HospitalInspections.org

Based on document review and staff interview, the facility failed to complete blood transfusions according to physician order and facility policy and complete post transfusion documentation according to facility policy for 2 of 7 patients (patients #4 and #5).

Findings include:

1. Review of patient #4 medical record indicated the following:
(A) He/she was admitted on 12/3/11 and an order was written on 12/3/11 to transfuse two (2) units of packed red blood cells (PRBC's) each over 4 hours.
(B) The first unit was started at 10:35 p.m. on 12/3/11. The transfusion record lacked documentation of the end time, however the post transfusion vital signs were documented at 1:04 a.m. 12/4/11 which would make the transfusion infusing in less than 3 hours instead of the 4 hours per order. The second unit was started at 2:10 a.m. on 12/4/11 and ended at 4:30 a.m. on 12/4/11 which indicated the unit was infused in 2 hours and 20 minutes instead of the 4 hours per order.
(C) The transfusion record for the first unit lacked documentation of the end time of the transfusion.
(D) The transfusion record for the second unit lacked documentation of the amount infused and the post transfusion vital signs.

2. Review of patient #5 medical record indicated the following:
(A) He/she was admitted on 12/3/11 and an order was written on 12/3/11 to transfuse five (5) units of platelets.
(B) The transfusion was started at 11:20 p.m. on 12/3/11 and the patient had a spike in temperature and seizure like activity beginning at 12:10 a.m.
(C) A discrepancy was noted in the documentation on the infusion record and the narrative nurses notes. Per the narrative nurses notes, the transfusion was stopped immediately at 12:10 a.m. and the physician was notified, however the transfusion record indicated the end time of the transfusion was 12:44 a.m.

3. Facility policy titled "BLOOD & BLOOD PRODUCT ADMINISTRATION-PLASMA, ALBUMIN, PLATELETS, & CRYOPRECIPITATE" last reviewed/revised 11/11 states on page 1 under policy: "Blood and Blood products will be administered upon a physician's order." and page 5 of same policy states: "18. Post infusion documentation will be completed in section 3, by a Registered Nurse, with the following information: a) Amount of infusion in milliliters (mls); b) Time completed/interrupted; .................."

4. Staff member #2 verified the medical record information above at 3:30 p.m.