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Based on hospital policy and procedure review, medical record review and staff interviews, the nursing staff failed to monitor a patient receiving a blood transfusion per hospital policy for 1 of 1 patients receiving blood (Patient #10).

The findings include:

Review of the hospital's policy "Blood and Blood Components, Administration of" Policy Number: PPB-WFBMC-169, Revised 2/2014... "F. In-Patient Monitoring and Documentation Standards" 1. Vital signs including Temp, BP, Pulse and Respiratory rate should be recorded at the following intervals for each unit transfused. a) Pre-Transfusion b)Within 15 minutes after blood reaches patient c) One hour after blood reaches patient d) Hourly until completion of transfusion (post transfusion)- this may include units orders to infuse less than one hour or units that run just beyond one hour. 2. Document "Yes" in Wake One to "Blood Reached Patient" at the time blood reaches the patient...."

Closed medical record review of Patient #10 revealed a 54 year old male who was admitted on 04/16/2015 for Congestive Heart Failure (CHF), Obesity, Hypertension (HTN) and had a left ventricular assist device (LVAD) placed on 04/17/2015. Review of medical record revealed a physican order on 07/27/2015 at 1955 to transfuse 1 unit PRBC in 2-4 hours. Record Review revealed at 2150 Pre transfusion vital signs were documented (Temp, BP, Pulse and Respiratory rate) at 2159 "YES" was documented "Blood Reached Patient" and at 2215 vitals signs were documented. Record review revealed at 2250 no Pulse was recorded as part of vital signs documentation. Review of the record revealed the unit of PRBC completed at 0005 with vital signs documented. Review of the physician orders revealed on 07/28/15 at 1043 to transfuse 2 units PRBCs 1-2 hours per unit. Review of the nursing documentation revealed at 1215 Pre transfusion vital sign documentation recorded. Record review revealed no documentation of "YES" "Blood Reached Patient". Record review revealed at 1230 and 1315 no pulse was recorded with the components of the vital signs documented. Record review revealed at 1408 a MAP value was documented for Pre transfusion/Post transfusion vital signs and a volume of 300. Record review revealed at 1423 and 1508 no pulse was recorded with the components of the vital signs documented. Record review revealed at 1528 no BP was recorded with the components of the vital signs documented and at 1530 no post transfusion vital signs were documented.

Interview on 7/30/2015 at 0930 with the Clincal Analyst confirmed the nursing staff did not assess and document vital signs (Temp, BP, Pulse and Respiratory rate) while administering blood to Patient #10 per the hospital's policy.

NC00107966