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Based on interview, medical record, and facility document review, it was determined the facility failed to perform all necessary vital signs-to include temperature monitoring-within sixty minutes of completion of blood product transfusion, per policy, for two (2) of four (4) patients reviewed.

The findings include:

The facility's policy titled "Transfusion of Blood Products" (effective date 08/08/2025), stated in part, "Vital signs are performed ...within 60 [sixty] minutes after the end of the transfusion ...".

On 09/09/2025 at 2:04 PM, the surveyor initiated the medical record review of four sampled patients (Patient # 3-6) who had received recent blood product transfusions with the assistance of Staff Member #3 and Staff Member #4.

The following information was ascertained from the blood transfusion records of Patient #5 and Patient #6:

Patient #5: Blood product was transfused on 09/08/2025 between 10:35 AM until 1:45 PM. Vital sign flowsheet record indicated that the patient's temperature was not collected until 09/08/2025 at 4:00 PM following transfusion completion.

Patient #6: Blood product was transfused on 09/08/2025 between 11:31 AM until 2 :00 PM. Vital sign flowsheet record indicated that the patient's temperature was not collected until 09/08/2025 at 4:00 PM following transfusion completion.

In the afternoon of 09/09/2025, the surveyor verified and confirmed with Staff Member #3 during interview that there were no other recorded temperatures documented within the medical record for either aforementioned patient within one hour of transfusion completion.

On 09/10/2025 at approximately 1:30 PM, the surveyor met with Staff Member #2, Staff Member #11, and Staff Member #12. The surveyor reiterated the above findings and received confirmation that appropriate temperature monitoring throughout a blood transfusion is an important component in assessing for transfusion-related reactions.