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Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 2 of 2 sampled patients reviewed for blood transfusions, (Patient #6 and #7) as evidenced by failure to reassess patients' condition during a blood transfusion as specified per facility protocols.


The findings included:

Facility policy titled "administration of Blood and Blood Products" effective 11/12/24 documents:
MONITORING THE TRANSFUSION
1. Start infusion of PRBC @ 2 ml/min (120 ml/hour) for 15 minutes.
2. Initiate non-emergent transfusions slowly and remain near the patient; major reactions usually appear before the first 50 ml have been transfused. Stop the transfusion immediately if signs and symptoms of a transfusion reaction are present (see Transfusion Reactions); notify the provider and blood bank and administer emergency medications as prescribed.
i. Do not administer emergency medications through the blood administration set; prime a new administration set with 0.9% sodium chloride for infusion through the VAD
3. After 15 minutes of infusion, check vital signs. If no signs and symptoms of a transfusion reaction are noted, the rate of infusion may be increased to infuse over the period of time, as designated by the physician order or at a rate of 4 ml/min (240 ml/hour). For patients at risk for fluid overload consult physician for flow rate. The full unit of blood must be administered within four hours from the time it was removed from the blood bank.
a. Platelets should be administered over 1 to 2 hours.
b. Plasma should be administered a quickly as tolerated by the patient or over 15 to 60 minutes.
4. Monitor and document the patients vital signs during the transfusion, as indicated by the patient's clinical needs. Assess the patient for any adverse reactions at least every 30 minutes throughout the transfusion.
5. During blood administration blood and blood components are only administered with 0.9% sodium chloride. No other solutions or medications can be added to or infused through the same administration set with blood or blood components unless they have been approved by the US Food and Drug Administration for this use.
6. The blood administration set may be used for up to two units of packed red blood cells for fast administration of blood -two units transfused in 4 hours. However, if the first unit required 4 hours for transfusion, the blood tubing will not be re-used.
7. At the completion of the infusion, complete the flowsheet documentation in EPIC
a. Post-transfusion vitals
b. Stopped transfusion time
C, Volume
d. Documented suspected reaction yes or no
8. Discard the blood bag in a biohazard container.
The policy documents transfusion reactions includes: Fever, Headaches, Anxiety, Flushing, Itching, Chest Pain, Chills, Marked Hypotension, Tachycardia and others.


Clinical record review conducted on 01/07/25 and 01/08/25 revealed Patient #6 was prescribed a blood transfusion on 01/07/25.
The record indicates the staff obtained pre transfusion vital signs at 1:51 PM; the transfusion started at 1:53 PM and the blood hit the vein a 1:56 PM at a rate of 120 milliliters per hour. The staff monitored the patient at 2:11 PM with a complete set of vital signs and the next set of vital signs was documented at 4:11 PM, post transfusion assessment.
The nurse failed to follow the facility policies and procedures for blood transfusion monitoring, as evidenced by lack of clinical data validating monitoring every 30 minutes to ensure there were no suspected reactions.

Clinical record review conducted on 01/07/25 and 01/08/25 revealed Patient #7 was prescribed a blood transfusion on 01/05/25.
The record indicates the staff obtained pre transfusion vital signs at 10:41 AM; the blood hit the vein a 10:45 AM at a rate of 125 milliliters per hour. The staff monitored the patient at 11 AM with a complete set of vital signs and the next set of vital signs was documented at 1 PM. The post transfusion assessment was documented at 2 PM.
The nurse failed to document on the suspected reaction field, with a yes or no answer.
The nurse failed to follow the facility policies and procedures for blood transfusion monitoring, as evidenced by lack of clinical data validating monitoring every 30 minutes to ensure there were no suspected reactions.

Interview with the Operating Room Manager who navigated the electronic medical record and the Risk Manager on 01/07/25 at approximately 2:40 PM and on 01/08/24 at approximately 11 AM verifies there is no documentation to validate the staff monitored Patients #6 and #7 according to the policy provided.

Interview with the Assistant Vice President of Nursing (AVPN) conducted on 01/08/24 at approximately 11:15 AM revealed her expectations is for the staff to follow the policy and was asked how is the staff to assess and monitor for possible reactions if they are not documenting vital signs to validate no changes in condition. The AVPN explained is possible they are doing the assessment but not documenting the findings.