HospitalInspections.org

Based on review of hospital policy, medical record review and staff interviews, the nursing staff failed to monitor a patient receiving a blood transfusion per hospital policy for 3 of 3 patients receiving blood (Patient #1, #2 and # 3).


The findings include:

Review of the hospital's policy, "Transfusion Therapy(Blood/Blood Components)", revised 05/2015, revealed, " A. Guidelines to Follow Prior to Actual Administration of Blood/Blood Components ... 3. Assess patient's status a. Prior to sending for blood take TPR (Temperature, Pluse, Respirations) and BP ( Blood Pressure) ...C. Guidelines for Documentation: 1. Documentation in patient record will be done in the Transfusion section of the Nursing Flowsheet Tab or paper record depending on unit, such as the Operating Room. Documentaion will include component or name of product. ... b. Time started c. Time completed (or discontinued). d. Vital Signs prior to sending for blood, 15 minutes post initiation, and every hour while infusing, and at the end of the transfusion..."

1. Closed medical record review revealed Patient #1, a 68 year old patient,who was admitted for a hip fracture on 06/29/2015 with an order to transfuse 2 units of PRBC's (Packed Red Blood Cells) at 1822. Record review revealed the first unit began at 2341 with vitals signs taken at 2337 ( pre transfusion), 2356 (19 minutes after start), 0030 ( 53 minutes after start) and 0212 (at completion). The second unit of PRBC's began at 0500 with vital signs at 0500 ( at start of transfusion), 0515 ( 15 minutes later), 0630 ( 1 hour 30 minutes after start of transfusion) and transfusion completed at 0751 and vital signs documented at 0807 (16 minutes after completion).

Interview on 08/25/2015 at 1530 with Administrative nursing staff confirmed that nursing staff did not follow hospital policy in monitoring and documenting a patients vital signs during blood administration.

2. Closed medical record review revealed Patient #2, a 85 year old Cancer Center patient, who presented outpatient for a blood transfusion on 07/13/2014. Record review revealed an order for 2 units of PRBC's (Packed Red Blood Cells) to be transfused. The first unit started at 1320 with vital signs at 1320 (start of transfusion), 1335 ( 15 minutes later), 1520 (1 hour 45 minutes later), and 1545 at completion.

Interview on 08/25/2015 at 1530 with Administrative nursing staff confirmed that nursing did not follow hospital policy in monitoring and documenting a patients vital signs during blood administration.

3. Closed medical record review revealed Patient #3, an 82 year old patient, who was admitted for constipation with a history of gastric cancer on 08/19/2015. Record review revealed an order 2 units of PRBC's (Packed Red Blood Cells) on 08/20/2015. The second unit of PRBC's was started 0628 with vital signs at 0618 (pre transfusion), 0633 ( 5 minutes later), 0820 at completion ( 1 hour 47 minutes later).

Interview on 08/25/2015 at 1530 with Administrative nursing staff confirmed that nursing did not follow hospital policy in monitoring and documenting a patients vital signs during blood administration.

NC00109324