HospitalInspections.org

Based on document review and interview the Governing Body failed to ensure:

1. Physician #20 reported a blood transfusion reaction in 1 (Patient #1) of 6 medical records reviewed.

The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

2. Physician #21 followed hospital policies when ordering the emergent release of uncrossmatched blood/blood products to be administered to 1 (Patient #5) of 3 (Patients #2, #4, and #5) of 3 medical records reviewed.

3. Physician #20 and #22 ordered a rate of infusion for the transfusion of blood/blood products in 2 (Patient #8 and #9) of 2 patient medical records reviewed.

Refer to Tag A0347


4. Nursing Services obtained and followed the physician's orders for blood/blood product transfusion rates in 3(Patient #1, #8, and #9) of 6 patient medical records reviewed.

5. Nursing Services followed the hospital policy titled Transfusion of Blood Products.

Refer to Tag A0410

Based on document review and interview, the Medical Staff failed to ensure 3 (Physician #20, #21, and #22) of 3 physicians provided safe medical care to 4 (Patients #1, #5, #8, and #9) of 6 (Patients #1, #2, #4, #5, #8, and #9) patients receiving blood/blood product transfusions. The Medical Staff failed to:

1. ensure 1 (Physician #20) of 1 physician reported a possible blood transfusion reaction in 1 (Patient #1) of 7 medical records reviewed.

The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

2. ensure 1 (Physician #21) of 1 physician followed hospital policies when ordering the emergent release of uncrossmatched blood/blood products to be administered to 1 (Patient #5) of 3 (Patients #2, #4, and #5) of 3 medical records reviewed.

3. ensure 2 (Physician #20 and #22) of 2 physicians ordered a rate of infusion for the transfusion of blood/blood products in 2 (Patient #8 and #9) of 2 patient medical records reviewed.


Refer to Tag A0347

Based on the document review and interview, Nursing Services failed to:

1. Obtain and follow the physician's orders for blood/blood product transfusion rates in 3 (Patient #1, #8, and #9) of 6 patient medical records reviewed.

2. Follow the hospital policy titled Transfusion of Blood Products.

Refer to Tag A0410

Based on document review and interview, the Medical Staff failed to ensure 3 (Physician #20, #21, and #22) of 3 physicians provided safe medical care to 4 (Patient #1, #5, #8, and #9) of 6 (Patient #1, #2, #4, #5, #8, and #9)patients receiving blood/blood product transfusions. The Medical Staff failed to:

1. ensure 1 (Physician #20) of 1 physician reported a blood transfusion reaction in 1 (Patient #1) of 6 medical records reviewed.

The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

2. ensure 1 (Physician #21) of 1 physician followed hospital policies when ordering the emergent release of uncross matched blood/blood products to be administered to 1 (Patient #5) of 3 (Patients #2, #4, and #5) of 3 medical records reviewed.

3. ensure 2 (Physician #20 and #22) of 2 physicians ordered a rate of infusion for the transfusion of blood/blood products in 2 (Patient #8 and #9) of 2 patient medical records reviewed.


Findings:

Medical Record reviews were completed with Registered Nurse (RN) Staff #2, RN Staff #7, and RN Staff #13 on 6/30/2025 and 7/01/2025 in the administrative conference room.

1.

Patient #1
Patient #1 was a 54-year-old female who presented to the Emergency Room (ER) on 6/23/2025 with complaints of increased weakness, fatigue, belly pain, decreased appetite, and her urine was brown. She had a history of Breast Cancer that had spread to the bones. A review of the ER Physician Note revealed the patient was jaundiced (yellow). Her vital signs upon admission to the ER were Blood Pressure (BP) 78/61 (normal 120/80), Pulse 80 (Normal 60-100), Respirations 21 (normal range 12-20), oxygen level was 93 % on room air, and Temperature was 97 degrees Fahrenheit. She was placed on 2 liters of oxygen via nasal cannula. Patient #1 had no other complaints. Lab work was completed and resulted in a Hemoglobin of 4.5 (normal reference range 12.0-14.0) and a low platelet count of 65 (normal reference range 130-400). On 6/23/2025 at 5:22 PM, Physician #21 ordered 3 units of Packed Red Blood Cells (PRBC) to be transfused.

A review of the transfusion record revealed that Unit #1 was started in the ER on 6/23/2025 at 8:00 PM and ended on 6/23/2025 at 11:50 PM. Further review of the transfusion record revealed there were no adverse reactions during the blood transfusion.

Patient #1 was admitted as an inpatient to the ICU on 6/23/2025 at 10:22 PM with a diagnosis of Acute Anemia, Cholecystitis, and Urinary Tract Infection-possible sepsis. At this time, she was on 2 liters of oxygen via nasal cannula.

A review of the transfusion record for Unit #2 revealed the Registered Nurse documented the unit was started on 3/24/2025 at 12:05 AM and ended on 6/24/2025 at 4:00 AM. Further review of the transfusion record revealed there were no adverse reactions during the blood transfusion.

During the medical record review with Registered Nurse (RN) Staff #2, it was confirmed that the RN documented the wrong date on the transfusion record for Unit #2. The start date for Unit #2 should have been 6/24/2025 and not 3/24/2025. On 6/24/2025, the patient's oxygen flow was increased to 3 liters and increased again at 9:00 PM to 6 liters of oxygen. Patient continued to complain of shortness of breath, and on the morning of 6/25/2025 at 2:11 AM, she was placed on a non-rebreather (an oxygen mask used to deliver a high concentration of oxygen in an emergency). At 6:51 AM, she was placed on BiPAP (a machine that delivers pressurized air through a mask and helps to open the airway and improve airflow in and out of the lungs). A rapid response was called at this time, and it was recommended that the patient be transferred to a higher level of care. At 10:27 AM on 6/25/2025, the patient's respiratory status continued to decline, and the patient was intubated at 10:27 AM.

Patient #1 was transported to a higher level of care on 6/26/2025 at 2:00 AM. Patient #1 expired on 6/27/2025.


A review of Physician #20's progress note dated 6/25/2025 at 7:44 PM was as follows:

" ...Pt. had respiratory depression today requiring intubation.

Assessment and Plan of Treatment
Respiratory failure-most likely 2/2 volume overload in the setting of acute renal failure. Pt did receive 2 units of blood and boluses of IVF for renal failure. TRALI should also be in consideration, but timing does not fit perfectly. ...
Hypotension-likely related to ARF and metabolic acidosis, though TRALI and sepsis are considerations ..."

According to the Association for the Advancement of Blood and Biotherapies, transfusion-related acute lung injury (TRALI) is a rare but serious complication of blood transfusions and can lead to respiratory failure requiring intubation of a patient.

An interview was conducted on 6/30/2025 at 10:25 AM with Laboratory Manager Staff #11. Staff #11 was asked if there were any blood transfusion reactions reported for June 2025. Staff #11 confirmed that no blood transfusion reactions were reported for June. Staff #11 was asked what the process was for a transfusion reaction. Staff #11 replied, "The nurse calls the lab and lets the lab know of a possible reaction, and fills out the transfusion reaction form. The blood bag and the tubing get sent to the blood bank immediately. The nurse also gets a urine sample from the patient and a blood sample for a type and screen and a Direct Antiglobulin Test (DAT, also known as a Direct Coombs Test, that detects the presence of antibodies or complement proteins attached to the red blood cells, which aids in the detection of a transfusion reaction). The pathologist was notified of the results, and then they will determine if further testing is needed".

An interview was conducted with Laboratory Director Staff #10 on 6/30/2025 after 1:30 PM. Staff #10 confirmed that no transfusion reactions were reported for June 2025.

An interview was conducted with Physician #16 on 7/01/2025 after 1:00 PM. Physician #16 was asked if he was aware of a possible TRALI blood transfusion reaction for Patient #1. Physician #16 stated, "No, I am not aware of this. TRALIs are a very rare reaction". Physician #16 was asked if he thought the possibilities of a TRALI for Patient #1 were likely. Physician #16 replied, "These reactions usually happen shortly after the blood transfusion has started, and in this case, it was several hours later. It does not fit the timeline for a TRALI". Physician #16 was asked if the patient could have had a delayed adverse reaction to the blood transfusion. Physician #16 replied that it was unlikely that the patient had a transfusion reaction, and especially a TRALI. Physician #16 was asked if he could confirm that Patient #1 did not have a blood transfusion reaction. Physician #16 confirmed he could not confirm or deny that the patient had a transfusion reaction. Physician #16 was asked if other physicians called him with concerns of a possible transfusion reaction. He confirmed physicians will call him if they suspect a transfusion reaction has occurred, and we will start the process of the reaction protocol at that time. Most of the time, it was the nurses who initiated the protocol".

A telephone interview was conducted with Physician #20 on 7/02/2025 at 1:27 PM. Physician #20 was asked if he thought that Patient #1 had a TRALI. Physician #20 stated, "I had just seen her at 7:00 PM on 6/24/2025 and she was good. It did not fit the timeline perfectly for a TRALI, but it was a consideration." Physician #20 was asked if he had told the family that he thought Patient #1 had a severe blood transfusion reaction. Physician #20 stated, "I saw the patient and the family on 6/25/2025 and told them that a TRALI was a consideration. I also told them that it could be other things as well, like Hemolytic Anemia caused by the oral chemotherapy drugs she was on, Sepsis, Fluid Volume Overload, or Acute Renal Failure. I spent time with the family and explained that it was a consideration of multiple things. Her hemoglobin was 4.5 when she came in, and after 2 units of blood, it was up to 10, so I felt like the initial result was likely incorrect. I told them every single thing that was going through my head." Physician #20 was asked if he reported the possible transfusion reaction to the lab, and he confirmed he did not. Physician #20 stated, "I did talk to her Primary Care Physician/Intensivist about all the possibilities". Physician #20 was asked what he would normally do in the event of a possible blood transfusion reaction. Physician #20 replied that he would give some steroids and contact the pathologist immediately.

A review of the medical record did not reveal any documentation by the intensivist (a physician caring for critically ill patients) that a possible blood transfusion occurred.

A review of the hospital policy titled "Transfusion of Blood Products" with a revised date of 8/12/2024 was as follows:

"Policy
...
P. Transfusion reactions:
a ...
b ...
c. Signs or symptoms of a transfusion reaction may occur 24 hours after a transfusion is complete.

Q. All suspected transfusion reactions should be immediately reported to the Blood Bank at extension 7918 ..."


An interview was conducted with Chief Medical Officer (CMO) Staff #3 on 6/30/2025 after 1:30 PM. Staff #3 was informed that the patient's family made a written public statement on social media that the patient's family was told by the physician the patient had a severe reaction to a blood transfusion. Staff #3 was informed that Physician #20 documented in his note that Patient #1 had a possible TRALI, and it was not reported to the blood bank for the transfusion reaction protocol to be implemented. Staff #3 confirmed that Physician #20 should have reported the possible transfusion reaction to the blood bank. Staff #3 was asked if Physician #20 would have a Focused Professional Practice Evaluation (FPPE) regarding the care of this patient. Staff #3 confirmed that Physician #20 would go through FPPE due to the care of this patient.


A review of the Medical Staff Bylaws approved on 8/29/2024 was as follows:

" ...12.C.2 Ongoing and Focused Professional Practice Evaluation (OPPE/FPPE)

Concerns raised about a Practitioner's practice during the FPPE process will be evaluated or otherwise addressed through the Initial focused professional practice evaluation process which may include an analysis of data to provide feedback, to validate clinical competence, and to identify issues in Practitioner's professional performance, if any.

(1) Practitioners who are initially granted Clinical Privileges, whether at the time of the initial grant, renewal, or during the term of Clinical Privileges, will be subject to focused professional practice evaluation to confirm their competence."

(2) All Practitioners who provide patient care services at the Hospital, pursuant to Clinical Privileges that have been granted, will have their care evaluated on an ongoing basis. This ongoing professional practice evaluation process may include an analysis of data to provide feedback, to validate clinical competence and to identify issues in Practitioner's professional performance, if any.

(3) Concerns raised about a Practitioner's practice through the ongoing professional practice evaluation process or through a specialty-specific performance measure, a reported concern, or other triggers (e.g., clinical trend or specific case that requires further review, patient feedback, or sentinel event) will be evaluated or otherwise addressed through the focused professional practice evaluation process, collegial Intervention or other progressive steps, as defined in this Section. Serious concerns shall be referred immediately to the MEC ..."

An interview was conducted with CMO Staff #3 and Staff #6, Market Director of Patient Care Services on 7/01/2025 after 12:00 PM. Staff #3 and #6 confirmed that Physician #20 should have reported the possible TRALI to the blood bank so that the transfusion reaction protocol could be implemented.


2.

Patient #5
Patient #5 was a 77-year-old female who presented to the ER via Emergency Medical Services (EMS) on 6/15/2025 with a Gastrointestinal Bleed and was given a triage level of 2-Emergent.

A review of Physician #21's ER Note dated 6/15/2025 revealed Patient #5's vital signs on admission were BP-156/71, Pulse-90, Respirations-21, and O2 Sat-100%. No Temperature was measured. Physician #20's physical exam revealed the patient was in no apparent distress, alert and oriented X 4, no respiratory distress, normal breath sounds, regular heart rate and rhythm, delayed capillary refill time noted, abdomen soft and non-tender, skin was warm, dry, and normal in color. The patient's eyes appeared a pale conjunctiva (this is a sign of anemia).

A review of the nurse's note dated 6/15/2025 at 6:15 PM, documented by RN Staff #24, revealed the patient was taken to the trauma room upon arrival. She was noted to be covered with blood and emesis. The patient was in no apparent distress, and vital signs remained stable. "Crash blood" was started by the charge nurse (no identification of the charge nurse noted and there was no unit number of the blood documented in the patient's medical record), and medications were started. The patient was taken to Endo for an EGD.

A review of the document titled "Emergency Request for Uncrossmatched Blood" revealed 1 (one) unit of uncrossmatched blood was released to the RN on 6/18/2025 at 5:11 PM. There was no physician signature, and there was no additional signature of an authorized person on the physician's behalf.

A review of the hospital policy titled "Transfusion of Blood Products" with a revised date of 8/12/2024 was as follows:

"POLICY
A. A provider order is required for the preparation and transfusion of blood products ...
PROCEDURES: All Patient Care Areas

...7. Emergency Release of Uncrossmatched Blood
a. Uncrossmatched blood is ordered when blood is needed emergently and the current type and screen is not available.
b. For emergent transfusions, group O RBC's should be issued emergently, if full testing of ABO/Rh has not been completed.
c. Call the Blood Bank to request the emergency release of uncrossmatched blood.
d. The Blood Transfusion Emergency Request form is taken to the Blood Bank to pick up the blood products requested. The ordering provider authenticates a Blood Transfusion Emergency Request within 24 hours ..."


A review of the hospital policy titled "Emergency/Uncrossmatched Blood" with a review date of 12/31/2023 was as follows:

"POLICY
1.0 PRINCIPLE:

When there is a desperate requirement for blood, the patient's physician must weigh the hazard of transfusing uncrossmatched or partially crossmatched blood against the risk of waiting while testing is completed. When blood is released before the crossmatch is completed, the records must contain a statement of the requesting physician indicating that the clinical situation was sufficiently urgent to require release of blood. Such a statement does not absolve the blood bank from its responsibilities to issue properly labeled donor blood of an ABO group compatible with the patient.

2.0 PROCEDURE:

2.1 Perform an ABO and Rh on the patient's specimen, if possible type specific units may
be given ...

2.6 The requesting physician or authorized person must sign the Emergency Request form prior to issuance of blood ..."


An interview was conducted with Staff #10 in the afternoon on 6/30/2025. Staff #10 was asked to explain how a unit of uncrossmatched blood was released to the nurse in an emergency. Staff #10 replied, "The nurse comes to the blood bank and fills out the request form for the uncrossmatched blood. Once the nurse and the employee in the blood bank sign the form, it gets released to the nurse". Staff #10 was asked how she ensured that the physician ordered the uncrossmatched blood before it was released. Staff #10 stated, "We just take their word for it. The physician can sign the form within 24 hours."

Staff #10 was asked which policy the lab followed because the policy titled, Transfusion of Blood Products states the ordering provider can have up to 24 hours to authenticate the Blood Transfusion Emergency Request document and the policy titled Emergency/Uncrossmatched Blood states the requesting physician or authorized person must sign the Emergency Request form prior to issuance of blood. Staff #10 stated, "If it's not signed at the time, we have to go find the form and bring it back and put it in our book." (The emergency request form is a triplicate document.)

In an interview on 7/01/2025 after 12:00 PM, Staff #10 confirmed that as of 7/1/2025, Physician #21 had not signed for the emergency release of the uncrossmatched blood administered to Patient #5. This was 16 days after Patient #5 received the uncrossmatched blood transfusion.


3.

Patient #8

Patient #8 was an 83-year-old male who presented to the hospital for outpatient services for a blood transfusion on 6/25/2025. Patient #8 had a history of Acute Myeloblastic Leukemia.

A review of the Blood Transfusion Orders by Physician #20, dated 6/24/2025 at 12:30 PM, was as follows:

"Type and Crossmatch for Packed Red Blood Cells-Irradiated 2 Units and Transfuse 2 Units of Packed Red Blood Cells Irradiated."

A review of the blood transfusion record dated 6/25/2025 revealed RN Staff #26 started Unit #1 at 10:20 AM at 75 milliliters/hour (ml/hr) and increased the rate at 10:35 AM to 200ml/hr and increased the rate again at 11:30 AM to 300 ml/hr. The blood transfusion was completed at 12:30 PM. RN Staff #26 started Unit #2 at 12:50 PM at 75 ml/hr and increased the rate at 1:05 PM to 200 ml/hr and increased the rate again to 300 ml/hr at 1:15 PM. The blood transfusion was completed at 1:55 PM.


In an interview with RN Staff #13 on 7/01/2025 at 1:30 PM, RN Staff #13 confirmed that Physician #20 did not order a rate of infusion for the blood transfusions Patient #8 received on 6/25/2025.


Patient #9

Patient #9 was a 78-year-old female who presented to the hospital for outpatient services for a blood transfusion on 6/26/2025. Patient #9 had a history of Acute Myeloblastic Leukemia.

A review of the Blood Transfusion Orders by Physician #22, dated 6/26/2025 at 9:15 AM, was as follows:

"Type and Reserve for Plateletpheresis-1 Unit and Transfuse Platelets-Single Donor 1 Unit".

A review of the Transfusion Record dated 6/26/2025 revealed RN Staff #25 started the platelet transfusion at 12:55 PM and it was completed at 1:24 PM. RN Staff #25 documented the rate as "Open to gravity".


In an interview with RN Staff #13 on 7/01/2025 at 1:30 PM, RN Staff #13 confirmed that Physician #22 did not order a rate of infusion or duration for the Platelet transfusion Patient #9 received on 6/26/2025.


An interview was conducted with RN Staff #6 on 7/01/2025 at 2:30 PM. RN Staff #6 was asked if all outpatient blood transfusion orders are sent from the physician's clinic. RN Staff #6 stated, "Yes, there are some that come like that. Our computer system places a hard stop when they order blood and forces the provider to order a rate, or they cannot continue with the order. I do not think that we talked about outpatient orders from the clinics, but the providers know they have to order a rate for the transfusion."

Based on the document review and interview, Nursing Services failed to:

1. Obtain and follow the physician's orders for blood/blood product transfusion rates in 3 (Patient #1, #8, and #9) of 6 patient medical records reviewed.

2. Follow the hospital policy titled Transfusion of Blood Products.


Findings:


Patient #1
Patient #1 presented to the Emergency Room on 6/23/2025 with complaints of increased weakness, fatigue, belly pain, decreased appetite, and her urine was brown. She had a history of Breast Cancer that had spread to the bones.

A review of the orders dated 6/23/2025 at 5:22 PM by Nurse Practitioner (NP) Staff #28 was as follows:
"Transfuse 3 units Packed Red Blood Cells (PRBC); Initiate blood/blood products at a rate of 75 milliliters per hour (ml/hr) for the first 15 minutes (mins); after 15 mins, increase infusion rate to 150 ml/hr."

A review of the transfusion record dated 6/23/2025 revealed Registered Nurse (RN) Staff #27 started the blood transfusion at 8:44 PM at an initial rate of 75 ml/hr. At 9:00 PM, RN Staff #27 increased the rate of infusion to 125 ml/hr. This rate was less than what NP Staff #28 ordered, and there was no documentation in the patient's medical record that NP #28 changed the order.

Patient #1 was admitted to the hospital Intensive Care Unit at 10:22 PM. The blood transfusion was completed at 11:50 PM.

A review of the orders dated 6/23/2025 at 11:06 PM by Physician #29 was as follows:

"Transfuse 2 units Packed Red Blood Cells (PRBC); Initiate blood/blood products at a rate of 75 ml/hr for first 15 mins; after 15 mins, increase infusion rate to 125 ml/hr."

A review of the blood transfusion record dated 6/23/2025 revealed RN Staff #23 started the transfusion on 6/24/2025 at 12:05 AM at an initial rate of 50 ml/hr and increased the infusion rate to 75 ml/hr at 12:20 AM. The transfusion was completed at 4:00 AM.

An interview was conducted with RN Staff #4 and RN Staff #6 on 6/30/2025 at 2:45 PM. RN Staff #6 was asked if the nursing staff could change the infusion rate of a blood transfusion without a physician's order. RN Staff #6 replied, "No, and they know they have to have a rate and follow the physician's order or call the physician and have the order changed depending on the patient's needs." RN Staff #6 confirmed there was no documentation in Patient #1's medical record that the physician had been contacted regarding a rate change for the transfusion.


Patient #8
Patient #8 was an 83-year-old male who had a history of Acute Myeloblastic Leukemia. He was admitted for an outpatient blood transfusion on 6/25/2025.

A review of the orders given by Physician #20 was as follows:
"Transfuse 2 Units of Packed Red Blood Cells (PRBC)-Irradiated".

A review of the Transfusion record dated 6/25/2025 revealed RN Staff #26 started the blood transfusion for Unit #1 at 10:20 AM at a rate of 75 ml/hr. RN Staff #26 increased the rate to 200 ml/hr at 10:35 AM and increased the rate again to 300 ml/hr at 11:30 AM. The blood transfusion was complete at 12:30 PM.

A review of the Transfusion record dated 6/25/2025 revealed RN Staff #25 started the blood transfusion for Unit #2 at 12:50 PM at a rate of 75 ml/hr. RN Staff #25 increased the rate to 200 ml/hr at 1:05 PM and increased the rate again to 300 ml/hr at 1:15 PM. The blood transfusion was completed at 1:55 PM. RN Staff #25 documented that the patient refused to stay for the 1-hour post-transfusion vital sign check.


Patient #9
Patient #9 was a 78-year-old female who had a history of Acute Myeloblastic Leukemia. She was admitted for an outpatient blood/blood product transfusion on 6/26/2025.

A review of the orders given by Physician #22 was as follows:

"Transfuse 1 Unit of single donor platelets".

A review of the transfusion record dated 6/26/2025 revealed RN Staff #25 started the platelet transfusion at 12:55 PM. RN Staff #25 documented the rate as "open to gravity". The transfusion was completed at 1:24 PM. RN Staff #25 documented Patient #9 refused to stay for the one-hour post-transfusion vital sign check.

An interview was conducted with RN Staff #7 on 7/01/2025 after 1:00 PM. RN Staff #7 was asked how fast a platelet transfusion can infuse. RN Staff #7 replied that platelets can be transfused faster than blood. RN Staff #7 was asked if the hospital policy required a rate of infusion for platelets. RN Staff #7 confirmed the hospital policy did not say anything specific regarding platelet transfusions and that all transfusions required a physician order. RN Staff #7 confirmed RN Staff #25 administered the platelet transfusion without a rate or duration ordered by Physician #22.

An interview was conducted with RN Staff #13 on 7/01/2025 after 1:00 PM. RN Staff #13 was asked if the physician did not order a rate for the blood transfusion, how did the RN know what rate to infuse the blood. RN Staff #13 stated, "The RN should have called the physician and gotten an order for the transfusion rate before starting the blood transfusion."

An interview was conducted with RN Staff #9 on 7/01/2025 after 1:00 PM. RN Staff #9 confirmed 2 (RN Staff #25 and #26) of 2 RN's administered blood transfusions without a completed transfusion order from 2 (Physician #20 and #22) of 2 Physicians. RN Staff #9 confirmed there was no order for the starting rate or the increase in rate for the blood/blood products transfused in 2 (Patient #8 and #9) of 2 outpatients that received a blood/blood product transfusion.


A review of the hospital policy titled, Transfusion of Blood Products with a revised date of 8/12/2024 was as follows:

"POLICY
A. A provider order is required for the preparation and transfusion of blood products.
...
K. Transfusions should be administered per provider order, not to exceed expiration date and time
listed on the blood product.

L. Maximum time for the use of a blood filter and tubing is 4 hours.

M. Transfusion reactions can be life-threatening and occur with exposure to even a small amount of
blood; therefore, transfusions should be started at a rate of< 100 ml/hour unless the patient's
condition requires a rapid, life-sustaining transfusion. Following a provider's order, and as tolerated
by the patient, the rate may be increased after the initial 15 minutes ..."

According to the Texas Board of Nursing (BON), the BON requires that any initiation or change to a continuous infusion, including blood products, must be based on a specific provider order or a facility-authorized written protocol signed by a licensed independent provider, MD/DO/APRN. A RN initiating or titrating blood/blood products without a provider's order is practicing outside the scope of practice for a Registered Nurse.

During an interview on 7/01/2025, after 10:00 AM with RN Staff #4 and RN Staff #6, it was confirmed that the Nursing Services failed to obtain or follow physician orders when administering a blood transfusion in 3 (Patient #1, #8, and #9) of 6 patient medical records reviewed. Also, it was confirmed that the Nursing Services failed to follow the hospital policy titled Transfusion of Blood Products. RN Staff #4 confirmed the hospital did not have a written protocol for the infusion rate of a blood/blood product transfusion.