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. 30, 2017
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record review, and staff interview, hospital staff failed to administer blood transfusions by failing to perform blood transfusions correctly in 2 of 3 patients (Patients #5 and #8).

The findings include:

Review of hospital policy titled, "Blood Product Transfusion - Packed Red Blood Cells ...", last revised: 12/2016, revealed, " ...PROCEDURE 1. Prior to obtaining the blood ... Vital Signs: The patient's temperature, pulse, respirations and blood pressure are taken prior to obtaining the blood from the blood bank within 1 hour of the transfusion starting time ... Document in the patient's EMR (Electronic Medical Record) ... Assess the vital signs as follows: 1. At least 1 hour prior to start 2. Within 15 minutes after start of infusion (test dose) 3. Every hour during the transfusion from the start time of the infusion 4. At the end of the transfusion ..."

1. Medical record review revealed Patient #5 was a [AGE] year old male, who received a transfusion of Packed Red Blood Cells (PBRC) on 08/11/2017 at 0545. Vital signs were obtained at 0530 (15 minutes prior to the infusion) as follows: Temperature (T) 97.2 degrees Fahrenheit (F), Pulse (P) 76, Respirations (R) 19, and Blood Pressure (BP) 127/54. Vital signs were obtained at 0600 (15 minutes after the start time of the infusion) as follows: T not recorded, P 71, R 22, BP 129/57. Vital signs were obtained at 0715 (1 hour from the start time of the infusion) as follows: T not recorded, P 71, R 25, BP 139/62. The transfusion ended at 0900 with the remainder of required vital signs obtained per hospital policy. Patient #5 required a second transfusion of PRBC, which was initiated at 0945. Prior to initiation, and during the transfusion, vital signs were obtained per hospital policy, until the end of the transfusion at 1224, were vital signs were obtained as follows: T not recorded, P 71, R 20, BP 140/73.

The Registered Nurse (RN) that initiated, and monitored Patient #5 during the transfusion was not available for interview.

Interview conducted with the Director of Nursing (DON) on 08/30/2017 at 1430 revealed patient's temperature should be included with each set of vital sign measurement required during blood transfusions, and hospital policy was not followed.

2. Medical record review revealed Patient #8 was a [AGE] year old male, who received a transfusion of PBRC on 07/13/2017 at 2007. Vital signs were obtained at 1826 (1 hour and 41 minutes prior to the infusion) as follows: T not recorded, P 73, R 16, BP 114/60. The transfusion ended at 2200 with the remainder of required vital signs obtained per hospital policy.

Telephone interview conducted with RN #1 on 08/30/2017 at 1302, revealed she was the RN that initiated Patient #8's transfusion. Interview revealed she did not recall the patient, however temperature should be included with each set of vital sign measurement required during blood transfusions. Interview revealed no explanation could be offered as to why the vital signs taken prior to the initiation of the PRBC transfusion were not within 1 hour of the transfusion starting time; or why the vital signs did not include a temperature.

Interview conducted with the Director of Nursing (DON) on 08/30/2017 at 1430 revealed patient's temperature should be included with each set of vital sign measurement required before and/or during blood transfusions; the vital signs obtain prior to the initiation of a blood transfusion should be within 1 hour of the initiation of the transfusion. Interview revealed hospital policy was not followed.

NC 128
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record review, and staff interview, hospital staff failed to complete a consent form per hospital policy for 1 of 3 patients (Patient #5) requiring a blood transfusion.

The findings include:

Review of hospital policy titled, "Blood Product Transfusion - Packed Red Blood Cells ...", last revised: 12/2016, revealed, " ...PROCEDURE A. Administration of Blood Products 1. Prior to obtaining the blood ... Obtain consent using the Consent for Transfusion of Blood or Blood Products (Form NS-1252) from the patient or patient representative ..."
Review of hospital policy titled "Informed Consent", last revision date: 10/2011, revealed, "Information to be included on all consent forms ... Date/Time of signatures ..."

Medical record review revealed Patient #8 was a [AGE] year old male, who received a transfusion of Packed Red Blood Cells on 07/13/2017 at 2007. Review of the Consent for Transfusion of Blood or Blood Products (Form NS-1252), revealed the form was signed by Patient #8 and witnessed by Registered Nurse (RN) #1 on 07/13/2017. Review revealed no time was documented for either Patient #8 or RN #1's signatures.

Telephone interview conducted on 08/30/2017 at 1302 with RN #1, revealed she did not realize hospital policy required signatures on consent forms to be timed.

Interview conducted on 08/30/2017 at 1430 with the Director of Nursing (DON) revealed signatures on consent forms should be both dated and timed, and hospital policy was not followed.