is transfused and no reaction is noted increase the blood flow to the prescribed rate. The transfusion must be completed within 4 hours." There was no other direction in the policy and procedure for the nurse to determine the rate of infusion.