The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NEW HANOVER REGIONAL MEDICAL CENTER 2131 S 17TH ST BOX 9000 WILMINGTON, NC 28402 Aug. 24, 2016
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review and staff interview, nursing staff failed to monitor a patient receiving a blood transfusion per hospital policy in 1 of 4 patients who received a blood transfusion (Patient #10).

Findings include:

Review of the hospital's policy and procedure titled, "Blood Product Transfusion - Packed Red Blood Cells, . . . ", last revised 06/2016, revealed ". . . b. Assess the vital signs (temperature, blood pressure, heart rate, and respiratory rate) as follows: 1. At least 1 hour prior to start . . . 3. Every hour during transfusion from the start time of the transfusion 4. At the end of transfusion . . . K. Required documentation: . . . b. Estimated volume . . . d. Transfusion vital signs (pre-transfusion, 15 minute, 1 hour, . . . end of transfusion e. Time started and time completed . . ."

Closed medical record review on 08/24/2016 revealed a [AGE] year old female patient (Patient #10) admitted on [DATE] status post a motor vehicle accident and discharged to a Skilled Nursing Facility on 07/22/2016. Record review revealed a physician's order written on 06/27/2016 at 1029 by MD #1 to "Transfuse 2 units PRBC (Packed Red Blood Cells)." Review of Patient #10's Electronic Medical Record (EMR) revealed the start time for Patient #10's second unit of PRBCs was 06/27/2016 at 1525. Further review revealed documented pre-transfusion vital signs at 1414; the 15 minute vital signs at 1540 and vital signs at 1626. Review of Patient 10's EMR revealed no documentation of blood transfusion completion time, end of transfusion vital signs, and estimated volume transfused per the hospital's policy.

Interview on 08/24/2016 at 1430 with the hospital's Adult Health Administrator (AS #2) revealed the required blood transfusion elements per hospital policy are a provider's order, double nurse verification, vital signs one hour prior (or within one hour), first 15 minute vital signs and every hour vital signs until the transfusion is complete. AS #2 stated blood "Completion (time) and blood transfusion amount should be documented." NC 740, NC 754