Survey Report for 070034

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	070034	A. BUILDING __________ B. WING ______________	09/14/2023
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
NORWALK HOSPITAL	24 STEVENS STREET, NORWALK, CT, 06856
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
A0338	Medical Staff 482.22 Corrected On: 11/14/2023
A0338	41683 The Condition of Participation for Medical staff had not been met. Based on clinical record reviews, review of facility documentation and interviews for 1 of 3 sampled patients (Patient #11) who was reviewed for care during labor, the Hospital failed to ensure the responsible Obstetrical Medical provider (Hospitalist) rounded on the patient and reviewed the fetal heartrate strip consistent with the hospital's practice and Medical Bylaws when the laboring patient on Pitocin developed persistent category 2 fetal heart tracing (non-reassuring and associated with fetal metabolic acidosis) leading to prolonged and terminal bradycardia, stat cesarean delivery, and fetal demise. Cross Reference CFR 42 482.22 (b). Medical Staff Organization and Accountability (A-347)
A0347	Medical Staff Organization & Accountability 482.22(b)(1), (2), (3) Corrected On: 11/14/2023
A0347	41683 Based on clinical record reviews, review of facility documentation, and interviews for 1 of 3 sampled patients (Patient #11) who was reviewed for care during labor, the Hospital failed to ensure the Certified Nurse midwife (CNM) alerted the Obstetrical (OB) provider when she was unable to consistently monitor the patient and failed to ensure the responsible OB Medical provider (Hospitalist) rounded on the patient and reviewed the fetal heartrate strip consistent with the hospital's practice and Medical Bylaws when the laboring patient on Pitocin developed persistent category 2 fetal heart tracing (non-reassuring and associated with fetal metabolic acidosis) leading to prolonged and terminal bradycardia, stat cesarean delivery, and fetal demise. The finding includes: Patient #11 was admitted to the hospital at 39 weeks gestation with a history of reduced fetal movement and non- reassuring fetal non stress test in the midwife's office. On admission to the hospital, patient #11's fetal heart tracing was identified as category 1 (indicative of a normal tracing not associated with fetal asphyxia). Review of Patient #11's fetal tracing and the medication administration record (MAR) for Pitocin infusion (medication used to induce the start of labor) dated 8/9/23 at 1:30 PM to 8/11/23 at 10:43 AM with the Quality Specialist identified the following: Pitocin at 1 mu/m was initiated on 8/10/23 at 4:57 AM and a cervical check at that time documented cervix at 5 centimeters (cm) dilated, 80% effaced and at 0 station. The records identified Pitocin was discontinued on 8/10/23 at 11:27 AM secondary to census and staffing issues and restarted at 2 mu/m on 8/10/23 at 4:30 PM. The medication administration record identified Pitocin was infusing at 12 mu/min at 8:30 PM on 8/10/23. A cervical check identified the patient's cervix was 5.5 cm dilated at 7:26 PM and 6 cm at 10:20 PM (no appreciable change in 19 hours). Review of the fetal tracing from 2:00 AM - 4:00 AM on 8/11/23 identified fetal HR baseline of 130's to 140's, minimal to moderate variability with intermittent late decelerations (sign of oxygen deprivation), variable decelerations (indicative of cord compression), and early decelerations (indicative of head compression not hypoxia). The record identified Patient #11's membranes were artificially ruptured at 3:07 AM on 8/11/23 with copious amounts of moderate meconium. The MAR identified Pitocin drip was decreased from 12 - 6 mu/m at 4:10 AM on 8/11/23 (after 2 hours of category 2 tracing 2:00AM-400AM). The medical record noted a vaginal exam performed by certified nurse midwife (CNM) #1 at 4:45 AM identified the cervix remained at 6 cms dilated, 100 % effaced and at +1 station. The MAR identified Pitocin was increased to 8 mu/min at 6:00 AM and 10 mu/m at 6:30 AM. Fetal tracings on 8/11/23 from 7:30 AM to 10:00 AM identified fetus continued to experience late and variable decelerations, areas of indeterminate baseline, and areas of loss of tracing. The MAR identified Pitocin was increased to 12 mu/m at 9:45 AM. The fetal tracing identified at 10:11 AM the fetus experienced a prolonged decelerations with the fetal heart rate down to 70's (normal 110 - 160) for a duration of 160 seconds. The fetal heart rate strip documented another prolonged deceleration at 10:19 AM with fetal heart rate identified at 50/min. The MAR identified Pitocin was discontinued at 10:22 AM (11 minutes after the initial prolonged bradycardic episode). The clinical record identified that the CNM was called at 10:24 AM, MD #1 was at the patient's bedside at 10:25 AM, a fetal scalp electrode was placed at 10:28 AM and the decision was made for a cesarean delivery(surgical delivery of the fetus) at 10:30 AM. Fetal bradycardia continued until the patient was removed from continuous monitoring at 10:36 AM. Review of delivery consult note dated 8/11/23 at 3:29 PM entered by Physician Assistant #1 identified the PA was called to an emergency cesarean section delivery for fetal bradycardia at 10:33 AM. The note identified the infant was born at 10:43 AM, was limp, apneic, cyanotic and with no heartrate on auscultation. The note identified there was no delay in cord clamping and infant was brought to the warmer, suctioned, stimulated, and positive pressure ventilation (PPV) was immediately started with 21% oxygen and increased to 100% oxygen with good chest rise but with no heart rate heard and chest compressions were started at 2 minutes and 30 seconds after birth. The note identified the infant was suctioned for copious amounts of meconium, intubated with 3.5 ET after second attempt, and a total of 6 doses of epinephrine were administered (first dose ET, 5 via umbilical vein catheter), normal saline bolus, with chest compression and positive pressure ventilation. The note identified that at 19 minutes there was no heart rate on auscultation or on monitor and MD #3 and MD #4 (neonatologist) were consulted on the phone due to no detectable heart rate and the decision was made to continue PPV and chest compression until MD #3 arrived. The note identified PPV continued with no change in infant's status remained limp, apneic, blue and with appreciable purposeful movement. The note identified MD #3 arrived and the code was discontinued at 11:14 AM. Apgar scores at 1 min-0, 5 min -0, 10 min- 0, 15 min- 0, 20 min- 0, and 30 min- 0. The hospital failed to ensure the responsible medical provider (MD#2) monitored the laboring patient consistent with the hospital's practice and Medical Bylaws. Interview with MD #1 (delivering OB) on 8/24/23 at 4:20 PM identified that during report on the morning of 8/11/23 she was told that Patient #11 had category 2 tracing overnight, but strip had improved after rupture of membranes. MD #1 identified she reviewed the strip at 9:40 AM identified the strip as category 1 at that time, left the floor to see another patient and when returned checked the patient's cervix, identified patient was fully dilated, and informed midwife to start pushing with the patient. MD #1 stated she was in the process of charting when she pulled up Patient #11's fetal strip and identified patient had an episode of deceleration. MD #1 identified she responded to the patient's room at approximately 10:25 AM and was unable to appreciate the fetal heart rate. MD #1 identified she placed an internal monitor, placed the patient on hands and knees and called for a stat cesarean section delivery. MD #1 stated she was not made aware of the patient's deceleration that occurred at approximately 10:11 AM and indicated that looking back on the fetal tracing for the overnight period and if she had this information earlier she would have made the decision to deliver patient #1 at 8:30 AM prior to the scheduled cesarean section of another patient. An interview with MD #2 on 8/30/23 at 3:30 PM (the Hospitalist on call 8/10 - 8/11/23) identified he was never informed that there were issues with Patient #11's fetal heartrate strip overnight on 8/11/23. MD #2 identified that his responsibilities as the on-call physician included seeing unassigned patients and reviewing the fetal strips of the patients assigned to midwives every 4 hours. MD #2 identified he could not recall when he last reviewed Patient # 11's fetal tracing but stated it was his practice to review strips at 11 PM and would be called by nurses if they needed him throughout the night. In an interview with MD #7 (OB Director) on 9/18/23 at 11:00 AM, MD #7 identified it was the responsibility and expectation that the OB Hospitalist have knowledge of all patients in the labor and delivery unit when on call. MD # 7 indicated that it was the expectation that the Hospitalist on call lead safety huddles, review fetal heat tracings of all patients on labor and delivery every 3 hours and round on patients every 4 hours to look for trends overtime. Interview with CNM (Certified Nurse Midwife) #1 on 8/24/23 at 2:10 PM identified she was on shift 7:30 AM to 7:30 AM on 8/10 - 8/11/2023 and identified her responsibilities included monitoring fetal strips, performing vaginal exams and providing labor support. CNM #1 identified for the overnight period she had another patient she was with for 4 hours. The CNM identified she saw patient #11 at 3:00 AM, identified she monitored the fetal strip, artificially ruptured the membranes, noted there was moderate meconium and identified patient was having decelerations which improved with repositioning and administration of fluids. CNM #1 identified she did not review the previous hours of strip and was not made aware that the patient was experiencing later decelerations starting at about 2:00 AM. CNM #1 identified she responded to the patient's bedside when she was made aware the Pitocin dose was cut in half at approximately 5:00 AM. CNM # 1 indicated she checked the patient's cervix at this time. CNM #1 identified she had a busy night with one (1) Cesarean section delivery, one (1) forceps assisted delivery, and one patient on magnesium. CNM #1 identified she was working with 1 midwife student, identified she could have called another midwife in for assistance and could have notified the MD in house on call but did not. CNM #1 identified that at 7:30 AM she had a conversation with the patient who requested a caesarean section delivery and informed the patient the last vaginal exam showed the most progress and the decision was made to continue with labor. CNM #1 indicated she should have made the decision for a cesarean section delivery at 8:00 PM (on 8/10/23) when it was identified the patient was not making any progress in cervical dilatation. The hospital failed to ensure the Midwife informed the the physician when she was unable to closely monitor the laboring patient and the medical provider failed to monitor the laboring patient consistent with the hospital's practice and Medical Bylaws. Review of the Hospital's Medical Staff Bylaws Policies, Rules and Regulations 2.B.1. Basic Responsibilities and Requirements, directed, as a condition of being granted appointment, reappointment and or clinical privileges, and as a condition of maintaining ongoing appointment and or clinical privileges every medical staff member must agree to (a) provide continuous and timely quality care to all patients for whom the individual has responsibility. The Connecticut General Assembly Chapter 377 Midwifery Sec. 20-86b. Scope of practice directed in part, Nurse midwives shall practice within a health care system and have clinical relationships with obstetrician- Gynecologists that provide for consultation, collaborative management, or referral as indicated by the health status of the patient.
A0385	Nursing Services 482.23 Corrected On: 11/14/2023
A0385	41683 The Condition of Participation of Nursing Services was found to be out of compliance. Based on clinical record reviews, review of facility documentation, policies, and interviews for 1 of 3 sampled patients (Patient #11) who was reviewed for care during labor, the Hospital failed to ensure the Pitocin protocol was followed, failed to ensure staff used the chain of command, failed to correctly interpret the fetal strip, and failed to honor the patient's request for a cesarean section delivery when the patient experienced prolonged periods of category 2 fetal heart tracing with late and variable decelerations leading to prolonged and terminal bradycardia, stat cesarean delivery, and fetal demise. In addition, for 1 of 3 sampled patients (Patient #16) who was reviewed for monitoring during blood transfusion, the hospital failed to ensure staff monitored the patient consistent with the Hospital's practice and protocol. Cross references CFR 482.23 (b) (3) RN Supervision of Nursing Care (A- 395) CFR 482.23 (c) (4) Blood Transfusion and IV medications (A- 409)
A0395	Rn Supervision Of Nursing Care 482.23(b)(3) Corrected On: 11/14/2023
A0395	41683 Based on clinical record reviews, review of facility documentation, policy review, and interviews for 1 of 3 sampled patients (Patient #11) who was reviewed for care during labor, the Hospital failed to ensure the Pitocin protocol was followed, failed to correctly interpret the fetal strip, and failed to exercise the chain of command when the patient experienced prolonged periods of category 2 fetal heart tracing with episodes of late and variable decelerations leading to prolonged and terminal bradycardia, stat cesarean delivery, and fetal demise. The findings include: Patient #11 was admitted to the hospital at 39 weeks gestation with a history of reduced fetal movement and non- reassuring fetal non stress test in the midwife office. On admission to the hospital, patient #11's fetal heart tracing was identified as category 1 (indicative of a normal tracing and not associated with fetal asphyxia). Review of Patient #11's fetal tracing and the medication administration record (MAR) for Pitocin infusion (medication used to induce the start of labor) dated 8/9/23 at 1:30 PM to 8/11/23 at 10:43 AM with the Quality Specialist identified the following: Pitocin at 1 mu/m was initiated on 8/10/23 at 4:57 AM and a cervical check at that time documented cervix at 5 centimeters (cms), 80% effaced and at 0 station. The MAR identified Pitocin was increased 2 mu/min according to protocol until 11:27 AM on 8/10/23 when the Pitocin was discontinued secondary to acuity level of unit. The MAR identified the Pitocin was restarted at 2 mu/min at 4:30 PM and increased (per protocol) to 12 mu/min at 8:30 PM on 8/10/23. The MAR further identified Pitocin was maintained at 12 mu/m until 8/11/23 at 4:10 AM when the Pitocin was reduced to 6 mu/min. Review of the fetal tracing with the Quality specialist, certified nurse midwife (CNM) #1, and RN #1 duirng the period of 4:57 AM on 8/10/23 to 2:00 AM on 8/11/23 identified the fetal heart rate strip was predominantly category 1( normal - not associated with fetal asphyxia). The fetal heart rate tracing on 8/11/23 at 2:00 AM - 4:30 AM identified fetal HR baseline of 130's to 140's, minimal to moderate variability with intermittent late decelerations (sign of oxygen deprivation), variable decelerations (indicative of cord compression), and early decelerations (indicative of head compression not hypoxia). The MAR identified Pitocin drip was decreased from 12 mu/m- 6 mu/m at 4:10 AM on 8/11/23, after 2 hours of category 2 tracing. Staff failed to accurately interpret the fetal heart rate strip and failed to modify the rate of the Pitocin timely when the fetal heartrate monitoring strip identified a category 2 tracing with no changes despite interuteroresuscitation. The record identified cervical checks revealed the patient's cervix was 5.5 cms dilated at 7:26 PM and 6 cms at 10:20 PM on 8/10/23. (no appreciable change in 19 hours). Review of RN #1's nurses note identified Patient #11's membranes were artificially ruptured by CNM #1 at 3:07 AM on 8/11/23 with copious amounts of moderate meconium. The Obstetric Progress note by CNM #1 dated 8/11/23 at 3:13 AM identified cervical exam 5-6 cms dilated/80 % effaced /-1, fetal exam noted patient had 3 late decelerations, and identified membranes were artificially ruptured with copious amounts of moderate meconium. The record noted a vaginal exam performed by CNM #1 at 4:45 AM identified the cervix remained at 6 cm dilated, 100 % effaced and at +1 station. The MAR identified Pitocin was increased to 8 mu/min at 6:00 AM and 10 mu/m at 6:30 AM. The fetal hearate tracing dated 8/11/23 at 7:30 AM to 10:00 AM identified the fetus continued to experience late and variable decelerations, areas of indeterminate baseline, and areas of loss of tracing. The MAR identified Pitocin was increased to 12 mu/m at 9:45 AM despite episodes of late and variable decelerations, areas of indeterminate baseline, and areas of loss of tracing between 7:30AM and 10:00AM. The fetal tracing identified at 10:11 AM the fetus experienced a prolonged decelerations with the fetal heart rate down to 70's (normal 110 - 160) for a duration of 160 seconds. The fetal heart rate strip documented another prolonged deceleration at 10:19 AM with fetal heart rate identified at 50/min when a fetal scalp electrode was placed at 10:28 AM. The fetal bradycardia continued until the patient was removed from continuous monitoring at 10:36 AM. The MAR identified Pitocin was discontinued at 10:22 AM (11 minutes after the initial prolonged bradycardic episode). The clinical record identified that the Midwife was called at 10:24 AM, MD was at the patient's bedside at 10:25 AM, and the decision was made for a C/S delivery at 10:30 AM. The RN failed to turn off the Pitocin and failed to alert the physician when the fetal heart rate strip identified a prolonged fetal bradycardic episode at 10:11 AM. Review of CNM #1's note dated 8/11/23 at 10:16 AM identified patent #11 and family were requesting a cesarean section (C/S) delivery because of the meconium in fluid. The note identified CNM #1 explained to the family that meconium was not a reason to consider a C/S delivery and informed the family that the C/S could not be done at that time as there was another C/S in progress and offered for the family to speak with the Obstetrician. Review of delivery consult note dated 8/11/23 at 3:29 PM entered by PA # 1 identified the PA was called to an emergency cesarean section delivery for fetal bradycardia at 10:33 AM. The note identified the infant was born at 10:43 AM, was limp, apneic, cyanotic, and with no heartrate on auscultation. The note identified there was no delay in cord clamping and infant was brought to the warmer, suctioned, stimulated, and positive pressure ventilation (PPV) was immediately started with 21% oxygen and increased to 100% oxygen with good chest rise but with no heart rate heard and chest compressions were started at 2 minutes and 30 seconds after birth. The note identified the infant was suctioned for copious amounts of meconium, intubated with 3.5 ET after second attempt, and a total of 6 doses of epinephrine were administered (first dose ET, 5 via umbilical vein catheter), normal saline bolus, with chest compression and positive pressure ventilation. The note identified that at 19 minutes there was no heart rate on auscultation or on monitor and MD # 3 and MD #4 (Neonatologist) were consulted on the phone due to no detectable heart rate and the decision was made to continue PPV and chest compression until MD #3 arrived. The note identified PPV continued with no change in infant's status remained limp, apneic , blue and with appreciable purposeful movement. The note identified MD # 3 arrived and the code was discontinued at 11:14 AM. Apgar scores at 1 min-0, 5 min -0, 10 min- 0, 15 min- 0, 20 min- 0 and 30 min- 0. Interview and review of fetal tracing with RN #1 on 8/31/23 at 5:00 PM identified between 2:00 AM and 4:00AM on 8/11/23 she interpreted the strip as predominantly early decelerations (indicative of head compression not hypoxia). RN #1 stated she participated in huddle with the charge nurse, and staff all agreed that the fetal tracing was predominantly early deceleration and did not require modification of the Pitocin dose. Interview with RN #2 on 8/24/23 at 4:55 PM identified she was informed in report on 8/11/23 that patient #11 had category 1 to category 2 tracing overnight, and identified the family was concerned with the patient's meconium in amniotic fluid which was addressed by CNM #1 and MD #1. RN #2 identified that upon review of the strip after the incident she identified that 7 AM to 8 AM the strip showed variable with intermittent late variable deceleration and identified consistent with the policy the Pitocin should have been discontinued. RN #2 identified that at 10:11 AM the patient experienced a prolonged deceleration with heart rate down to 80 and identified she did not inform MD #1 of this. RN #2 stated there was a second prolonged deceleration at 10:17 AM and identified the Pitocin was not discontinued until 10:22 AM. RN #2 stated she overlooked discontinuing the Pitocin at the time when patient first experienced a prolonged deceleration. Staff failed to accurately interpret fetal heart rate strips when strip exhibited areas of intermittent and recurrent late decelerations. Interview with CNM #1 on 8/24/23 at 2:10 PM identified she was on shift 7:30 AM to 7:30 AM on 8/10 - 8/11/2023 and identified her responsibilities included monitoring fetal strips, performing vaginal exams and providing labor support. CNM #1 identified for the overnight period she had another patient she was with for 4 hours. The CNM identified she saw patient #11 at 3:00 AM, identified she monitored the fetal strip, artificially ruptured the membranes, noted there was moderate meconium and identified patient was having decelerations which improved with repositioning and administration of fluids. CNM #1 identified she did not review the previous hours of strip and was not made aware that the patient was experiencing later decelerations starting at about 2:00 AM. CNM #1 identified she responded to the patient's bedside when she was made Pitocin was cut in half the rate at approximately 5:00 AM. CNM # 1 indicated she checked the patient's cervix at this time. CNM #1 identified she had a busy night with one (1) Cesarean section delivery, one (1) forceps assisted delivery, and 1 patient on magnesium. CNM #1 identified she was working with 1 midwife student, identified she could have called another midwife in for assistance and could have notified the MD in house on call but did not. CNM #1 identified that at 7:30 AM she had a conversation with the patient who requested a caesarean section delivery and informed the patient the last vaginal exam showed the most progress and the decision was made to continue with labor. Interview with MD #1 (delivering OB) on 8/24/23 at 4:20 PM identified that during report on the morning of 8/11/23 she was told that Patient #11 had category 2 tracing overnight, but strip had improved after rupture of membranes. MD # 1 identified she returned checked patient's cervix identified patient was fully dilated and informed midwife to start pushing with the patient. MD #1 stated she was in the process of charting when she pulled up Patient #11's fetal strip and identified patient had an episode of deceleration. MD #1 identified she responded to the patient's room at approximately 10:25 AM and was unable to appreciate the fetal heart rate. MD #1 identified she placed an internal monitor, placed the patient on hands and knees and called for a stat cesarean section delivery. MD #1 stated she was not made aware of the patient's deceleration that occurred at approximately 10:11 AM and indicated that looking back at the strip she would have made the decision to deliver patient #1 on 8/10/23 at 8:00 PM. In an interview with RN #3 (Maternal child educator) on 8/24/23 at 3:00 PM, RN #3 identified nurses were educated on fetal strip interpretation with preceptor during the orientation process. RN #3 indicated that new nurses are given a 12-week orientation and experienced nurses are given 4-week orientation in which they were educated on fetal strip interpretation. RN #3 identified that all nurses in labor and delivery were expected to complete an electronic fetal monitoring course after working in the specialty for a year. RN #3 identified staff was trained to handle category 2 tracings asking questions if unsure, if patient was on Pitocin in the presence of category 2 tracing to change the patient's position, administer IV solution bolus and oxygen along with changing the rate of the Pitocin to half or discontinue and notify the provider if the category 2 persist beyond 30 minutes. The educator identified that staff were expected to escalate concerns up the chain of command to include charge nurse, inhouse supervisor, educator, and director. Review of the Labor Induction/Augmentation policy and tachysystole algorithm directed the purpose of the policy was to provide nursing and medial management to patients receiving intrapartum Oxyctocin for induction or augmentation of labor. The policy further directed that with fetal heart rate category two and category three, indeterminate or abnormal tracing, to discontinue Oxyctocin, notify provider, and begin fetal resuscitative measures. Review of the Electronic Fetal monitoring policy directed Category 2 tracings with features to include thick meconium, fetal bradycardia or prolonged decelerations will require the certified nurse midwife or the RN to notify the covering Obstetrician/ gynecologist.
A0409	Blood Transfusions And Iv Medications 482.23(c)(4) Corrected On: 11/14/2023
A0409	41683 Based on clinical record reviews, review of facility documentation and interviews for 1 of 3 sampled patients (Patient #16) who was reviewed for monitoring during blood transfusion, the hospital failed to ensure staff monitored the patient consistent with the Hospital's practice and protocol. The finding includes: Patient #16 was admitted to the hospital with diagnoses to include myelodysplastic syndrome (MDS) (drop in the number of normal blood cells). The history and physical (H&P) note dated 9/13/23 identified the patient had a known history of MDS and thrombocytopenia, both transfusion dependent. The note identified patient # 16's hemoglobin was variable occasionally less than 7 mg/dl but typically with transfusion is 8mg/dl. The history and physical identified plan to transfuse 1 unit packed red blood cell. A review of Patient #16's hematology results dated 9/13/23 identified a hemoglobin level of 6.9 mg/dl (low) and a hematocrit of 20.2 (low). The physician's order dated 9/13/23 at 8:20 AM directed to Transfuse 1 Unit leuko-reduced red blood cells. Review of the Blood transfusion documentation identified the blood transfusion was initiated on 9/13/23 at 9:59 AM. The Vital signs documentation for patient # 16 dated 9/13/23 identified vital signs were documented at 9:59 AM , 10:19AM (20 minutes later, no temperature documented), 11:53 AM (1 hour 34 minutes later) and at 1:50 PM ( 1 hour and 57 minutes later - no temperature documented) An interview with the Quality Specialist on 9/14/23 at 2:30 PM identified it was the expectation that during a blood transfusion the patient's vital signs were monitored according to the hospital policy. The hospital failed to monitor and document the patient's vital signs during a blood transfusion according to the hospital's policy. Review of the Blood Component Administration Policy directed to obtain vital signs to include temperature, pulse, respirations and blood pressure 15 minutes after the start of the infusion and minimally every hour, and 60 minutes after completion.