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Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the laboratory staff failed to ensure antibody screening was completed prior to the transfusion of blood for one of 10 medical records reviewed (MR1).

Findings include:

Review on July 25, 2013, of the facility's "Antibody Screen" policy, last revised July 30, 2012, revealed "Purpose: The antibody screen procedure shall define a standard methods [sic] for the detection of clinical significant unexpected antibodies. ... Scope: Antibody screening shall be performed prior to the transfusion of whole blood or blood components containing red blood cells, and in any case wherein the detection of clinically significant unexpected antibodies is relevant. ..."

Review on July 17, 2013, of MR2 revealed the patient received a non-emergent blood transfusion on May 7, 2013. MR2 received one unit of O positive blood on May 7, 2013. MR2's blood type was A positive. MR2 contained no documentation the antibody screen was performed prior to the transfusion.

Interview on July 16, 2013, with EMP1 at approximately 10:30 AM confirmed MR2 received O positive blood on May 7, 2013, and MR2 was A positive.

Telephone interview with EMP1 and EMP2 on July 25, 2013, at 9:00 AM confirmed the antibody screening was not performed on MR2 prior to the administration of the blood transfusion. EMP2 noted the error was identified eight hours following the administration of the unit of blood.

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the nursing staff failed to ensure required nursing records were completed with transfusion of blood for eight of 10 medical records reviewed (MR1, MR2, MR3, MR4, MR6, MR7, MR8, MR10).

Findings include:

Review of the facility's "Blood Administration Products" policy, last reviewed November 30, 2012, revealed "Purpose: ... All blood products are ordered by the Healthcare Provider and administered by Professional Registered Nurse and monitored using the Blood Administration form (Attachment A). ... After completing transfusion, return empty bag to the blood bank with completed transfusion data sheet. ..."

Review on July 17, 2013, of MR1 revealed the patient received blood transfusions. Review of the transfusion data sheet revealed the blood pressure, temperature, pulse, respirations, unit administered by, print name, physician, and computer ID areas were not completed.

Review on July 17, 2013, of MR2 revealed the patient received a blood transfusion. Review of the transfusion data sheet revealed the computer user ID area was incomplete.

Review on July 17, 2013, of MR3 revealed the patient received blood transfusions. Review of the transfusion data sheet revealed the physician and computer user ID areas were incomplete.

Review on July 17, 2013, of MR4 revealed the patient received blood transfusions. Review of the transfusion data sheet revealed the print name, physician, and computer user ID areas were incomplete.

Review on July 17, 2013, of MR6 revealed the patient received a blood transfusion. Review of the transfusion data sheet revealed the physician and computer user ID areas were incomplete.

Review on July 17, 2013, of MR7 revealed the patient received blood transfusions. Review of the transfusion data sheet revealed the print name and computer user ID areas were incomplete.

Review on July 17, 2013, of MR8 revealed the patient received blood transfusions. Review of the transfusion record sheet revealed the amount infused and discontinued by areas were incomplete.

Review on July 17, 2013, of MR10 revealed the patient received blood transfusions. Review of the transfusion data sheet revealed the physician and computer user ID areas were incomplete.

Interview with EMP3 on July 17, 2013, at approximately 11:30 AM confirmed the transfusion data sheets and transfusion record sheets for MR1, MR2, MR3, MR4, MR6, MR7, MR8, MR10 were incomplete.