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Based on an interview and record review, the hospital failed to ensure the hospital's P&P for Transfusion Therapy was impertinent for one of the seven sampled patients (Patient 2) when Patient 2's vital signs were not checked at 15 minutes after the start of the transfusion as per the hospital's P&P. This failure created an increased risk of substandard health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Transfusion Therapy dated June 2023 showed the vital signs will be observed and documented at minimum at the following intervals or times:

* Check pre -transfusion's baseline vital signs immediately prior to initiation of transfusion.
* Check the vital signs 15 minutes after the start of transfusion.
* Thereafter, check the vital signs hourly until the transfusion is completed.
* Check the vital signs 30 minutes after the transfusion is completed.
* Immediately when a transfusion reaction is suspected or change in clinical condition occurs.

On 1/8/25 at 0940 hours, an interview and concurrent review with Patient 2's medical record was conducted with the Director of Quality Management.

Review of Patient 2's medical record showed Patient 2 was admitted to the hospital on 12/24/24.

Review of the Blood/Blood Component Transfusion Record dated 12/30/24, showed the following:

* Patient 2 received blood transfusion started at 1535 hours and ended at 1830 hours.

* The Vital Signs section showed the patient's vital signs were taken as follows:

- At 1535 hours, the pre-transfusion's vital signs showed the patient's temperature was 98.7 degrees F, the patient's pulse was 85 beats per minute, the patient's BP was 106/66 mmHg, and the patient's RR was 25 breaths per minute.

- At 1615 hours (or 40 minutes after the start of the blood transfusion), the patient's temperature was 98.6 degrees F, the patient's pulse was 81 beats per minute, the patient's BP was 110/60 mmHg, and the patient's RR was 20 breaths per minute. The vital signs were taken at 40 minutes instead of 15 minutes after the start of the blood transfusion.

- At 1700 hours, the patient's temperature was 98.7 degrees F, the patient's pulse was 83 beats
per minute, the patient's BP was 121/97 mmHg, and the patient's RR was 21 breaths per minute.

- At 1800 hours, the patient's temperature was 98.6 degrees F, the patient's pulse was 79 beats per minute, the patient's BP was 146/79 mmHg, and the patient's RR was 22 breaths per minute.

- At 1830 hours, the patient's temperature was 98.8 degrees F, the patient's pulse was 70 beats per minute, the patient's BP was 120/65 mmHg, and the patient's RR was 20 breaths per minute.

- At 1900 hours (or 30 minutes post transfusion), the patient's temperature was 98.7 degrees F, the patient's pulse was 72 beats per minute, the patient's BP was 118/61 mmHg, and the patient's RR was 19 breaths per minute.

On 1/8/25 at 0940 hours, an interview was conducted with the Director of Quality Management. The Director of Quality Management was asked about the patient's vital signs recorded for 15 minutes after the start of the blood transfusion. The Director of Quality Management verified the vital signs recorded at 1615 hours.