HospitalInspections.org

Based on interviews and review of documentation the facility failed to ensure that nursing services followed the facility's policy and procedure for blood product administration in 1 of 10 records reviewed (Patient ID #5) who received a blood transfusion. The vital signs were not recorded per the facility's Blood Product Addministration policy.

This deficient practice had the livelihood to affect all patients who received blood transfusions.

Findings Included:

Review on 12/2/2019 at 3:00 p.m. of the facility's current policy and procedure titled "Nursing, Policy Number NUR 013", subject: Blood Product Administration; Applies To: Houston Methodist Clear Lake Nursing: Date Revised/Reviewed 08/2017. Policy Statement: To provide guidelines for the safe and appropriate transfusion of blood and blood products. Blood and blood products will be transfused in a safe and appropriate manner, following the physician's orders, patient and/or family consent, Houston Methodist Clear Lake Blood Bank guidelines, and the recommendation of the American Association of Blood Banks (AABB)....E. Preparatory Phase 2. Obtain and record baseline vitals. a. Vital signs must be taken. If temperature is above 100 degrees F, the physician must be notified and permission to obtained to give the blood/blood product....G. Utilize the BPAM routine when blood product Status is "Issued". 1. Documentation b. Vital Signs must be taken and documented electronically (Pre-transfusion, 15 minutes after starting of the transfusion and post transfusion). c. Document transfusion process in EMR (electronic medical records). H. Administration/Performance Phase 2. An RN must initiate the blood transfusion and monitor the patient for the first 15 minutes of the transfusion. I. Upon completion of the transfusion the nurse should: 1. Measure and record the vital signs immediately and one (1) hour post-transfusion.

Interviews:

Interview on 12/3/2019 at 2:30 p.m. with the Assistant Chief Nursing Officer Employee ID #B confirmed the registered nurse administering the blood transfusion should check and document the patient's vital signs with one hour prior to initiating the blood transfusion to use as a base line and vital signs should be taken again after 15 minutes of starting the blood. Employee ID #B confirmed there was no documentation found in the electronic medical records of the baseline vital signs or the 15 minute after vital signs after the blood was started for Patient ID #5.

Interview with Registered Nurse (RN), Employee ID #G on 12/3/2019 at 11:00 confirmed she was a lead RN in the outpatient infusion center. Employee ID #G confirmed a patient receiving a blood transfusion should have their base line vital signs taken with the hour prior to blood being administered and 15 minutes after starting the blood. Review of the electronic medical records for Patient ID #5 with Employee#G confirmed there were no vital signs documented within the required policy time frame. Employee ID #G stated the electronic medical records may have been down and a paper record may have been used. No additional documentation was received.

Record Review Patient ID #5:

Record Review on 12/3//2019 at 2:00 p.m. revealed:

Patient was seen at her physician's office and referred to the out patient intravenous infusion center at Houston Methodist St. John Hospital for transfusion of 1 unit of Irradiated Packed Red Blood Cells (PRBC).
Order written on 8/21/2019 for 1 unit of Packed Red Blood Cells. Transfuse 1 unit of PRBC for hemoglobin less than 7.0.
Patient with Anemia. History of anemia due to other bone marrow failure.
Patient admitted to outpatient transfusion center at 11:06 a.m. Assessment and vital signs were documented at this time.

11:06 a.m. - Blood Pressure 98/54, Pulse 87, Temperature 98.0, Respirations 17, Pulse Oximetry 100%
19:31 p.m. - Blood Pressure 109/67, Pulse 62, Temperature 97.9, Respirations 16, Pulse Oximetry 99%

Blood infusion was initiated at 16:00 p.m. and completed at 18:30 p.m. Pre vital signs were documented approximately 5 hours prior to start of blood transfusion. Vital signs were not documental again for approximately 7.5 hours later. No documentation of vital signs 15 minutes after blood transfusion started.

No additional vital signs were documented in the patient's records. No additional information was received prior to the surveyor exiting the facility.