HospitalInspections.org

Based on a review of the hospital's blood transfusion policy and procedures, medical record review and a staff interview, nursing staff failed to document the transfusion stop time and transfusion reaction vital signs in 1 of 1 blood transfusion reaction records reviewed. (Patient #2)

The findings included:

Review of the hospital policy titled, "Blood & Blood Product Administration", last revised on 03/2021, revealed "...TRANSFUSION REACTIONS...A Report of Transfusion Reaction Form should also be completed...most common signs of complications include but are not limited to: Increase in temperature...Chills...1. If any severe untoward sign occurs...a change of at least 1 degree C (Celsius)/1.8 degrees F (Farenheit) from pre-transfusion vital signs, stop transfusion immediately...."

Review of "The Report of Transfusion Reaction Form" revealed, "INSTRUCTIONS: If a transfusion reaction occurs or is suspected...4. Assess the patient's condition, including vital signs...9. Check vital signs q [every] 5 minutes x 4, q 15 minutes x 2, then if stable, q 30 minutes x 2..."

Record review on 07/22/2021 of the medical record for Patient #2 revealed a 74-year-old male admitted to the hospital on 06/14/2021 at 2046 for an AKI (Acute Kidney Injury) secondary to bladder retention of urine with bilateral hydroureter and hydronephrosis. Record review revealed an order to transfuse 1 unit of packed red blood cells was written by MD (medical doctor) #5 on 06/18/2021 and a Blood Consent was signed by Patient #2 on 06/18/2021 at 0914. Review of the Vital Sign Flowsheet revealed Patient #2's baseline vital signs at 0958 were recorded as T (Temperature) 36.1, HR (Heart Rate) 94, BP (Blood Pressure) 98/73, RR (Respiratory Rate) 17 and O2 (Oxygen Saturation) 99%. Review revealed RN (registered nurse) #17 documented a transfusion start time of 1000 and a transfusion reaction time of 1315. Record revealed Patient #2's vital signs documented at the time of the reaction were T 37.9, HR 100, BP 118/75, RR 19 and O2 100%. Review further revealed Patient #2's transfusion reaction symptoms included chills and a rise in temperature by 1.8 degree Celsius. Record review failed to reveal a stop time was documented and blood reaction vital signs every 5 minutes times 4 sets, every 15 minutes times 2 sets, and every 30 minutes times 2 sets were not taken per hospital policy.

Request for interview with RN #17 revealed she was unavailable.

Interview on 07/23/2021 at 1200 with RN #15 (Nurse Manager) revealed there should have been a stop time documented and multiple sets of vital signs should have been taken after Patient #2's blood transfusion reaction. Interview revealed RN #17 did not follow hospital policy.

NC00175489, NC00179424