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CENTRAL MAINE MEDICAL CENTER
EMERGENCY SERVICES POLICIES
Tag No.: A1104
Based on document review and interviews, three (3) out of three (3) patient medical records demonstrated the Emergency Department (ED) clinical staff failed to follow the clinical policy for blood administration.
Findings:
The hospital's policy "Administration of Blood Components," last updated December 29, 2022, states in part ...
"Consent or refusal of blood products will be documented on form 443464 CMMC Consent-Refusal Non-Emergency Blood Transfusions ..."
- A copy of the consent was not found during chart review for the medical record of Patient #3. This was confirmed by the ED Nurse Lead and the ED Nurse Director at 9:57 on 5/16/2024.
The hospital's policy "Administration of Blood Components," last updated December 29, 2022, states in part ...
"Document vital signs at the following intervals ..."
- A medical record review of three (3) out of three (3) patients who received blood products in the ED was conducted. The medical records of Patients #2, #3, and #4 failed to contain documentation that vital signs were completed per hospital policy. This was confirmed by ED Nurse Lead and ED Nurse Director at 10:30 on 5/16/2024.