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Based on review of hospital policy, medical record review and staff interviews, the nursing staff failed to monitor a patient receiving a blood transfusion per hospital policy for 2 of 3 patients receiving blood (Patient #6 and 7).

The findings include:

Review of the hospital's policy, "Transfusion Therapy", revised 02/2014, revealed, "...B. Guidelines to Follow During Transfusion of Blood/Blood Components"...4. Assess TPR (temperature, pulse, respirations) 15 minutes after blood is started. ...7. Obtain vital signs every 1 hour...C. Guidelines for Documentation: ...d. Vital signs prior to sending for blood, 15 minutes post initiation of transfusion and at the end of the transfusion...".

1. Closed medical record for Patient #6 revealed a 59 year-old male who was admitted on 04/06/2015 with gastrointestinal (GI) bleeding. Record review revealed a physician's order on 04/08/2015 at 0309 to transfuse patient with one unit of packed red blood cells and another order at 0725 to transfuse another unit of blood. Record review revealed the first unit was started at 0642. Record review revealed no documentation that Patient #6's respiratory rate, pulse and blood pressure were checked until 0715 (30 minutes after the transfusion was started). Record review revealed the second unit of blood was started at 0840. Record review revealed no documentation that Patient #6's temperature and blood pressure were checked until 1025 (1 hour, 45 minutes after the transfusion was started).

Interview on 05/05/2015 at 1600 with Administrative Nursing Staff confirmed the nurse did not assess vital signs (temperature, pulse, respirations and blood pressure) while administering blood to Patient #6 per the hospital's policy.

2. Closed medical record for Patient #7 revealed a 64 year old male who was admitted on 04/13/2015 for change in mental status. Record review revealed a physician's order on 04/13/2015 at 0117 to transfuse the patient with two (2) units of packed red blood cells. Record review revealed the first unit was completed at 0604 on 04/13/2015 and the second unit started at 0636. Record review revealed no documentation of any vital signs (temperature, pulse, blood pressure, respirations) until 0728 (52 minutes after start of transfusion). Record review revealed the second unit transfusion was completed at 0937. Record review revealed no further vital signs were documented until 1125 ( 1 hour, 48 minutes after transfusion completed).

Interview on 05/06/2015 at 1115 with Administrative Nursing Staff confirmed the nurse did not assess and document vital signs (temperature, pulse, respirations and blood pressure) while administering blood to Patient #7 per the hospital's policy.

NC00105356 NC00104699