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Based on record review and staff interview, the facility failed to ensure the quality of medical care for 2 of 7 sampled patients (#1 & 2). This included the failure to order coagulation studies/anticoagulation on a patient with a deep vein thrombosis and on anticoagulation therapy ( #1). Eight days after admission, (#1) developed a pulmonary embolus. Failure to respond to documented consistent high blood sugar levels, reorder reassessments of the blood sugar resulting in a patient remaining ineffectively treated during the hospitalization (#2). These failures demonstrate a deficiency at the standard level of care for medical staff.

The findings include:

1. Patient #1 was admitted to the facility on 9/3/2010 via the Emergency Department (ED) with chief complaint of nausea, vomiting and diarrhea for 3 days, decreased urination. Per the emergency department record, the patient review of symptoms showed all systems negative, except for abdominal pain, nausea, vomiting and diarrhea. Surgical history includes a nephrectomy secondary to ischemic infarct, partial colectomy secondary to perforation (no dates given). Past medical history was significant for COPD, gastritis, hypothyroidism, hypertension, past medical history of congestive heart failure, hyperlipidemia, hypertension, mitral regurgitation and stenosis, neck pain, bronchitis secondary to smoking, chronic obstructive pulmonary disease,cholecystectomy, colectomy, dermatitis, gastro-intestinal bleed in the past, gastritis, resection of colon for interposition, thoracic outlet syndrome associated with cervical rib, GERD, status post hernia repair, congestive heart failure, thyroidectomy, tonsilectomy, right kidney surgery removal for status post infarction. Abdomen was soft, non-distended with mild tenderness in the right upper quadrant, guarding negative, rebound negative, bowel sounds normal, organomegaly negative, trauma negative, mass negative. Additional notes state "Patient anticoagulated for hx prior of a-fib diagnosed as outpatient for DVT bilateral LE. INR 2.4 discussed case with PA " Home medications listed in the ED include: Zetia 10mg daily, Metropolol 25mg 1/2 tab, po twice per day, Saccharomyces Boulardi 250mg daily, Prilosec 20mg po daily, Flagyl 500mg po, daily, Synthroid .175mg po daily, Calcium and Vitamin D supplement, orally twice per day. After stabilization and evaluation in the ED, the patient was admitted to the medical care unit on the 6th floor. Physician orders were for sequential compression devices (SCD's).

Review of the medical record on 12/20/2010 at 11:00am revealed on the day of admit, 9/3/10, there was no documentation for the use of SCD's. On 9/4/10 at 0000, 0400 and 0600 nursing documentation stated the equipment was not available and at 2100, the patient declined the use of the SCD's. The record showed there was no further documentation for the use of the SCD's until 9/6/10 at 2000, applied to the patient. No further documentation until 9/15/10 at 2100, that stated the SCD's were taken off by the MD.

On 9/11/2010, documentation stated the patient developed shortness of breath, with low saturation levels, the patient was placed on oxygen. A VQ scan showed the patient had multiple pulmonary emboli. On this date, the first anticoagulation studies were performed for this patient, revealing a Prothrombin time of 16.1 (high), INR of 1.3 and PTT of 38.7. The following day, on 9/12/10 cardiology consult states the patient had an acute renal infarction along with an acute pulmonary embolus.

The ED physician who admitted this patient was interviewed on 12/21/10 at 9:28am. Per the physician, he remembers speaking to the primary care physician's assistant for this patient, who told him the patient was being treated for bilateral lower extremity deep vein thromboses and atrial fibrillation, the patient was on Coumadin. He documented this on the ED record.

The primary physician was interviewed on 12/20/10 at 2:00pm to determine the reason why the patient with this known history and symptomology was not anticoagulated or had anticoagulation studies. Per the primary physician, the patient had occult blood in the stools, and did not meet criteria for anticoagulation or anticoagulation studies.

The Chief of the Peer Review Committee was interviewed on 12/21/2010 at 9:45am. Per this physician, he has not had the opportunity to review the medical record and could not comment on the appropriateness of using anticoagulation on this patient. He agreed that prudent care would have been to do coagulation studies on this patient on admit to determine if anticoagulation was appropriate.

2.Clnical record of Patient #2 revealed that the blood sugar level was recorded a minimum of 7 times from 12/19/2010 at 1016 up until 12/20/2010 at 1140. All 7 times her blood sugars were found to be above 300 milligrams/deciliters (mg/dl). The normal value referenced at the facility for blood sugar is at 70-100mg/dl.
On 12/19/2010 at 1016 the blood sugar was found to be 378 mg/dl. There was a physician's order placed by the emergency department's physician on 12/19/2010 at approximately 1240 for the patient to receive a total of 8 units of regular insulin as a one time and STAT order, meaning immediately and only once. The nursing staff administered 4 units of regular insulin by subcutaneous injection at 1240 and 4 units intravenously (IV) at 1300 in response.
At 1316 the patient's blood sugar was recorded to be at 307mg/dl. There were no further orders at that time to respond to the high blood sugar and no more insulin was ordered to treat that specific blood sugar. On 12/19/2010 at approximately 1739 the attending physician placed at order for the patient to have her blood sugar checked before each meal and at bedtime. The mode was by finger stick. A set of parameters called a correctional dose schedule or commonly referred to as a sliding scale was ordered for the nursing staff to respond to the blood sugars by administering a fast acting injectable medium dose insulin (Novolog) ,to be given subcutaneously (SQ). The correctional dose schedule was as follows:

Glucose Level Pre-Meal
150-199 1 unit
200-249 3 units
250-299 5 units
300-349 7 units
350 or greater 8 units

Glucose Level Bedtime
150-199 none
200-249 2 units
250-299 3 units
300-349 5 units
350 or greater 7 units

The following blood sugars, minus the above mentioned, were recorded in the clinical record:

Date and Time Results and mode
12/19/10 at 2343 318mg/dl finger stick

Intervention and when: Nurse administered 7 units of Novolog at 2100.
12/20/10 at 0432 303mg/ml finger stick

Intervention and when: No intervention found in chart.
12/20/10 at 0505 331mg/dl laboratory

Intervention and when: Nurse administered 7 units of Novolog at 0730 (over 2 hours after the blood sugar was taken).

12/20/10 at 1133 493mg/dl finger stick

Intervention and when: Nurse administered 7 units of Novolog at 1130.
No order was ever given by the attending physician at anytime to re-check the blood sugars after the patient was administered insulin; therefore, making it impossible to assess the effectiveness of the insulin treatments. Subsequently, the next blood sugar that was checked was a minimum of 4 hours after the fast acting insulin was given. This continued until 12/20/10 at 1140 when the nurse, who administered the most recent 7 units of insulin, contacted the attending MD with the results of Patient #2's blood sugar. He responded by ordering an additional 5 units of Novolog IV and to re-check the blood sugar in 2 hours. That would be the first time since admission that a follow up blood sugar would be performed to assess the effectiveness of the treatment given. It was noted in his progress note on 12/20/10 at 0815 that the patient's diabetes was uncontrolled but gave no further orders to help control it.
An interview conducted on 12/20/2010 at 1155 with Patient #2's registered nurse (RN) revealed that she does not ever re-check a patient's blood sugar following insulin administration unless specifically ordered to do so. She stated that she felt prompted to contact the MD following the most recent blood sugar results only after she was made aware that this state surveyor was inquiring as to why the patient's high blood sugar had appeared to not been addressed and or reassessed by the nursing staff and physicians.
She stated that she would not ordinarily notify the physician of a blood sugar in the 300mg/dl range. She stated that a blood sugar less than 500mg/dl and above 70mg/dl was not considered to be critical values and did not warrant the notification of the physician. She stated that 12/20/10 was the only day she that she had been the patient's RN and her shift was from 0700 to 2100. She further stated that she was aware of the patient's history of high blood sugars and that they had remained in the 300's during this hospitalization; however, expressed no concern about them as it was neither policy nor did the computer red flag or alert any action on the part of the nurse which would include either contacting the MD or conducting a re-check blood sugar to check the effectiveness of the insulin given. She stated that the blood glucose monitor would read " high", if during a finger stick test, the blood sugar was critical and if that were to occur she would then contact the attending physician with the result per policy. In addition, she stated that she had spoken to the physician on 12/20/10 at approximately 0800 and even though he was aware of the patient's blood sugars he had no new orders for her. She was also aware that the patient was ordered and received high doses of a medication, Solu-Medrol 125mg IV every 6 hours, that will cause blood sugars to increase. She stated that the physician had just decreased the dosage to 80mg IV in response to her most recent contact with him which was prompted by this surveyor's inquiries.
An interview with the executive nursing officer on 12/20/2010 at 1605 revealed that the hospital does not have a policy to address blood sugars that are high yet fall below the critical 500mg/dl result. He also stated that the facility did not have a policy that instructed the nursing staff to re-check blood sugars at anytime following administration of insulin. He stated that the amount of insulin may not have been enough to lower the blood sugar while the patient was on such high doses of steroids and that he felt that it was the nurse's and physician's responsibility to address any abnormal values appropriately. He stated that this particular case, that is not what occurred. He was unable to explain why the hospital had no policy to address the above concerns but felt it was basic nursing judgment and could not explain why the nurses who took care of the patient did not notify their chain of command when the physician did not respond with an appropriate plan of action to assess and lower the blood sugar.
An interview with the patient on 12/20/10 at approximately 1135 revealed that she was very concerned that the nursing staff and her physician did not seem to be concerned with her blood sugars and how high they have been since her admission. She stated that at home her blood sugars are never that high. She also stated that the nurses check her blood sugar and give her insulin injections but they never come back in afterwards to check her blood sugar again to see if the insulin is working or not.