HospitalInspections.org

Based on hospital policy reviews, medical record reviews and interviews, the hospital staff failed to document blood transfusion vital signs per hospital policy for 2 of 2 sampled emergency department patients that received a blood transfusion (Patient #3 and #13).

The findings include:

Review on 10/09/2024 of the hospital policy titled "Blood and Blood Products Transfusion - Adult" effective date 07/03/2024 revealed "... Documentation: ...Routine Transfusion - Document vital signs at baseline, 15 minutes after the start, 55-65 minutes after the start (if applicable), and at completion/termination of the transfusion."

Review on 10/09/2024 of the hospital policy titled "Adult Nursing Admission Assessment and Reassessment..." effective 06/17/2023 revealed "... Vital signs include temperature, pulse, respirations, blood pressure and pulse oximetry..."

1. Review on 10/08/2024 of the medical record for Patient #3 revealed a 64-year-old female that presented to the Emergency Department on 09/29/2024 at 1536 with a chief complaint of shortness of breath. Review of the physician orders documented on 09/29/2024 at 1642 revealed an order to transfuse one (1) unit of PRBC (packed red blood cells). Review of the nursing flowsheet revealed the blood transfusion was started at 1830. The nursing flowsheet indicated that a complete set of vital signs were documented at baseline, 15 minutes after the start and at completion. Review of the nursing flowsheet revealed that a temperature and blood pressure were documented 55-65 minutes after the start. The record review failed to reveal documentation of a heart rate (pulse), respiratory rate (respirations) and pulse oximetry (level of oxygen in the blood) 55-65 minutes after the start of the blood transfusion.

Interview on 10/09/2024 at 1455 with RN #1 revealed the staff were expected to document a full set of vital signs to include temperature, heart rate, respiratory rate, blood pressure and pulse oximetry during a blood transfusion. The expectation was for staff to document vital signs at baseline, 15 minutes after start, 1 hour after start and at completion of blood transfusion. Interview revealed the staff failed to follow the hospital policy.

Interview on 10/09/2024 at 1625 with RN #2 revealed that a complete set of vital signs included a temperature, heart rate, respiratory rate, blood pressure and pulse oximetry. RN #2 indicated that a complete set of vital signs should be obtained during a blood transfusion at baseline, 15 minutes after start, 1 hour after start and at completion.

2. Review on 10/09/2024 of the medical record for Patient #13 revealed a 69-year-old male that presented to the Emergency Department on 09/29/2024 at 1952 with a chief complaint of shortness of breath. Review of the physician orders documented on 09/29/2024 at 2103 revealed an order to transfuse one (1) unit of PRBC (packed red blood cells). Review of the nursing flowsheet revealed the blood transfusion was started at 0218 on 09/30/2024. The nursing flowsheet indicated that a complete set of vital signs were documented at baseline, 55-65 minutes after the start and at completion. Review of the nursing flowsheet revealed that a temperature and blood pressure were documented 15 minutes after the start. The record review failed to reveal documentation of a heart rate (pulse), respiratory rate (respirations) and pulse oximetry (level of oxygen in the blood) 15 minutes after the start of the blood transfusion.

Interview on 10/09/2024 at 1455 with RN #1 revealed the staff were expected to document a full set of vital signs to include temperature, heart rate, respiratory rate, blood pressure and pulse oximetry during a blood transfusion. The expectation was for staff to document vital signs at baseline, 15 minutes after start, 1 hour after start and at completion of blood transfusion. Interview revealed the staff failed to follow the hospital policy.

Interview on 10/09/2024 at 1625 with RN #2 revealed that a complete set of vital signs included a temperature, heart rate, respiratory rate, blood pressure and pulse oximetry. RN #2 indicated that a complete set of vital signs should be obtained during a blood transfusion at baseline, 15 minutes after start, 1 hour after start and at completion.

NC00183531, NC00191329, NC00201118