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Based on medical record review, interviews and document review, it was determined the facility failed to properly monitor patients (MR) receiving blood products in two (2) out of three (3) medical records reviewed, MR11 and MR13.

The findings:

In the facility document, "Blood Products Transfusion," number PA.BB.006, effective date February 19, 2025, revision number 6.0, reads, in part:
..."8. Patient Monitoring
8.1. Monitor patient by obtaining vital signs to include temperature, blood pressure, heart rate, and respiration. At the end of the transfusion, complete a post transfusion assessment and document patient's response to the transfusion.
8.2. Document vitals at the following times: (Variations in frequency may be dependent on the patient's clinical status and location such as procedural areas, OR, ED, and ICUs.)
8.2.1. All transfusions to include RBCs, Platelets, Plasma, and Cryoprecipitate at:
* Start of the transfusion
* Fifteen (15) minutes
* End of transfusion"

On April 8, 2025, a review of the medical record for MR11 reveals the patient received red blood cells (RBC) on April 6, 2025. The infusion was started at 11:50 P.M. The first monitoring recorded was at 00:15 A.M. on April 7, 2025, twenty-five (25) minutes after initiation of the transfusion.

A review of the medical record of MR13 indicated that the infusion for RBC ended at 9:15 P.M. on April 4, 2025. The last documented monitoring was at 8:00 P.M., one hour fifteen minutes (1:15) before the transfusion ended.

EMP2 and EMP3 verified and agreed that the documentation in both medical records did not reflect the facility's transfusion policy.