HospitalInspections.org

Based on policy review, medical record review and staff interviews, nursing staff failed to ensure patients' rights as evidenced by failing to obtain an informed blood consent according to policy prior to administering blood for 1 of 5 sampled patients that received blood (#2).

The findings include:

Review of the "Informed Consent" released 06/2021 revealed..."iv. For both inpatients and outpatients, prior to initiating the first transfusion and each subsequent transfusion, the nurse administering the transfusion must confirm that a current, signed informed consent form is in the chart...vi. For both inpatients and outpatients, confirmation that a current, signed informed consent form is in the chart must be done by the nursing staff as part of the patient identification process prior to the initial and any subsequent treatments."

Medical record review of patient #2 revealed a 60-year-old female admitted on 11/03/2023 for end stage renal disease and respiratory failure post tracheostomy placement in 2020. Chart review revealed the patient had been a previous patient in named facility from 07/23/2020 to 10/28/2023. During the previous admission patient had received some blood transfusions. Further chart review revealed that the patient was readmitted to named facility on 11/03/2023 and Physician order on 10/28/2024 revealed order for 2 units PRBC's (packed red blood cells) to be given. Review of blood consent form revealed date of 10/31/2021 from prior admission. Further review of the record revealed no evidence the hospital had obtained an informed consent for administration of blood during this current admission. Record review revealed the first unit of blood was started on 10/28/2024 at 0930 and completed at 1040. Second unit given at 10/28/2024 at 1540 and completed at 1905. Numerous other transfusions were found to be in the record without a current informed consent present. Further review of record revealed an informed consent was not obtained according to the hospital's policy prior to the administration of blood.

Interview on 10/31/2024 at 0905 with Dialysis nurse (#2) revealed that "when patient is in dialysis and critical hemoglobin comes back then (dialysis) nurse gets the orders and lets primary nurse know. Primary nurse checks chart for the order and consent then brings the blood to the dialysis unit and together we hang the unit of blood." The interview revealed that patient information regarding risks and benefits of blood administration should be explained with each administration prior tom obtaining consent and administration.

Interview on 10/31/2024 at 0930 with Director of Quality (#4) revealed that consent should be obtained prior to administration of blood and it should be a current consent. "We should have gotten a new consent for this admission but she (patient) had been here so long."

Interview on 10/31/2024 at 0940 with staff nurse (#3) revealed that " (I) would expect to see current consent for this admission." Interview revealed consent is good for one admission and "consent was there but didn't check the date of the consent, (It) didn't come to mind because she (patient) gets so much blood. I have checked the informed consent form but have never looked at the date on the consent." The interviews revealed there was no evidence that an informed consent was obtained prior to blood administration and that the nursing staff failed to follow hospital policy for obtaining an informed consent.