HospitalInspections.org

Based on interview, review of documentation in 3 of 21 medical records (Records 4, 6 and 7 ), and review of policies and procedures, it was determined the hospital failed to ensure that medical records were complete and accurately documented.

Findings:

Record 4: Review of documentation revealed Patient 4 received blood transfusions on 2/4/2017 as an outpatient at the hospital.

Documentation on the transfusion flowsheet revealed, "New Bag [blood product]" was started at 1100 and completed at 1158. Documentation on the "Blood Product Fulfillment" record indicated a blood product had been signed out of the laboratory at 1105 on 2/4/2017 for Patient 4. Documentation indicated that the blood product had been signed out 5 minutes after documentation in the medical record indicated that Patient 4's transfusion had been started.

Documentation on the transfusion flowsheet indicated a "New Bag [blood product]" was started for Patient 4 at 1245 and completed at 1605.

Documentation on the "Blood Product Fulfillment" record indicated a blood product had been signed out of the laboratory at 1245, the same time documentation in the medical record indicated the transfusion for Patient 4 had been started.

Documentation on the transfusion flowsheet revealed that "Vitals [vital signs]" for Patient 4 were recorded at 1100, at the initiation of the first transfusion. Documentation failed to reflect that Patient 4's vital signs were taken again until 1158, when the transfusion was completed.

Documentation failed to reflect that Patient 4's vital signs were taken at the time the second transfusion was completed.

Record 6: Review of documentation revealed Patient 6 received blood transfusions on 4/22/2017 as an outpatient at the hospital.

Documentation on the transfusion flowsheet indicated a "New Bag [blood product]" was started for Patient 6 at 1545 and completed at 1918. The "Blood Product Fulfillment" record indicated a blood product for Patient 6 had been signed out of the lab at 1549, four minutes after documentation in the medical record indicated the transfusion had been started.

Documentation on the transfusion flowsheet revealed that "Vitals [vital signs]" for Patient 6 were recorded at 1545 when the transfusion was intimated. Documentation revealed that Patient 6's vital signs were not taken again until 1615, 30 minutes after the transfusion was initiated.

Record 7: The review of documentation revealed Patient 7 was admitted to the hospital on 7/13/2017 and received a blood transfusion on 7/16/2017. Documentation on the transfusion flowsheet revealed a "New Bag [blood product]" was started at 0117 and completed at 0415.

Documentation on the transfusion flowsheet revealed Patient 7's "Vitals [vital signs] were recorded at 0100. Documentation revealed that Patient 7's vital signs were not taken again until 0143, 26 minutes after the transfusion was initiated.

The review of documentation failed to reflect that Patient 7 had signed a "Blood or Blood Products Consent" form for the transfusions he/she received.

During an interview with a staff RN on 8/15/2017 at 1415, he/she confirmed the blood transfusion consent form was not in Patient 7's medical record and that Patient 7's vital signs had not been documented according to the hospital's policy and procedure.

Review of documentation included "Blood and Blood Product Administration Procedure", effective date 4/26/2016. Instructions in this procedure included but were not limited to, "Informed Consent for blood transfusion is obtained by the provider prior to administration...All blood/blood products begin infusion within 30 minutes of leaving blood bank/lab...A second set of vital signs is obtained 15 minutes after the initiation of the transfusion, and recorded in the EHR...At the completion of the transfusion, obtain third set of vital signs and record in the EHR."