HospitalInspections.org

Based on policy review, open and closed medical record review, and staff interviews, the hospital nursing staff failed to follow the hospital's policy and procedure for blood administration in the documentation of one hour post transfusion vital sign assessment according to blood administration policy for 4 of 9 blood transfusions completed.

The findings included:

Review of the hospital's policy, "BLOOD ADMINISTRATION", revised on 10/10 revealed, "... B. ESSENTIAL STEPS:...6. DOCUMENTATION a. (11) Vital signs (T-P-R & BP) (Temperature-Pulse-Respirations and Blood Pressure) i. Before transfusion started ii. 15 minutes after transfusion began and q (every) 1 hr (hour) until blood product infused. iii. At end of transfusion iv. One hour post-transfusion..."

1. Open transfusion record review conducted on 03/14/2013 revealed patient #12 received blood products on 03/14/2013 with a start time of 0340. Further review revealed the blood transfusion ended at 0715 and the one hour post-transfusion vital sign was documented at 1013 (two hours and 58 minutes later). Interview conducted on 03/14/2013 at 1625 with the hospital administrative staff revealed no further documentation was available for the blood transfusion administered. The interview revealed the nursing staff did not follow the hospital's policy for blood administration in the documentation of vital signs assessment.

2. Closed medical record review conducted on 03/13/2013 revealed patient #8 received blood products on 01/15/2013. Record review revealed the transfusion started at 1850 and the transfusion ended at 2145. Record review revealed no documentation of the one hour post transfusion vital signs. Interview conducted on 03/14/2013 at 1625 with administrative staff revealed there was no further documentation was available for the blood transfusion administered. The interview revealed the nursing staff did not follow the hospital's policy for blood administration in the documentation of vital signs assessment.








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3. Closed medical record review of patient # 9 revealed an 82 year old admitted on---with a diagnosis of-----. Review of the record revealed the patient received a blood transfusion on 09/20/2012. Review of the nursing documentation revealed the transfusion started at 0100 and ended at 0200. Record review revealed no documentation of a one hour post transfusion vital sign assessment. Record review revealed a second unit of blood was administered on 10/01/2012 starting at 0345 and ending at 0600. Record review revealed no documentation of a one hour post transfusion vital sign assessment. Record review revealed the patient received a third unit of blood on 10/06/2012 starting at 2310 and ending at 0200. Record review revealed no documentation of the one hour post vital sign assessment.

Interview conducted on 03/14/2013 at 1625 with administrative staff revealed there was no further documentation available for the blood transfusions administered. The interview revealed the nursing staff did not follow the hospital policy for blood administration regarding the assessment of vital signs one hour after the transfusion is completed.


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