HospitalInspections.org

Based on policy and procedure review, clinical record review and interview it was determined the Facility failed to follow policy and procedure for three (#1, #7 and #9) of eight (#1-#3, #6-#10) patients in that consent for blood transfusion was not obtained from Patient #1 and the blood unit number stickers were not placed on the nursing notes of Patients #7 and #9. Failure to obtain consent for blood transfusion did not allow Patient #1 to make an informed decision of the risks and benefits of the blood transfusion. Failure to place the blood unit number stickers on the nursing notes did not allow exact documentation of the specific unit administered by the nursing staff to be tracked. The failed practices affected three (#1, #7 and #9) of eight patients who received blood/blood products at the Facility. Findings follow:

A. Review of the policy and procedure titled "Blood and Blood Components, Administration" received from the DON revealed under PROCEDURE: 2. Nursing Responsibilities: a. Explain procedure to the patient and family and obtain consent... under Special Considerations: 5. Blood unit number stickers are to be placed on the following: a. Nurse Note, b. Blood Administration Record, c. Consent form and d. All cross match slips.
B. Review of the clinical records of Patients #1-3, #6-10 revealed three (#1, #7 and #9) records did not meet policy and procedure requirements. Patient #1's clinical record lacked a signed consent for blood transfusion. Patients #7 and #9 did not have the blood unit number stickers affixed to the nursing notes.
C. The above findings were verified by the Director of Nursing at 1000 on 03/07/14.