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Based on hospital policy and procedure review, open and closed medical record review and staff and physician interview, the nursing staff failed to follow a physician's order for 1 of 2 patients with an alcohol assessment (Patient #1) and failed to obtain vital signs per hospital policy for 2 of 4 patient receiving a blood transfusion (Patient #8, #7).

Findings included:

A. Review on 09/06/2018 of the hospital policy titled "Medication Administration" origination date June 29, 2017, revealed "Policy: ...A. Medications are administered only upon the order of a member of the medical/dental staff or other individuals who have privileges to write such orders."

Review on 09/05/2018 of the closed medical record for Patient #1 revealed a 62 year-old female admitted on 08/04/2018 at 1433 with a diagnosis of Left buttock wound. Record review revealed Patient #1 was discharged to a Skilled Nursing Facility (SNF) on 08/13/2018 at 1712. Review of the physician orders revealed a CIWA (alcohol withdrawal assessment) Scale order dated 08/04/2018 at 1629 with instructions to assess alcohol withdrawal signs/symptoms every six (6) hours and as needed. Review of the nursing flowsheet revealed the first (1st) alcohol withdrawal assessment was completed on 08/04/2018 at 2000. Further review of the nursing flowsheet revealed the next available documentation of an alcohol withdrawal assessment was completed on 08/05/2018 at 0900 (13 hours later). Review of the nursing flowsheet revealed the alcohol withdrawal assessment were completed every 12 hours from 08/05/2018 at 0900 through 08/07/2018 at 0745. Review of the nursing flowsheet revealed alcohol withdrawal assessments were completed on 08/07/2018 at 1253, at 2122 (9 hours and 15 minutes later), on 08/08/2018 at 0202, at 0504, at 0754 and at 2107 (13 hours and 13 minutes later). Further review of nursing flowsheets revealed documentation of alcohol withdrawal assessment completed on 08/09/2018 at 0011, at 0330, at 0835, at 2016 (11 hours and 31 minutes later) and at 2342, on 08/10/2018 at 0423 (41 minutes later) and at 1945 (15 hours and 22 minutes later), on 08/11/2018 at 0715 (11 hours and 30 minutes later), and at 2016 (13 hours and 1 minute later), on 08/12/2018 at 0730 (11 hours and 14 minutes later), and at 1957 (12 hours and 27 minutes later) and on 08/13/2018 at 0730 (11 hours and 33 minutes later) and at 1200. Review of the medical record revealed the nursing staff did not follow the physician order to assess the alcohol withdrawal signs/symptoms every six (6) hours.

Interview on 09/06/2018 at 1000 with nursing management revealed staff were expected to follow the physician's orders as written. Interview revealed the nursing staff failed to assess the alcohol withdrawal signs/symptoms every six (6) hours as ordered by the physician.

B. Review on 09/05/2018 of the hospital policy titled "Blood and Blood component Administration (blood transfusion)" revised July 6, 2017 revealed "Appendix C: summary Chart of Blood Components ...Red Blood Cells Leuko-reduced ...Vital Signs: *Baseline prior to standard infusion *15 minutes into infusion *Every hours during infusion *At completion of infusion."

1. Review on 09/06/2018 of the open medical record for Patient #8 revealed an 85 year-old female admitted on 08/30/2018 at 0358 with a diagnosis of blood sugar problems. Review of the physician orders dated 08/30/2018 at 0300 revealed an order to transfuse two (2) units of PRBC's (packed red blood cells). Review of the blood administration nursing flowsheet revealed the second unit of blood was started on 08/30/2018 at 1709. Review of nursing notes revealed vital signs to include a temperature, heart rate, respiratory rate, blood pressure and oxygen saturations were completed on 08/30/2018 at 1709, 1728, and 1830. Review of the nursing notes revealed documentation of a heart rate, respiratory rate, blood pressure and oxygen saturation were completed at 1930. Review of the nursing notes revealed documentation that the transfusion was completed at 2046 with documentation of temperature, heart rate, respiratory rate, blood pressure and oxygen saturation completed at 2047. Review of the physician orders dated 08/31/2018 at 0402 revealed an order to transfuse one (1) unit of blood. Review of the blood administration nursing flowsheet revealed the blood transfusion was started on 08/31/2018 at 0436. Review of nursing notes revealed vital signs to include a temperature, heart rate, respiratory rate, blood pressure and oxygen saturations were completed on 08/30/2018 at 0436, 0446, and 0556. Review of the nursing notes revealed documentation of a heart rate, respiratory rate, blood pressure and oxygen saturation were completed at 0700 and 0800. Review of the nursing notes revealed documentation that the transfusion was completed at 0859 with documentation of temperature, heart rate, respiratory rate, blood pressure and oxygen saturation completed at 0900. Review of the medical record revealed no available documentation of a temperature obtained at 0700 and 0800. Review of the medical record revealed nursing staff failed to obtain vital signs per the hospital blood transfusion policy.

Interview on 09/06/2018 at 1000 with nursing management revealed staff were expected to obtain vital signs per the blood transfusion hospital policy. Interview revealed vital signs should include a temperature, blood pressure, heart rate, respiratory rate and oxygen saturation. Interview revealed the nursing staff failed to obtain a complete set of vital signs per hospital policy for Patient #8.

2. Review on 09/05/2018 of the closed medical record for Patient #7 revealed a 77 year-old female admitted on 07/25/2018 at 0613 with a diagnosis of lethargy, decreased hemoglobin and red knee. Record review revealed Patient #7 was discharged on 08/23/2018 at 1039. Review of the physician orders dated 07/24/2018 at 2203 revealed an order to transfuse two (2) units of PRBC's (packed red blood cells). Review of the blood administration nursing flowsheet revealed the first unit of blood was started on 07/25/2018 at 0127. Review of nursing notes revealed vital signs to include a temperature, heart rate, respiratory rate, blood pressure and oxygen saturations were completed on 07/25/2018 at 0126 and 0141. Review of the nursing notes revealed documentation of a heart rate, respiratory rate and oxygen saturation were completed at 0315 and 0354. Further review revealed documentation of a heart rate, respiratory rate, blood pressure and oxygen saturation were completed at 0407. Review of the nursing notes revealed documentation that transfusion was completed at 0417 with documentation of temperature, heart rate, respiratory rate, blood pressure and oxygen saturation completed at 0418. Review of the medical record revealed a transfusion reaction was identified at 0300 and no documentation of the discontinuance of the blood transfusion. Review of the medical record revealed no available documentation of vital signs obtained at 0241 and no documentation of a temperature or blood pressure obtained at 0315 and 0354. Review of the medical record revealed nursing staff failed to obtain vital signs per the hospital blood transfusion policy.

Interview on 09/06/2018 at 1000 with nursing management revealed staff were expected to obtain vital signs per the blood transfusion hospital policy. Interview revealed vital signs should include a temperature, blood pressure, heart rate, respiratory rate and oxygen saturation. Interview revealed the nursing staff failed to obtain a complete set of vital signs per hospital policy for Patient #7.

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