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CJW MEDICAL CENTER 7101 JAHNKE ROAD RICHMOND, VA 23235 Jan. 18, 2018
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
Based on interview and document review it was determined nursing staff failed to obtain vital signs at the required intervals for two (2) of three (3) patients in the survey sample who were administered blood or blood products. (Patients #7 and #10)

The findings include:

The clinical records for Patient #7 and Patient #10 were reviewed with the assistance of a navigator provided by the facility (Staff Member (SM) # 13).

Patient #7 was administered two units of platelets (components of blood that help the clotting process) on January 18, 2018 with administration of the first unit beginning at 2:15 p.m. Review of the clinical record revealed nursing staff failed to obtain the patient's vital signs prior to the administration of blood products as defined by hospital policy. The absence of documented vital signs prior to administration of blood products was confirmed by SM #13.

Patient #10 was administered one unit of red blood cells on January 16, 2018 beginning at 12:51 p.m. and ending at 4:00 p.m. Review of the clinical record revealed nursing staff failed to obtain the patient's vital signs after completing the administration of blood products as defined by hospital policy. The absence of documented vital signs after the administration of blood products was confirmed by SM #13.

Hospital policy "Blood & Blood Products, Administration Of" revised 02/2014 contains the following, in part:

"N. Patient Monitoring
1. RN/LPN remains with the patient for the first fifteen (15) minutes of the transfusion.
2. Vital signs: Blood Pressure, Temperature, Pulse, Respirations, Pulse Oximetry
a. At the initiation of transfusion
b. 15 minutes after the start of the transfusion
c. Completion of the transfusion"

The failure of nursing staff to obtain vitals signs for patients receiving blood or blood products was confirmed by SM # 15 and shared with the management team prior to exit. No further information was provided to the survey team.