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Based on record review and staff interviews and policy review the facility failed to assess 1 of 3 sampled patients (#1) to evaluate the patient's response to blood transfusion during the first 15 minutes after the blood was started and every 30 minutes throughout the blood transfusion as required by the hospital policy for the administration of blood and blood components effective 03/27/10.

The findings include:

Clinical record review revealed patient #1 was admitted to the Hospital outpatient unit on 05/27/01 for blood transfusion for diagnosis of anemia secondary to Myelodysplasia. The patient medical history is significant for Coronary Artery Disease, Status post Coronary artery bypass, Hypertension and Diabetes.
On 05/26/11 a physician ordered type and cross match of 2 units of packed red blood cells to be transfused in 4 hours, followed by 20 mg Lasix IV for diagnosis of Anemia.
A type and cross match report dated 07/26/11 revealed the patient's blood type is A Rh negative.
The patient signed consent for blood /blood product transfusion on 05/27/11 at 9:00 AM.
A registered nurse documented in an outpatient treatment record at 0930 on 05/27/11, the patient is admitted for blood transfusion. A pre transfusion assessment revealed the patient is alert and oriented x 3, Hematocrit (HCT) 20.3, B/P 107/52. Temp 97.6 Pulse 78 SpO2% 100 and IV Peripheral to left arm (LA) with saline lock. The patient complained of aching pain intermittently all over the neck, back and right arm and the patient was placed in bed for blood transfusion. The nurse documented on 5/27/11, the patient and husband were taught pre transfusion, to report signs and symptoms of blood reaction and to call for assistance.

A transfusion record indicated on 05/27/11 at 0936 a registered nurse (#6) verified the blood by bar code transfusion administration procedure and began infusing the first unit of Red blood Cells (Unit # W067111047235, Product PC E0316). The record revealed the patient' vital signs were checked at 09:50 AM and at 12:50. The blood transfusion was administered in 3 hrs and 16 minutes and was completed at 12:50 PM.
Further review of the clinical record revealed a registered nurse (#6) verified the second unit of blood (Unit # W036811142555, Product LPC E4532) by bar code transfusion administration procedure and began infusing the blood at 1300 (1:00 PM) on 05/27/11. There is no documented evidence in the clinical record to substantiate the nursing staff had evaluated the patient fifteen (15) minutes after the second blood transfusion was started or the patient had been observed every 30 minutes throughout the blood transfusions on 05/27/11, as specified in the hospital policy.
A registered nurse (#6) documented on 05/27/11, at approximately 1400 while the patient was receiving a second unit of blood transfusion, the patient's husband came from the room and stated the patient needs help. When the nurse went to the room, the patient was unresponsive, without pulse or respirations. CPR (cardiopulmonary resuscitation) was initiated. At 14:03 (2:03 PM) the Code Blue team arrived, the patient was found to be in Ventricular Fibrillation, The patient was resuscitated, intubated and admitted to the intensive care unit on 05/27/11.
On 8/1/11 at 3:45 PM an interview was conducted with the director of out- patient services. The director stated the patient's transfusion record does not have the vital signs documented 15 minutes after the second blood was started on 05/27/11.

The Hospital policy titled: Administration of blood and blood components (effective date 03/27/10) specifies " The Transfusionist (RN) shall remain with the patient for the first five (5) minutes of the transfusion which should be started slowly... After the first fifteen (15) minutes, the patient should be observed and the vital signs recorded on the transfusion slip. Completion of the transfusion should be prior to component expiration or within 4 hours, whichever is sooner. The patient should be observed periodically throughout the transfusion (every thirty 30 minutes) and up to an hour after completion if indicated".

Interview with registered nurses on 08/01/11 at 3:00 PM and 8/2/11 at 3:00 PM the nurses stated they are required to verify the blood and patient identity by a scanning on each blood unit and completing a blood transfusion check list electronically, using the bar code transfusion administration (BCTA) procedure. The nurses also stated the vital sign should be monitored and documented before the transfusion, 15 minutes after starting the transfusion and at the end of the transfusion. The nurses stated the patient is periodically observed, the observation is not documented if the patient condition is stable..