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Based on policy and procedure review, closed medical record review, and staff interview nursing staff failed to supervise and monitor care by failing to monitor a patient's temperature according to hospital policy for 1of 4 patients with blood transfusions. ( Pt #14)

Findings Include:

Review of the "Blood and Blood Product Administration" policy, dated 08/11/2015, revealed "...H. Blood Administration Monitoring 1. Monitor vital signs, patient's tolerance, and observe for possible transfusion reaction. Monitor vitals (at a minimum) a. Within 60 minutes prior to administration b. Within 5-15 minutes of beginning the transfusion c. Within 45-75 minutes of beginning the transfusion d. Within 15 minutes of completed transfusion e. Within 45 minutes of the completed transfusion....Addendum 1 TRANSFUSION REACTIONS/ ADVERSE EFFECTS ....Extravascular Hemolysis....Symptoms....Fever....**Febrile Non-hemolytic ....Symptoms: Temp (temperature) rise (symbol for greater than or equal to) 1.8 (symbol for degrees) F (Fahrenheit) associated w/ (with) transfusion with no other explanation. ..."

Closed medical record review of Pt # 14 revealed the patient was admitted for a Gastrointestinal (GI) bleed on 01/09/2016. Review revealed a physician order for two units of blood. On 01/09/2016 at 2112, review revealed pre-transfusion vital signs including Temperature 98.7, Pulse (P)-137, and Blood Pressure 93/59. Record review revealed the blood started at 2115. Record review revealed the next vital signs obtained were at 2200 (45 minutes later) and were documented as P-136 and BP-100/64. Review did not reveal documentation of a temperature at that time. Further review revealed some vital signs taken at 2230, 2300, and 2330, but did not reveal another temperature taken until after the unit of blood finished infusing at 2336. A temperature of 98.7 was documented at 2337 (2 hours, 16 minutes after the blood started). Further record review revealed a second unit of blood started on 01/10/2015 at 0045. Review revealed a temperature was taken at 0041, prior to the start of the second unit, and again at 0048, 0056, and 0135. Review did not reveal a temperature documented at 0337 when the blood finished infusing. Further review did not reveal another temperature documented until 0639 (3 hours, 2 minutes after the blood ended and 5 hours, 4 minutes after the most recent documented temperature during blood administration.

Interview on 01/21/2016 at 0945 with Nurse Manager (NM) # 1 and NM # 2 revealed vital signs to be taken during blood administration include temperature. Interview revealed policy for vital signs during blood administration was not followed.

NC 00112592
NC 00112915