HospitalInspections.org

Based on policy review, medical record review, staff nurse interview, and physician and administrative staff interview, hospital staff failed to inform a physician about a vital sign change in 1 of 2 patients (Patient #10) that experienced a blood transfusion reaction.

Findings included:

Review of hospital policy on 07/18/2018 titled, "Blood and Blood Products Transfusion - Adult" effective date 02/21/2018, revealed, "...Signs and symptoms indicative of a potential Significant change in vital signs. Example: 2 ° (degree) F (Fahrenheit) ... rise in temperature ... 10 beats per minute rise in pulse ... The transfusionist STOPS transfusion and initiates actions listed below if a transfusion reaction is suspected ... Notify LIP (Licensed Independent Practitioner) for further orders when a potential transfusion reaction is suspected ..."

Closed medical record review conducted on 07/18/2018 revealed Patient (PT) #10 was a 36-year-old female admitted on 07/09/2018 with multiple diagnoses, including anemia. Review revealed a blood transfusion was initiated on 07/09/2018 at 2300. Review of vital signs obtained by Registered Nurse (RN) #1 at 2308 revealed, "...Temp (Temperature) 99.8 ... Pulse 103 ..." Review of vital signs obtained by RN #1 at 2358 revealed, "...Temp 100.3 ... Pulse 137 (a 34 beat per minute rise in pulse)..." Review revealed no evidence a LIP was notified of the increased pulse rate. Review of vital signs obtained at 0142 (1 hour and 44 minutes after the previous vital signs) revealed, "...Temp 103.0 ... Pulse 125..." Review revealed the transfusion was stopped and Medical Doctor (MD) #1 was notified.

Telephone interview was conducted with RN #1 on 07/18/2018 at 1411. Interview revealed she recalled speaking with MD #1 three or four times regarding PT #10's care. Interview revealed PT 10's pulse had "been going up and down" numerous times during her care, notably whenever the patient would get up to go to the bathroom. Interview revealed MD #1 had said if the patient "got above a certain temperature then stop the infusion."

Telephone physician interview was conducted with MD #1 on 07/18/2018 at 1404. Interview revealed MD #1 was aware of PT #10 experiencing heart rate variations between in the "90's to 110's" which MD #1 attributed to the patient's admitting conditions. Interview revealed MD #1 was not made aware of a pulse rate of 137 beats per minute during the blood transfusion. Interview revealed MD #1 was notified of the increase in temperature from 100.3° F to 103.0° F, the transfusion was stopped, and further orders were given. Interview revealed, "I probably should have been made aware of the pulse rate increase."

Administrative staff interview was conducted with the Emergency Department Director (EDD) on 07/18/2018. Interview revealed no evidence was available in the medical record that action, per hospital policy, was taken when the increase in pulse rate was noted.

NC00139390