HospitalInspections.org

Based on medical record reviews, staff interviews, and policy review, the facility failed to administer blood transfusions in accordance with facility policy related to the timing of vital sign assessment and verification, by licensed nursing staff, of the correct blood product and correct patient prior to administering blood transfusions. This affected three of six sampled patients (Patients #7, #8, and #9) who received intravenous blood products, and involved the inpatient nursing unit 3ST and the outpatient cancer center.

Findings include:

1. The medical record review was conducted for Patient #7 on 07/23/13 between 4:00 PM and 5:00 PM, and on 07/24/13 from 1:00 PM to 1:30 PM.

The medical record revealed Patient #7 was admitted to the 3ST inpatient unit on 10/09/12 at 11:40 AM for Thrombocytopenia (abnormally decreased number of platelets in the blood). The patient was transfused with 2 units of blood on 10/09/12 from 3:45 PM to 4:15 PM, and at 4:40 PM to 8:35 PM. The medical record lacked documentation of a vital sign assessment, including the patient's temperature, within 30 minutes prior to the start of the transfusion. The last set of vital signs recorded were documented on 10/09/12 at 9:00 PM, at which time the patient's temperature was 99 degrees Fahrenheit (F.). The nursing documentation for the transfusion lacked a body temperature assessment prior the the start of the blood transfusion.

A nursing note, dated 10/10/12 at 4:07 AM, by a registered nurse, documented "the second unit of red blood cells stopped for possible blood reaction (increase in temperature). House office notified and transfusion reaction protocol followed accordingly." A 10/10/12 discharge note by a registered nurse revealed Patient #7's body temperature was 101.4 degrees Fahrenheit at 3:30 AM on 10/10/12. Patient #7's body temperature at 5:00 AM was documented as 97.4 and as 98.2 at 6:40 AM.
This medical record documented the patient was discharged on 10/10/12 at 3:25 PM to a nursing home.

On 07/23/13, between 4:00 PM and 5:00 PM, Staff H provided the surveyor with a form dated 10/10/12, titled "Transfusion Reaction Investigation Initial Testing Worksheet". This form listed Patient #7's name. This form revealed the patient received a blood transfusion on 10/10/12 beginning at 2:30 AM and ending at 3:30 AM. This form revealed the patient experienced a body temperature change (elevated). On this form, on 10/16/12, the Medical Director documented the following "Clinically a temperature change was noted during transfusion, but no information was provided to assess (the) degree of change. No evidence of hemolysis. Gram stain negative."

On 07/23/13, between 4:00 PM and 5:00 PM, Staff H stated the form titled "Component Transfusion Tag" was used to certify the patient's name and medical record number on the blood product tag matches the patient name and medical record number on the patient wristband. The form revealed an area for signatures by transfusions #1 and #2, who verified the patient and blood product were compared and found to match. During this interview, when questioned as to why this form was not a part of the patient's medical record, Staff H stated the verification form was given to the lab to review for the adverse reaction on 10/10/12. On 07/23/13 at 1:05 PM, an interview with Staff A revealed this verification form could not be located, and was not in the patient's medical record. Staff A stated the medical record was silent to verification of the correct blood product, and verified the facility policy was not followed to verify the correct blood product and patient prior to the transfusion.


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2. The medical record review for Patient # 8, completed on 07/23/13, revealed the patient's several visits to the outpatient cancer center for blood transfusions. On 07/12/13, Patient #8 received a platelet transfusion. The vital signs, including a temperature reading, were obtained at 2:40 PM., when the blood product was hung and the transfusion was started. The vital signs were obtained at 3:10 PM., one half hour after the start of the transfusion, and at the completion of the transfusion. There was no documentation of the patient's temperature reading included at either time. No other vital signs were documented as completed during the transfusion.
This was verified by Staff E on 07/23/13 at 2:45 PM.
3. The medical record review for Patient #9, completed on 07/23/13, revealed a visit on 07/23/13, to the outpatient cancer center for a platelet transfusion. The vital signs were taken at the start of the transfusion, and included documentation of a temperature reading. It was documented that vitals signs were taken 15 minutes later; however, no temperature reading was documented. The patient's vital signs were documented post transfusion but the documentation lacked the patient's temperature reading.
This was verified by Staff E on 07/23/13 at 3:15 PM.
4. Review of the nursing procedure dated 06/04/13, and titled "Blood and Blood Component Administration", completed on 07/24/13, revealed vital signs including temperatures are to be taken within 30 minutes prior to the start of the transfusion. Then again 15 minutes after the start of the transfusion, at any change in the patient's condition, and at the completion of the transfusion.