HospitalInspections.org

22676

Based on record review and interview, the facility staff failed to administer blood as ordered by the physician. Citing 1 (#1) of 4 (#1, #5, #6 and #7) patients with blood transfusions ordered.

Findings:

Review of Patient #1's medical record revealed the physician ordered a unit of Packed Red Blood Cells to be given during the dialysis treatment 07/06/2016. Review of the treatment sheet for 07/6/2016 revealed there was no evidence the blood was administered as ordered. Review of the blood bank records revealed the unit was set up but never administered and the unit was released back to the blood bank after the patient was discharge.

Interview with staff #10 on 07/13/2016 confirmed the above findings.