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Based on policy and procedure review, closed medical record review, and staff interviews, the hospital failed to reassess vital signs per policy for 2 of 3 blood transfusion records reviewed [Patients {Pt} # 4 and # 5]

The findings include:

Review of hospital policy and procedure "BLOOD AND/OR BLOOD COMPONENT TRANSFUSION", reviewed/revised 02/10/2016, revealed "...PC-121-IV. SPECIAL CONSIDERATIONS and PATIENT SAFETY....I. Periodic observation and recording of vital signs [VS] will occur during and after the transfusion to identify suspected adverse reactions. If the patient will not remain under direct medical supervision after the transfusion, instructions will be provided to the patient regarding possible adverse effects from the transfusion and who to contact in case of a reaction. (For example, outpatient transfusions and situations where the patient is discharged shortly after the transfusion)....PC-121-X. SUSPECTED TRANSFUSION REACTION/ADVERSE REACTION A. As soon as an adverse reaction is suspected, disconnect the transfusion and place 'on hold'....B. Obtain VS immediately....H. Continue to monitor vital signs every 15 minutes or as indicated by the severity of the reaction....PC-121-XIII. IMPLEMENTATION....C. RED BLOOD CELLS....2. Obtain baseline vital signs of temperature [T], pulse [Heart Rate - HR], respiration [Respiratory rate - RR], oxygen saturation (SpO2), blood pressure [BP] and pain intensity....10. Re-check and record vital signs, and observe for signs of blood transfusion reaction....Fifteen minutes after initiation....One hour after initiation....At end of transfusion (when blood tubing mostly cleared of product)....1 hour after transfusion completed. ..."

1. Closed medical record review of Patient (Pt) # 4 on 05/24/2016, revealed the 73 year old patient was ordered to receive two (2) units of packed red blood cells. Review revealed the second unit of blood was started on 04/02/2016 at 1310. Review revealed at 1521 "...called into pt room due to pt stating he is shaking and cannot stop. pt is visibly shaking at this time. have taken vs at this time and put in for transfusion reaction.. ..." Review revealed the physician was notified at 1530 and "...BLOOD HAS BEEN COMPLETELY DISCONNECTED FROM PT....WILL CONTINUE TO MONITOR VS." Review of flowsheets revealed VS documented at 1536 which included T 98.2, HR 91, RR 24, and BP 136/61. Review did not reveal VS recorded after 1536 until 1729 [1 hour 53 minutes later], with T 100.6, HR 87, and BP 122/55. Review of notes revealed the physician was called at 1730 about the 100.6 T and "...md [MD] has requested pt to stay overnight so he can see him in the am, md has given me orders for pt overnight. pt face is also flush at this time." Record review failed to reveal VS every 15 minutes after the potential transfusion reaction.

Interview with Nurse Administrator # 1, on 05/27/2016 at 1125, revealed "based on the data available, policy was not followed."

2. Closed medical record review of Pt # 5, on 05/24/2016, revealed the 60 year old patient received two (2)blood transfusions on 05/09/2016. Record review revealed the first unit of blood was started at 1030 and VS were T 100.2, HR 93, RR 18, and BP 102/62. Review of VS revealed at 1045 the patient's T was 102.3, HR 90, RR 18, BP 88/64. Record review revealed a potential transfusion reaction noted at 1053, the transfusion was stopped, and the provider and blood bank were notified. Review revealed the next set of VS at 1145 [1 hour after last VS and 53 minutes after potential transfusion reaction noted], with T 100.3, HR 93, RR 18, and BP 102/62. Record review did not reveal VS every 15 minutes following a potential transfusion reaction. Further record review revealed a second unit of blood was started at 1340, and VS taken, with T 99.8, HR 90, RR 18, BP 92/58. At 1355 [15 minutes after blood initiation] VS were T 99.8, HR 87, RR 16, BP 93/82. Review revealed the next set of VS at 1535 [1 hour, 55 minutes after the second unit of blood was initiated], which were T 98.2, HR 82, RR 18, BP 98/51. Record review did not reveal VS 1 hour after blood initiation.

Interview with the RN # 14, on 05/27/2016 at 1100, revealed RN # 14 cared for Pt # 5 during the blood transfusion. Interview revealed the blood was stopped at 1053 for a possible transfusion reaction. Interview revealed VS were not done every 15 minutes because "I did not realize it was supposed to be every 15 minutes." Interview revealed RN # 14 had "...not had a transfusion reaction in years." In relation to the second unit of blood and the 1 hour VS, RN # 14 stated "apparently I missed it."

Interview with Nurse Administrator # 1, on 05/27/2016 at 1125, revealed "based the data available, policy was not followed."

Based on policy and procedure review, observation during tour and staff interviews, the hospital staff failed to properly clean and disinfect glucometers (meters to test patients' blood glucose) to prevent availability of use of contaminated equipment for 3 of 4 glucometers observed.

The findings include:

Review of hospital policy and procedure "... POINT OF CARE TESTING (POCT): STATSTRIP BLOOD GLUCOSE [sugar] MONITORING", reviewed: 10/07/2015, revealed " PC-98-I. PURPOSE The StatStrip Glucose Meter by [Manufacturer name] is used for the quantitative [numerical] measurement of glucose in whole blood [drawing of blood directly from the body without removing any of the components] for the purpose of monitoring blood glucose levels.....PC-98-XIII. /CLEANING OF EQUIPMENT A. The blood glucose testing meter must be cleaned and disinfected after EACH patient use, whether or not blood contamination is suspected....1. Clean the meter thoroughly with a disposable [Manufacturer wipes name]..."wet time" is one (1) minute. The glucometer should be allowed to dry for a full one (1) minute to kill any organisms....2. Dry the lens area with a dry cotton swab or lint free cloth and wipe the entire meter dry with a soft lint free cloth...."

1. Observation during tour, on 05/24/2016 at 1530, of the ER (Emergency Room) revealed a glucometer was not clean and disinfected. Observation revealed dry blood on a docked and ready for use glucometer.

Interview with RN (Registered Nurse) #7 , on 05/24/2016 at 1532 , revealed " based on observation policy was not followed."

2. Observation during tour, on 05/25/2016 at 1030, of the ER revealed patient equipment was not clean. Observation revealed dry blood on two [2] docked and ready for use glucometers.

Interview with Administrator #2, on 05/25/2016 at 1045, revealed that Administrator #2 observed dry blood on two [2] docked and ready for use glucometers. Further interview revealed "the expectation of staff is to clean equipment between each patient per policy." Interview revealed policy was not followed.

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