HospitalInspections.org

Based on policy and procedure review, medical record review and staff interview, the nursing staff failed to obtain an informed consent for a blood transfusion in 1 of 2 blood transfusion records reviewed (Patient #1).

The findings include:

Review on 03/01/2017 of the hospital's policy and procedure "Blood or Blood Component Administration" (revised 09/2016) revealed " ...All patients receiving blood products shall be informed by the physician of benefits and potential risks via Informed Consent .... Obtain signed consent from the patient or individual who can consent on behalf of the patient. Consent indicates patient or individual has been informed by the physician of blood transfusion risks/benefits. Consent does not need to be signed immediately by the physician but shall be signed within 24 hours".

Closed record review on 03/01/2017 of Patient #1 revealed a 33 year old female patient admitted on 02/07/2017 for observation with a chief complaint of systematic anemia due to chronic blood loss with a history of GI (gastrointestinal) bleeding with bright red blood. Review of physician's orders revealed an order dated 02/07/2017 at 2128 for a blood transfusion of two units of PRBCs (packed red blood cells) and an order dated 02/07/17 at 2143 for the transfusion of two units of platelets (blood components that assist with blood clotting). Transfusion records indicated that both units of PRBCs were administered. Transfusion records indicated that both units of platelets were administered. Further review pf the medical record revealed no "Consent for Transfusion of Blood/Blood Products" form.

Interview on 03/02/2017 at 0955 with RN #1 (Registered Nurse) revealed that the procedure for receiving blood from the Lab required the registered nurse to verify the blood transfusion order with lab personnel (electronic or paper) and the patient's "Consent for Transfusion of Blood/Blood Products" form before the release of blood/blood products. "All that is currently used is the paper record" for consent forms. "The goal is to scan consent forms in to the medical record". RN #1 interview confirmed that there was no "Consent for Transfusion of Blood/Blood Products" form present in Patient #1's medical record as required by policy.

NC00124773