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Based on record review, policy review and staff interview it was determined the facility failed to ensure blood transfusions were administered according to facility policy for 3 (#1, #6, #8) of 10 sampled patients.

Findings include:

The facility's policy "Blood Administration", #620011.002, reviewed 4/10/13 was reviewed. The policy requires that the clinician administering the transfusion take the vital signs before initiating the transfusion, 5 minutes after the transfusion is started and hourly thereafter until the transfusion is completed. Vital signs are also to be taken when the transfusion is completed. The policy requires that the blood transfusion must be initiated no more than 30 minutes once the unit of blood is removed from the blood bank and the transfusion must be completed within 4 hours.

1. Patient #1 was admitted to the facility on 6/13/13. Review of physician orders revealed orders for a total of 5 units of packed red blood cells on 6/28/13 and two units on 7/1/13. Review of the Transfusion Record and the vital signs section of the electronic documentation revealed the following:

6/28/13 at 3:32 a.m.-vital signs were documented before the transfusion was started, but not until 15 minutes after the unit was started. Vital signs were being documented every 15 minutes, however, there was no documentation of when the transfusion was stopped.
6/28/13 at 5:03 a.m.-vital signs were documented before the transfusion was started, but not again for 15 minutes. Vital signs were recorded every 15 minutes, but the time the unit was discontinued was not documented.
6/28/13 at 6:42 a.m.-vital signs were documented at the time the transfusion was initiated and then every 15 minutes. Again the stop time was not documented.
6/28/13 at 9:20 a.m.-Vital signs were documented every 15 minutes. There was no documentation of when the transfusion was discontinued.
6/28/13 at 7:45 p.m.-Vital signs were documented before the transfusion, again at 7:50 p.m., at 8:09 p.m. and not again until 10:00 p.m. There was no documentation of when the transfusion was discontinued.
7/1/13 at 8:10 p.m.-The transfusion record documented two nurses verified the unit of blood at 8:10 p.m. There was no documentation of the time the transfusion was started, there were no vital signs documented on the transfusion record. Review of the electronic vital signs record revealed vital signs were documented at 8:15 p.m., 9:00 p.m., 10:00 p.m. and 11:00 p.m. There was no documentation of when the transfusion was discontinued.
7/1/13-11:45 p.m. Review of the transfusion record revealed that two nurses verified the unit of blood at 11:45 p.m. There was no documentation of a start time and no vital signs documented on the form. Review of the electronic documentation of the vital signs revealed vital signs were recorded at midnight on 7/2/13, 1:00 a.m., 2:00 a.m. and 3:00 a.m. There was no documentation of when the transfusion was discontinued.

The Risk Manager who was present during the record review on 10/24/13 at approximately 2:00 p.m. confirmed the nursing staff was not following the policy regarding vital signs and there was insufficient documentation to determine if the transfusion was started within 30 minutes after removal from the blood bank or completed within 4 hours.

2. Patient #6 was admitted to the facility on 10/18/13. Review of physician orders revealed an order on 10/20/13 to transfuse two units of packed red blood cells. Review of the transfusion record date 10/21/13 revealed two nurses verified the correctness of the blood, however, there was no time documented. Vital signs were documented at 2:25 a.m., 2:30 a.m., 2:45 a.m. and 6:00 a.m. The blood was discontinued at 6:00 a.m.

Review of the transfusion record dated 10/21/13 revealed two nurses verified the correctness of the blood, but did not document the time. Vital signs were documented at 7:30 a.m. 7: 45 a.m. and 10:30 a.m. The transfusion was completed at 10:30.

3. Patient #8 was admitted to the facility on 10/18/13. Review of physician orders revealed the physician ordered 2 units of packed red blood cells on 10/21/13 . Review of the transfusion record revealed the blood was started at 10:40 p.m. Vital signs were recorded at 10:40 p.m., 10:55 p.m. and at 1:40 a.m. on 10/21/13 when the transfusion was completed. The second unit was started at 1:45 a.m. on 10/21/13. Vital signs were documented at 1:41 a.m., 2:00 a.m., and 4:20 a.m. The transfusion was completed at 4:20 a.m.

The Nurse Manager who was present during the review of the medical record for patients #6 and #8 on 10/25/13 at approximately 11:00 a.m. confirmed the policy was not being followed.