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Based on observation, interview, record review, and policy review, the hospital failed to ensure:
- Patient identification and blood product verification were completed for one patient (#39) of three patients observed who received a blood transfusion (to administer blood into a vein);
- Safe patient vital sign (VS, measurements of the body's most basic functions) monitoring was completed per hospital policy for two patients (#11 and #42) of six patients reviewed who received a blood transfusion; and
- A safe initial infusion rate for three patients (#11, #39, and #42) of six patients reviewed who received a blood transfusion.
These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

Please refer to A-0410.

Based on observation, interview, record review, and policy review, the hospital failed to ensure:
- Patient identification and blood product verification were completed for one patient (#39) of three patients observed who received a blood transfusion (to administer blood into a vein);
- Safe patient vital sign (VS, measurements of the body's most basic functions) monitoring was completed per hospital policy for two patients (#11 and #42) of six patients reviewed who received a blood transfusion; and
- A safe initial infusion rate for three patients (#11, #39, and #42) of six patients reviewed who received a blood transfusion.

Findings included:

Review of the hospital's policy titled, "Blood Administration," dated 06/19/24, showed:
- VS were to be recorded no more than 30 minutes prior to the transfusion, 10 to15 minutes after the transfusion started, hourly throughout the transfusion, and within 30 minutes of the completion of the transfusion.
- Blood transfusions were to start at a rate of 30 milliliters (ml) over 15 minutes (2 ml per minute or 120 ml per hour).
- Staff were to remain with or be able to closely observe the patient for the first 15 minutes of the infusion to watch for adverse reactions.
- Patient and blood component verification must be performed using the Electronic Medical Record (EMR) and the Blood Bank database. The recipient and unit information should be verified immediately before transfusion and in the presence of the recipient. The patient armband and barcodes on the blood component are scanned. The system should display a message notifying the transfusionist of the electronic verification.
- The verification process must include patient identifiers on the blood component that matches the identity of the recipient, the recipient's blood type, the unit's identification number and blood type, and the unit's expiration date/time.

Observation on 02/04/25 at 1:30 PM, showed Staff U, Registered Nurse (RN), start a blood transfusion for Patient #39 at 1:40 PM. Blood reached the patient at 1:44 PM; the patient and blood product were scanned at 1:47 PM. The blood was started at a rate of 200 ml per hour.

Review of Patient #42's medical record, dated 01/20/25, showed the blood start rate of 150 ml per hour. Blood was started at 12:40 PM and ended at 3:20 PM. VS were recorded at 12:40 PM, 12:55 PM, and 3:20 PM, no hourly vital signs were recorded between 12:55 PM and 3:20 PM.

Review of Patient #11's medical record, dated 02/03/25, showed the blood start rate of 30 ml per hour. Blood was started at 12:27 PM, no VS were recorded until 12:44 PM.

During an interview on 02/04/25 at 4:10 PM, Staff U, RN, stated that she scanned Patient #39's blood after the transfusion began. She had read the patient's name on the blood product label before starting the transfusion. Patients and blood components should be scanned before administration and made a mistake.

During an interview on 02/04/25 at 3:30 PM, Staff G, Nurse Manager, stated that she expected patients and blood product components to be scanned prior to administration. The initial transfusion rate should comply with the policy. Administering blood products before the patient and blood component were scanned put the patient at risk of receiving incompatible blood. The starting time for blood was when the blood reached the patient.

During an interview on 02/06/25 at 9:00 AM, Staff B, Assistant Chief Nursing Officer, stated that she expected patients and blood products to be scanned before administration. The start rate should be 120 ml per hour and vital signs to be documented per policy.