HospitalInspections.org

Based on review of hospital policies and procedures, medical record review and staff interviews the nursing staff failed to administer blood transfusions according to hospital policy for 3 of 5 sampled patients that received a blood transfusion (#9, #2 and #8).

The findings include:

Review of the hospital's policy, "Blood & Blood Product Transfusion", revised 05/2009, revealed, "...Procedures...9. ...k. Vital signs should be taken every 15 minutes x (times) 2 then every hour until the transfusion is complete and at the completion of the unit of blood or blood product...."

1. Open medical record of Patient #9 revealed a 66 year-old male admitted 03/04/2011 with alcohol withdrawal and acute renal failure. Record review revealed a physician's order dated 04/11/2011 at 1020 to transfuse 2 units of packed red blood cells if the patient's hemoglobin was less than 8. Record review revealed the patient's hemoglobin was 7.8 on 04/12/2011 and the first unit of blood was started at 0310 and completed at 0724. Record review revealed the patient's temperature, pulse, respiratory rate and blood pressure was checked at 0310. Record review revealed the patient's temperature and respiratory rate was reassessed at 0542 (2 hours, 32 minutes later).

Interview on 04/12/2011 at 1345 with a staff registered nurse revealed, "vital signs should be taken before starting the blood, then every 15 minutes times 2, then every hour afterwards until the blood is complete. It's important to get the temperature and respirations because an increase in temperature or respirations are signs of a reaction". Interview confirmed there was no documentation that Patient #9's temperature and respiratory rate were checked every 15 minutes times 2 and then hourly during the administration of blood. Interview confirmed the nursing staff did not follow the hospital's policy for the administration of blood.

2. Open medical record review of Patient #2 revealed a 44 year-old female admitted 03/10/2011 with congestive heart failure and pneumonia. Record review revealed a physician's order dated 04/03/2011 at 0540 to transfuse 2 units of packed red blood cells. Record review revealed the first unit was started on 04/03/2011 at 1150 and completed at 1430. Record review revealed the patient's temperature, pulse, respiratory rate and blood pressure was checked at 1150. Record review revealed the patient's temperature was reassessed at 1245 (55 minutes later). Record review revealed the second unit of blood was started at 1525 and completed at 1800. Record review revealed the patient's temperature, pulse, respiratory rate and blood pressure was checked at 1525. Record review revealed the patient's temperature was reassessed at 1630 (55 minutes later).

Interview on 04/12/2011 at 1345 with a staff registered nurse revealed, "vital signs should be taken before starting the blood, then every 15 minutes times 2, then every hour afterwards until the blood is complete. It's important to get the temperature because an increase in temperature is a sign of a reaction". Interview confirmed there was no documentation that Patient #2's temperature was checked every 15 minutes times 2 during the administration of blood. Interview confirmed the nursing staff did not follow the hospital's policy for the administration of blood.

3. Closed record review of Patient #8 revealed an 81 year-old admitted 03/24/2011 with dehydration. Record review revealed a physician's order dated 04/02/2011 to transfuse 2 units of packed red blood cells. Record review revealed the first unit of blood was started on 04/02/2011 at 1308 and completed at 1600. Record review revealed the patient's temperature, pulse, respiratory rate and blood pressure was checked at 1308. Record review revealed the patient's temperature was reassessed at 1635 (3 hours, 27 minutes later). Record review revealed the second unit of blood was started at 1635 and completed at 1930. Record review revealed the patient's temperature, pulse, respiratory rate and blood pressure was checked at 1635. Record review revealed the patient's temperature was reassessed at 2205 (5 hours, 30 minutes later).

Interview on 04/12/2011 at 1345 with a staff registered nurse revealed, "vital signs should be taken before starting the blood, then every 15 minutes times 2, then every hour afterwards until the blood is complete. It's important to get the temperature because an increase in temperature is a sign of a reaction". Interview confirmed there was no documentation that Patient #8's temperature was checked every 15 minutes times 2 and then hourly during the administration of blood. Interview confirmed the nursing staff did not follow the hospital's policy for the administration of blood.