HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 2 patient records (Pts. #6 and #12) reviewed for blood transfusions, the Hospital failed to ensure that vitals signs were monitored and documentation of the blood transfusion was completed in accordance with approved policies and procedures.

Findings include:

1. The Hospital's Procedure/Reference for "Blood and Blood Product Transfusion" (dated 8/20/2020), was reviewed on 1/5/2021 and required, "...Monitoring Vital Signs: ... (temperature, blood pressure, heart rate, and respirations). 1) Prior to blood transfusion. 2) 15 minutes after the start of the infusion and then after 30 minutes, and one hour post initiation of blood product... At the completion of blood product administration, obtain the patient's vital signs... On the transfusion record, document: the date and time the transfusion was started and completed... the patient's vital signs before, during and after the transfusion..."

2. The clinical record of Pt. #6 was reviewed on 1/5/2021. Pt. #6 was admitted on 11/12/2020, with a diagnosis of respiratory failure. Pt. #6 had orders, dated 12/17/2020, to transfuse 3 units of red blood cells (RBCs). The record indicated that Pt. #6 received RBC transfusions on 12/17/2020 at 4:55 PM (1st unit), on 12/17/2020 at 7:50 PM (2nd unit), and on 12/28/2020 at 12:40 AM (3rd unit). The record lacked documentation of vitals signs taken at 30 minutes and one hour after initation of the first and third transfusions. The record also lacked documentation of the transfusion end time and post vital signs for the first transfusion.

3. The clinical record of Pt. #12 was reviewed on 1/6/2021. Pt. #12 was admitted on 12/22/2020, with a diagnosis of assault by firearm discharge. Pt. #12 had orders, dated 12/31/2020 and 1/4/2021, to transfuse 2 units of red blood cells (per order). The record indicated that Pt. #12 received RBC transfusions on 12/31/2020 at 4:45 PM, on 12/31/2020 at 8:58 PM, on 1/4/2021 at 5:30 PM, and on 1/4/2021 at 11:00 PM. The record lacked documentation of the following:
- Vital signs taken at 30 minutes and 1 hour after initiation of the transfusion on 12/31/2020 at 4:45 PM.
- Vital signs taken at 30 minutes after initiation of the transfusion on 1/4/2021 at 11:00 PM.

4. An interview was conducted with a Registered Nurse (E#4) on 1/5/2021, at approximately 11:30 AM. E#4 stated that vital signs should be taken prior to the start of transfusion, 15 minutes after initiation, periodically during the transfusion, and at the end of the transfusion. E#4 pulled up the Hospital's Blood Transfusion reference on the computer for review and clarified that vital signs should be monitored 30 minutes and 1 hour after initiation according to the reference. E#4 could not find documentation of vital signs for those times in Pt. #6's record.

5. An interview was conducted with the Nurse Manager (E#5) on 1/6/2021, at approximately 10:30 AM and again at 11:40 AM. E#5 reviewed Pt. #12's record and could not find documentation of the missing vitals. E#5 stated that vital signs should have been assessed and documented at those time intervals for each unit of blood transfused.