HospitalInspections.org

Based on staff interview, medical record review, and facility documentation review, it was determined the facility staff failed to adequately monitor one (1) (Patient #5) of two (2) patients in the survey sample, who received blood products per facility policy.

The findings included:

Patient #5 was admitted to the facility on 9/12/21 with diagnoses to include, but not limited to, anemia and atrial fibrillation. The patient was discharged home on 9/19/21.

On 9/28/21 at 9:25 a.m. an electronic medical record review was conducted with Registered Nurse (RN), Unit Manager (Staff #14), the Senior RN Director (Staff #15) and the RN Analyst/IT (Staff #16). The review revealed a physician's order entered on 9/14/21 at 11:11 a.m. for 1 unit of PRBC (packed red blood cells) for the treatment of a low hemoglobin level result on 9/14/21 at 10:12 a.m. of 7g/dl.

Review of nursing documentation revealed pre blood transfusion vital signs were obtained on 9/14/21 at 13:54 (1:54 p.m.) and the transfusion was started on 9/14/21 at 13:58 (1:58 p.m.). The next sets of documented vital signs were on: 9/14/21 at 15:19 (3:19 p.m.), 17:02 (5:02 p.m.), and 20:25 (8:25 p.m.). There was no other nursing documentation of patient monitoring during the blood transfusion. There was no documentation of when the blood transfusion was completed.

When asked what the expectations were for monitoring during a blood transfusion, Staff #14 stated, "Vitals before, in fifteen minutes, then hourly and at completion."

Review of the hospital policy titled "Blood Transfusion/Blood Component Administration: CLIN.02.08.07" read in part:
"POLICY:...7. Administration of Blood/ Blood Components
Blood/blood component must be administered (started) by a RN or physician within 30 minutes of the issue time from the Blood Bank. The RN is responsible for ensuring patient monitoring and status during the infusion in all areas except the Operating Room."
"9. Transfusion time and storage
a. The maximum hang time for a unit of blood is 4 hours..."
"Procedure:...
6. MONITORING during transfusion-...
a. Observe the patient very closely for the first 15 minutes and the frequency throughout the transfusion. Transfusion reactions most commonly occur within 15 minutes or sooner after initiation of transfusion.
b. Record vital signs at 15 minutes..."
"7. DISCONTINUING TRANSFUSION:...
d. record amount (check) volume of blood/blood component transfused on the transfusion form. Record volume infused in the EMR (blood IV section
e. observe the patient for 30-60 minutes post transfusion..."

On 9/28/21 at approximately 4:00 p.m. the Director of Accreditation and Licensure (Staff #2) was informed of the findings and confirmed there was not other documentation in regard to blood transfusion monitoring and when asked about a completion time, Staff #2 stated the blood would need to be completed within four hours.