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Based on review of hospital policy and procedures, medical record review and staff interviews the nursing staff failed to administer blood transfusions according to hospital policy for 2 of 3 sampled patients that received blood transfusions (# 4, #2 ).

The findings include:

Review of the hospital's policy, "Administration of Blood and Blood Components", revised 03/2009, revealed, "...V. Procedure...R. Take and record on Patient Flow Sheet TPR (temperature, pulse, respiratory rate) and BP (blood pressure) 20 minutes after beginning the infusion then hourly...".

1. Open record review of Patient #4 revealed a 90 year-old admitted 09/29/2010 with rectal prolapse and pneumonia. Record review revealed a physician's order dated 09/30/2010 to transfuse 2 units of RBCs (red blood cells). Record review revealed the first unit of blood was started on 09/30/2010 at 1610. Review of the patient's flow sheet revealed documentation by the registered nurse (RN) that Patient #4's temperature, pulse, respiratory rate and blood pressure was checked at 1610, 1630 and 1730. Record review revealed the transfusion was completed at 1910. Record review revealed no documentation the patient's temperature, pulse, respiratory rate and blood pressure were checked between 1730 and 1910 (1 hour and 40 minutes) while the patient was receiving the blood transfusion.

Interview on 10/06/2010 at 1030 with administrative nursing staff confirmed the nurse should monitor the patient's vital signs, including temperature, pulse, respiratory rate and blood pressure 20 minutes after starting a blood transfusion, then hourly. Interview confirmed there was no available documentation the patient's temperature, pulse, respiratory rate and blood pressure were checked between 1730 and 1910 (1 hour and 40 minutes) while the patient was receiving the blood transfusion. Interview confirmed the nursing staff failed to follow the hospital's policy for monitoring patients receiving blood.

2. Closed record review of Patient #2 revealed a 50 year-old admitted 09/24/2010 with recurrent menorrhagia (heavy menstrual flow) with severe anemia. Record review revealed a physician's order dated 09/24/2010 to transfuse 2 units of RBCs (red blood cells). Record review revealed the first unit of blood was started on 09/24/2010 at 1550 and completed at 1920. Review of the patient's flow sheet revealed documentation by the registered nurse (RN) that Patient #2's temperature, pulse, respiratory rate and blood pressure was checked at 1559, 1615, 1620, 1828 (2 hours, 8 minutes later) and 1936.

Interview on 10/06/2010 at 1030 with administrative nursing staff confirmed the nurse should monitor the patient's vital signs, including temperature, pulse, respiratory rate and blood pressure 20 minutes after starting a blood transfusion, then hourly. Interview confirmed there was no available documentation the nurse monitored the patient's vital signs between 1620 and 1828 (2 hours, 8 minutes), while the patient received the blood transfusion. Interview confirmed the nursing staff failed to follow the hospital's policy for monitoring patients receiving blood.

NC00064025