HospitalInspections.org

Based on interview, record review and policy review, it was determined the facility failed to ensure blood transfusions were administered in accordance with medical staff policies and procedures for one (1) of ten (10) sampled patients (Patient #5). Patient #5 received packed red blood cells and the transfusionist failed to document the pre-transfusion checks per standard of practice.

The findings include:

Review of the facility's policy, "Blood/Blood Components Administration", with a revised date of 07/01/12 revealed the purpose was for the safe administration of blood and/or blood components at hospitals. Before administering blood, staff should inspect unit for the integrity and cleanliness of the container and the presence of clots, aggregate, gas or a red-black color of a red blood cell product. Under documentation, the tranfusionist should complete the Blood Administration Record.

Review of Patient #5's clinical record revealed an admission date of 11/08/12 with diagnoses which included Respiratory Failure, Skull Fracture and Wean from Ventilator. Review of Patient #5's Blood Administration Record for 11/28/12 at 11:40 AM and 4:05 PM revealed no documentation that the pre-transfusion checks were completed prior to transfusion of the packed red blood cells (PRBC). There were no initials to verify the transfusionists verified the Physician order was present, the consent for the transfusion was signed and on the chart, the blood component description matched the actual component, that the product had not expired and that the blood was visually inspected for discoloration or clumping.

Interview with Registered Nurse (RN) #2, on 11/29/12 at 11:05 AM, revealed the blood administration record should be completed by the nurse who transfused the blood. RN #2 stated it was the facility's policy.

Interview with the Risk Manager, on 11/29/12 at 11:15 AM, revealed the nurse who administered the PRBC to Patient #5 failed to fill out the required documentation. She stated it was one of her responsibility's to review the transfusion records and ensure nurses received further training as needed.