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.

ADVOCATE LUTHERAN GENERAL HOSPITAL 1775 DEMPSTER ST PARK RIDGE, IL 60068 Jan. 8, 2019
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 4 of 8 (Pt.s #3, #5, #6, and #7) patients receiving a blood transfusion, the Hospital failed to ensure vital signs (blood pressure, temperature, pulse and respirations) were taken and documented per policy.

Findings included:

1. The Hospital's policy titled, "Blood and Blood Product Transfusion for the Adult Patient (revised 2/5/18)" was reviewed on 1/7/19 and required, "Obtain baseline vital signs before sending for the blood ... Obtain vital signs 15 minutes after the start of the transfusion ... At the completion of blood product administration, obtain the patient's vital signs ... document".

2. The clinical record of Pt. #3 was reviewed on 1/7/19. Pt. #3 was a [AGE] year old female, admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]#3 received a unit of platelets (tiny blood cells that help stop bleeding). The Transfusion Administration Record (TAR) lacked documentation of vital signs being taken 30 minutes after the end of the transfusion (replace blood into the body). The TAR also lacked documentation of the times that the vital signs were taken at the start and end of the transfusion.

3. The clinical record of Pt. #5 was reviewed on 1/7/19. Pt. #5 was an [AGE] year old male, admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]#5 received a unit of blood. The TAR lacked documentation of the vital signs being taken 30 minutes after the end of the transfusion.

4. The clinical record of Pt. #6 was reviewed on 1/7/19. Pt. #6 was a [AGE] year old female, admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. The TAR also lacked documentation of the times that the vital signs were taken at the start of the transfusion, 15 minutes later and at the end of the transfusion.

5. The clinical record of Pt. #7 was reviewed on 1/7/19. Pt. #7 was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]#7 received a unit of blood. The TAR lacked documentation of the vital signs at the end of the transfusion. The TAR also lacked documentation of the times that the vital signs were taken at the start of the transfusion and 15 minutes later.

6. During an interview on 1/7/19 at approximately 11:00 AM, the Clinical Excellence Nurse (E#7) stated, "The TAR form should be completed with the times and vital signs that were taken. It is important to know if there is a change in vital signs." E#7 stated that a change in vital signs is the first sign to indicate a potential transfusion reaction.