HospitalInspections.org

Based on document review and interview, the hospital failed to:

1. ensure 3 (Physician #10, #11, and #12) of 3 physicians' orders included a rate for the transfusion of blood/blood products in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed.

2. ensure 3 (Physician #10, #11, and #12) of 3 physicians gave orders to increase the rate of the transfusion of blood/blood products in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed.

3. ensure the nursing staff had a properly executed informed consent before initiating a blood/blood product transfusion in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed.

4. ensure the hospital policy and procedure gave clear guidelines for all blood/blood product administration.

5. ensure that a blood transfusion was completed within 4 hours in 1 (Patient #2) of 4 (Patients #2, #3, #4, and #6) patient medical records reviewed.

6. ensure a 2-person verification was completed before initiating a blood/blood product transfusion in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed.

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

7. ensure that nursing staff safely administered patient medications and followed its policy titled, "Medication Administration" in 1 (Patient #1) of 1 patient chart reviewed.

Based on document review and interview the hospital failed to ensure a properly executed informed consent was completed in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed. Also, the hospital failed to follow the policy titled, "Anesthesia, Surgical, and Medical Informed Consent".

Medical records were reviewed with Registered Nurse (RN) Staff #4 on 2/24/2025 after 10:30 AM.

Findings:

Patient #2
Patient #2 was a 54-year-old male admitted to the hospital on 1/31/2025 by Physician #10. Further review revealed Patient #2 received a blood transfusion on 2/01/2025.

A review of the informed consent for a blood transfusion dated 2/01/2025 revealed Patient #2 signed the informed consent on 2/01/2024 at 1440 (2:40 PM) and the RN witnessed the consent on 2/01/2025 at 1440.

The informed consent document had a signature line for the physician, but Physician #10 failed to sign the informed consent document. There was no documentation in the medical record by Physician #10 that the risks and benefits had been explained to the patient before Patient #2 gave informed consent to receive a blood transfusion.


Patient #3
Patient #3 was a 74-year-old male admitted to the hospital on 2/05/2025 by Physician #11. Further review revealed Patient #3 received a blood transfusion on 2/07/2025.

A review of the informed consent for a blood transfusion dated 2/07/2025 revealed Patient #3's Medical Power of Attorney (MPOA) gave telephone consent on 2/07/2025. Two RNs signed and witnessed the telephone consent on 2/07/2025 at 10:13 AM.

The informed consent document had a signature line for the physician, but Physician #11 failed to sign the informed consent document. There was no documentation in the medical record by Physician #11 that the risks and benefits had been explained to the patient's MPOA before the informed consent for the blood transfusion was verbally given to the RN.


Patient #4
Patient #4 was a 63-year-old male who was admitted to the hospital on 2/19/2025. Further review revealed Patient #4 received a blood transfusion on 2/20/2025.

A review of the informed consent for a blood transfusion dated 2/20/2025 revealed Patient #4 gave verbal consent on 2/20/2025 at 12:11 PM and two RNs signed and witnessed the informed consent on 2/20/2025 at 12:11 PM.

The informed consent document had a signature line for the physician, but Physician #12 failed to sign the informed consent. There was no documentation in the medical record by Physician #12 that the risks and benefits had been explained to the patient before Patient #4 gave informed consent to receive a blood transfusion.


Patient #6
Patient #6 was a 44-year-old female admitted to the hospital on 1/11/2025. Further review revealed Patient #6 received two blood transfusions on 1/20/2025.

A review of the medical record did not reveal a signed informed consent for the blood transfusions.

An interview was conducted with RN Staff #4 on 2/24/2025 at 11:30 AM. RN Staff #4 was asked if an informed consent was signed by the patient before the initiation of the blood transfusions. RN Staff #4 confirmed there was no signed informed consent for the blood transfusions. RN Staff #4 was asked how the staff would know if the physician talked to the patient regarding the risks and benefits of a blood transfusion. RN Staff #4 stated, "The physicians are required to sign the consent confirming they informed the patient of the risks and benefits of a blood transfusion".
An interview was conducted with Patient #6 on 2/24/2025 at 3:30 PM in the presence of RN Staff #4. Patient #6 was asked if she signed an informed consent for the blood transfusions. Patient #6 confirmed there was no informed consent signed before the blood transfusions.

A review of the hospital titled, Anesthesia, Surgical, and Medical Informed Consent" Policy Number 03.106.22 (3.8), with a reviewed date of 5/24 was as follows:

"1.0 PURPOSE

1.1 To Inform the patient of the nature of the treatment/procedure in language and terms the patient can understand, as well as an explanation as to what will occur (see Attachment A) and of
possible risks and hazards to which they are consenting during the treatment or procedure.

1.2 To Inform the patient of the risks associated with the procedure that are reasonably foreseeable and significant for that particular patient.

1.3 To inform the patient of the benefits of the procedure and how this will benefit the patient.

1.4 To Inform the patient of alternatives to the treatment, including the alternative of forgoing the treatment.

1.5 To conform as well as abide by the Texas Medical Disclosure and Consent for Anesthesia, Surgical and Medical Consents.

2.0 POLICY

2.1 The physician is responsible for disclosing to the patient all risks, benefits and alternatives ...

2.2 Hospital personnel or the physician may assist with completion of the Disclosure and Consent Form answer any questions the patient may have which is in their area of expertise and witness the patient's signature provided the physician has disclosed the risks, benefits, and alternatives involved with the procedure to the specific patient ..."




An interview was conducted with RN Staff #13 On 2/24/2025 AT 3:55 pm. Rn Staff #13 was asked who had the responsibility to get the informed consent signed by the patient before the blood transfusion was started. RN Staff #13 stated, "The nurses get the consent by the consent signed by the patient". RN #13 was asked if the nurse explained the risks and benefits of a blood transfusion to the patient. RN Staff #13 stated, "The risks and benefits are written on the consent, and we just get the consent signed".

An interview was conducted with RN Staff #14 on 2/24/2025 at 4:17 PM. RN Staff #14 was asked who explained the risks and benefits of a blood transfusion to a patient. RN Staff #14 said, "That is the physician's responsibility and not the nurses". RN staff #14 was asked where would the physician document that the risks and benefits had been explained to the patient. RN Staff #14 stated," The policy states the physician has to sign the informed consent, and the risks and benefits are listed on the consent document".

An interview was conducted on 2/24/2025 in the afternoon with RN Staff #2, #3, and #4. RN Staff #2, #3, and #4 confirmed it was hospital policy that the physician signs the informed consent for the transfusion of blood or blood products. RN Staff #4 confirmed the physician failed to sign the informed consent in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed.

Based on documentation review and interview the hospital failed to ensure that nursing staff safely administered patient medications and followed its policy titled, "Medication Administration" in 1 (Patient #1) of 1 patient chart reviewed.


Findings:

A review of the incident and complaint log was conducted on 2/24/2025 after 10:00 AM with Licensed Vocational Nurse (LVN) Staff #3. LVN Staff #3 confirmed Patient #1 was not on either log for a complaint or incident.

An interview was conducted with the Chief Nursing Officer (CNO) on 2/24/2025 at 12:34 PM. CNO Staff #2 was asked if Patient #1 or the patient's family made a complaint to her regarding the patient's care. CNO Staff #2 confirmed Patient #1s family was concerned about the patient's medications being left in the patient's room on the bedside table. CNO Staff #2 stated, "Patient #1's medication was left on the bedside table by the nurse, and I was called to speak to the family". CNO Staff #2 confirmed she spoke to the nursing staff and addressed the concerns with the charge nurse but failed to document any education given to the nursing staff or specific findings in the patient's medical record. CNO Staff #2 was asked what the procedure was for handing out medication to patients. CNO Staff #2 stated, "The nurse handing out medication to patients is to remain with the patient while they take the medication".


A review of the facility's policy titled "Medication Administration" approved 05/2024 was as follows:

"Purpose:

To establish a procedure for the administration of medication hospital wide that ensures patient safety ...
Procedure:

...Staff must remain with the patient until the patient takes the medication ..."


In an interview on 2/24/2025 at 12:34 PM CNO staff #2 confirmed that nursing staff did not follow the facility policy.

Based on document review and interview, the hospital failed to:

1. ensure 3 (Physician #10, #11, and #12) of 3 physicians' orders included a rate for the transfusion of blood/blood products in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed.

2. ensure 3 (Physician #10, #11, and #12) of 3 physicians gave orders to increase the rate of the transfusion of blood/blood products in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed.

3. ensure the nursing staff had a properly executed informed consent before initiating a blood/blood product transfusion in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed.

4. ensure the hospital policy and procedure gave clear guidelines for all blood/blood product administration.

5. ensure that a blood transfusion was completed within 4 hours in 1 (Patient #2) of 4 (Patients #2, #3, #4, and #6) patient medical records reviewed.

6. ensure a 2-person verification was completed before initiating a blood/blood product transfusion in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed.

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


Medical record reviews were conducted with Registered Nurse Staff #4 on 2/24/2025.

Findings:


Patient #2
Patient #2 was a 54-year-old male admitted to the hospital on 1/31/2025 with Necrotizing pancreatitis, Gallbladder fossa abscess, Recent Coranary Artery diseaase with a stent placement for a heart attack, Anemia, Hypertension, Diabetes, Atrial fibrillation, and Sqamous cell cancer of the neck and metastises to the neck lymph nodes. .

A review of the order dated 2/01/2025 at 10:50 AM by Physician #10 was as follows:
"Transfuse RBC (Red Blood Cells) 1 Unit, Routine.

Comments: RBC estimated total volume per unit: 350 milliliters (ml)
Adult non-emergent transfusions should be initiated at a rate of 100ml/hour(hr) for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ...

Results
Transfusion Information, Transfuse RBC-(Unit number), Status-Completed 2/02/2025, Volume-881.25 ml, Start-2/01/2025 at 1500 (3:00 PM), End-2/01/2025 at 2100 (9:00 PM).

Order Questions
Has consent been obtained? Yes
Transfusion duration per unit (within): 2 hours ..."

A review of the transfusion flow sheet dated 2/01/2025 revealed the blood transfusion was started at 1500 (3:00 PM) at 75ml/hr and increased to a rate of 150ml/hr at 1515 (3:15 PM) and ended at 2100 (9:00 PM) with a total RBC volume infused of 881.25 ml. This was a total transfusion time of 6 hours.

A review of the 2-person verification for safe blood administration was signed by RN Staff #15 at 1254 PM. This was greater than 2 hours before the blood transfusion was started.

There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record.


An interview was conducted with Chief Nursing Officer (CNO) Staff #2 on 2/26/2025 at 9:30 AM. CNO Staff was asked if the patient's blood transfusion dated 2/01/2025 lasted a total of 6 hours. CNO Staff #2 confirmed the documented completion time was 2/01/2025 at 2100 (9:00 PM with 881.25 ml total RBC volume infused. CNO Staff #2 stated, "The system does an automatic calculation of the total volume infused based on the transfusion rate and the length of time for the transfusion. There was a set of vital signs documented at 1901 (7:01 PM) during the transfusion and then the vital signs returned to every 4 hours so I think someone realized the blood transfusion was not charted as complete and at the end of the shift the nurse just documented at that time and did not go back and see what the actual completion time was".


A review of the order dated 2/08/2025 at 8:49 AM by Physician #12 was as follows:

"Transfuse RBC (Red Blood Cells) 2 Unit, Routine.

Comments: RBC estimated total volume per unit: 350 milliliters (ml)

Adult non-emergent transfusions should be initiated at a rate of 100ml/hour for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ...

Results
Transfusion Information, Transfuse RBC-(Unit number #1), Status-Completed 2/08/2025, Volume-395 ml, Start-2/08/2025 at 1234, End-2/01/2025 at 1555.

Transfusion Information, Transfuse RBC-(Unit number #2), Status-Transfusing, Volume-(blank), Start-2/08/2025 at 1642, End-(blank).

Order Questions
Has consent been obtained? Yes
Transfusion duration per unit (within): 2 hours ..."

A review of the transfusion flow sheet dated 2/08/2025 for Unit #1 revealed the blood transfusion was started at 1234 (12:34 PM) at 75ml/hr, increased to a rate of 100ml/hr at 1250 (12:50 PM), and increased again to 125ml/hr at 1300 (1:00 PM). There was no physician order to increase the rate of the transfusion. The blood transfusion was ended at 1555 (3:55 PM) with a total RBC volume infused of 395 ml. This was a total time of greater than 3 hours.

There was no documentation of a 2-person verification at the patient's bedside for safe blood administration before the blood transfusion was started.

There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record.


A review of the transfusion flow sheet dated 2/08/2025 for Unit #2 revealed the blood transfusion was started at 1642 (4:42 PM) at 75ml/hr. Further review revealed there was no end date, time, or total RBC volume infused documented for the Unit #2 blood transfusion.

There was no documentation of a 2-person verification at the patient's bedside for safe blood administration before the blood transfusion was started.

There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record.


An interview was conducted with CNO Staff #2 on 2/24/2025 after 11:00 AM. CNO Staff #2 was asked if the "Comments" section on the blood transfusion was considered the specified rate that the physician ordered. CNO Staff #2 stated, "That is an automatic default, and the physician should uncheck the box to give specific orders". CNO Staff #2 was asked if the physician orders the blood transfusion to be completed in 2 hours and the default says 100 ml/hr for the first 15 minutes and then no specific rate after the first 15 minutes how was the nurse to know what rate to run the blood transfusion. CNO Staff #2 confirmed that the physician would need to order a specific rate for the transfusion of blood/blood products and confirmed that just ordering a duration does not give clear guidelines to the nurses on how fast or slow the blood needs to be transfused.

RN Staff #4 confirmed that Physician #12 failed to sign the informed consent dated 2/01/2025 confirming that the risks and benefits of a blood transfusion were discussed with the patient before the blood was administered.


Patient #3
Patient #3 was a 74-year-old male admitted to the hospital on 2/05/2025 with a diagnosis of Sepsis secondary to pneumonia, Hypotension, Acute respiratory failure with hypoxia, Acute metabolic encephalopathy secondary to sepsis, Acute chronic heart failure with preserved EF, Restless leg syndrome, and Hyperlipidemia.

A review of the order dated 2/07/2025 at 7:23 AM by Physician #11 was as follows:
"Transfuse RBC (Red Blood Cells) 1 Unit, Routine.

Comments: RBC estimated total volume per unit: 350 milliliters (ml)
Adult non-emergent transfusions should be initiated at a rate of 100ml/hour for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ...
Results

Transfusion Information, Transfuse RBC-(Unit number), Status-Completed 2/07/2025 at 1745 (5:45 PM), Volume-347.5ml, Start-2/07/2025 at 1504, End-2/07/2025 at 1730.

Order Questions
Has consent been obtained? Yes
Transfusion duration per unit (within): 2 hours ..."


A review of the transfusion flow sheet dated 2/07/2025 revealed the blood transfusion was started at 1504 (3:04 PM) at 75ml/hr and ended at 1730 (5:30 PM) with a total RBC volume infused of 347.5 ml. This was a total time of greater than 2 hours.

There was no documentation of a 2-person verification for safe blood administration before starting the blood transfusion.

There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record.

RN Staff #4 confirmed that the blood was not administered within 2 hours as the physician ordered and that the nurse failed to follow the defaulted rate for the initiation of the transfusion ordered by Physician #11.

RN Staff #4 confirmed there was no physician name or signature on the informed consent for the transfusion of blood/blood products.


Patient #4
Patient #4 is a 63-year-old male who was admitted to the hospital on 2/19/2025 with a diagnosis of Spinal cord injury, quadriplegia, Acute respiratory failure with hypercapnia-ventilator dependent, Dysphagia, and Stage 2 sacral decubitus.

A review of the order dated 2/20/2025 at 11:16 AM by Physician #12 was as follows:

"Transfuse RBC (Red Blood Cells) 2 Unit, Routine.
Comments: RBC estimated total volume per unit: 350 milliliters (ml)

Adult non-emergent transfusions should be initiated at a rate of 100ml/hour for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ...
Results

Transfusion Information, Transfuse RBC-(Unit number #1), Status-Completed 2/20/2025 at 1654, Volume-342 ml, Start-2/08/2025 at 1355, End-2/01/2025 at 1653.

Transfusion Information, Transfuse RBC-(Unit number #2), Status-Completed, Volume-412.5ml, Start-2/20/2025 at 1715 (5:15 PM), End-2033 )8:33 PM).

Order Questions
Has consent been obtained? Yes
Transfusion duration per unit (within): 2 hours ..."

A review of the transfusion flow sheet dated 2/20/2025 for Unit #1 revealed the blood transfusion was started at 1355 (1:55 PM) at 125ml/hr and ended at 1653 (4:53 PM) with a total RBC volume infused of 342 ml. This was greater than a 2-hour total infusion time.

There was no documentation of a 2-person verification at the patient's bedside for safe blood administration before starting the blood transfusion.

There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record.


A review of the transfusion flow sheet dated 2/20/2025 for Unit #2 revealed the blood transfusion was started at 1715 (5:15 PM) at 125ml/hr and ended at 2033 (8:33 PM) with a total RBC volume infused of 252.08ml.
There was no documentation of a 2-person verification at the patient's bedside for safe blood administration before starting the blood transfusion.

There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record.

During an interview on 2/24/2025 after 10:00 AM, RN Staff #4 confirmed Physician #12 failed to sign the informed consent for the blood transfusion.


Patient #6
Patient #6 was a 44-year-old female admitted to the hospital on 1/11/2025 with a diagnosis of septic arthritis, L5-S1 discitis/osteomyelitis, Ovarian Cysts, intractable chronic pain, and Morbid obesity.

A review of the order dated 1/20/2025 at 1:21 PM by Physician #10 was as follows:

"Transfuse RBC (Red Blood Cells) 2 Unit, Routine.
Comments: RBC estimated total volume per unit: 350 milliliters (ml)

Adult non-emergent transfusions should be initiated at a rate of 100ml/hour for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ...
Results

Transfusion Information, Transfuse RBC-(Unit number #1), Status-Stopped, Volume-250ml ml, Start-1/20/2025 at 1745, End-1/20/2025 at 2015.

Transfusion Information, Transfuse RBC-(Unit number #2), Status-Stopped, Volume-350ml, Start-1/20/2025 at 2300, End 1/21/2025 2:30 AM.

Order Questions
Has consent been obtained? Yes
Transfusion duration per unit (within): 3 hours ..."

A review of the transfusion flow sheet dated 1/20/2025 for Unit #1 revealed the blood transfusion was started at 1745 (5:45 PM) at 100ml/hr and ended at 2015 (8:15 PM) with a total RBC volume infused of 250ml.

There was no documentation of a 2-person verification at the patient's bedside for safe blood administration before the transfusion was started.

There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record.


A review of the transfusion flow sheet dated 1/20/2025 for Unit #2 revealed the blood transfusion was started at 2300 (11:00 PM) at 100ml/hr by the RN. The transfusion ended on 1/21/2025 at 2:30 AM with a total RBC volume infused of 350ml.

There was no documentation of a 2-person verification at the patient's bedside for safe blood administration before the blood transfusion was started.

There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record.

A review of the medical record did not reveal a signed informed consent for the blood transfusions.
An interview was conducted with RN Staff #4 on 2/24/2025 at 11:30 AM. RN Staff #4 was asked if an informed consent was signed by the patient before the initiation of the blood transfusions. RN Staff #4 confirmed there was no signed informed consent for the blood transfusions.

An interview was conducted with Patient #6 on 2/24/2025 at 3:30 PM in the presence of RN Staff #4. Patient #6 was asked if she had signed an informed consent for the blood transfusions. Patient #6 confirmed there was no informed consent signed before the blood transfusions.

A review of the hospital policy titled "Laboratory Collection and Patient Care Administrative Policy for Transfusing Blood and Blood Bank Components" Policy Number 03.343.21 with a review date of 5/2024 was as follows:

"1. PURPOSE ...
2. POLICY

2.1 The initiation of blood and/or component therapy may be performed only by a physician or RN.

2.2 All blood and blood products must be identified by two (2) licensed nursing personnel prior to administration using the Compatibility Transfusion Tab. One of these must be an RN ...

2.6 Transfusions should be completed within four (4) hours. No blood container or recipient tubing should hang longer than four (4) hours. Red blood cells should be infused within two (2) hours unless physician orders otherwise ...

4. PATIENT PREPARATION
4.1 Check chart for physician's order ...
4.9 Check blood or blood component verifying identification data.

4.9.1 Inspect the blood or blood component unit for abnormal color or appearance.

4.9.2 Check unit of blood or blood component compatibility transfusion tab, and patient's armband to verify.

a. Patient's name
b. Patient's identification number
c. Unit number
d. ABO and RH type of blood component
e. Expiration date

4.9.3 Check patient's identification armband.

4.9.4 Check all data at patient's bedside. Two (2) licensed staff members should check data together. One of the staff members should be an RN or physician.

4.9.5 Both licensed staff members are to sign a Compatibility Transfusion Tab. Affix the tag label to the Transfusion Record. DO NOT detach the tag from the flood container at any time ...

4.10 Administer blood component, as prescribed by the physician ...


4.10.4 Infuse slowly for first 15 minutes, observing the patient for signs and symptoms of an adverse reaction. The patient will be observed every 30 minutes during the transfusion.

4.10.5 Vital Signs to be taken at initiation, 15 minutes, 30 minutes, then every hour until completion and 1 hour post completion.

4.10.6 Adjust infusion rate based on clinical condition of the patient and blood product being transfused ...

4.12 Complete the Transfusion Record, Record and sign the appropriate space.

4.12.1 Indicate presence or absence of any suspected transfusion reaction. The transfusion record is a legal document and must be retrained in the care ...


5. Nursing Administration Addendum

5.1 The patient's assigned nurse per each shift is accountable to ensure the physicians order for blood administration is fulfilled. If unable to complete the transfusion as ordered the chart will reflect reason and action-taken to notify physician for need to amend original order.

5.2 When blood/blood components are ordered to be given in a "series," the off-going shift nurse will validate order and number of units given to the on-going shift nurse. She will also validate blood documentation for off-going shift is correct prior to leaving duty".



An interview was conducted with RN Staff #13 on 224/2025 at 4:00 PM. RN Staff #14 was asked if the physicians ordered a rate for a blood transfusion. RN Staff #14 stated, "No, they usually don't write a rate on the order; they will just give you a duration time for the transfusion". RN Staff #14 was asked how she knew how fast or slow to run the blood. RN Staff #14 stated, "I will usually start it at about 100ml/hr or 125ml/hr and then increase it to 150ml/hr. It just depends on how the patient is doing". RN Staff #14 was asked to clarify what the ordered rate was on the actual physician order. RN Staff #14 confirmed that was a default box and that was not the rate that the nursing staff followed. RN Staff #14 stated, "The doctors should be unchecking that box when they give a blood order, but they usually just leave it checked so that is why it's on every order".

An interview was conducted with RN Staff #14 on 2/24/2025 at 4:17 PM. RN Staff #14 was asked if the physicians ordered a specific rate when they ordered a blood transfusion. RN Staff #14 confirmed that the physician did not include the rate for the transfusion in the order. RN Staff #14 was asked how he knew what rate to start the transfusion. RN Staff #14 stated, "I usually just start it at 75-100ml/hr and then increase it depending on the patient's health. RN Staff #14 was asked if the hospital required two nurses to verify the blood before the beginning of the transfusion. RN Staff #14 confirmed the hospital policy required two nurses to verify the blood at the patient's bedside before the blood transfusion was started".

An interview was conducted with RN Staff #4 and Licensed Vocational Nurse (LVN) #3 on 2/24/2025 at 4:40 PM. RN Staff #4 confirmed that physicians did not write a rate with the blood transfusion order. RN Staff #4 confirmed the nursing staff failed to make sure that there was a complete order that included the rate for blood transfusions.

During an interview on 2/26/2025 with CNO Staff #2, it was confirmed there was no 2-person verification at the patient's bedside before starting a blood transfusion in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed. Also, CNO Staff #2 confirmed that the policy did not give clear guidelines to ensure that a physician's order for the rate of the blood transfusion was required to start or increase the rate of the blood transfusion.