HospitalInspections.org

Based on policy review, document review, interviews, and observations, clinical staff did not verify the policies and procedures governing medical care provided in the emergency service or department are established by and are the continuing responsibility of the medical staff. Specifically, nursing staff failed to properly secure insulin (injectable medication used to maintain blood sugar) per the facility's policy.

Findings include:

Review on 10/31/2024 of the policy "Medication Administration," effective September 2024, indicated "Medications are to be removed from the automated medication dispensing cabinet and administered for one patient at a time. All medications may be retrieved for same time administration. Medications are not to be transported to bedside "in your pocket". All medications must remain in secure storage until administered to the patient by authorized personnel. The nurse draws up the required dose and returns the insulin vial back to the appropriate drawer in ADC (Automated Dispensing Cabinet).

Observation on 10/30/24 at 03:00 PM with Staff (D), Regulatory revealed a multidose insulin vial, admelog (lispro) 100 units/milliliters (fast-acting mealtime medication used to maintain blood sugar) was observed on the A-side nursing station counter, and supervision was alerted. The insulin vial was immediately removed. Staff (D) stated the insulin identified was not stored in accordance with the facility's policy and procedure.

Interview on 10/30/24 at 10:58 AM, with Staff (J), Clinical Pharmacist Specialist stated they work in the emergency department to restock medications in the Omnicell. Staff (J) stated insulin is kept inside the Omnicell and should be removed as needed and immediately returned to the Omnicell.

Interview on 10/30/24 at 11:40 AM with Staff (L), Registered Nurse stated insulin is typically removed from the Omnicell and sometimes put back in the Omnicell immediately and sometimes it is not.

Interview on 10/30/24 at 2:12 PM with Staff (N), Registered Nurse stated insulin is typically removed from the Omnicell and put back immediately however if the paper is out the vial is taken to the bedside to administer the medication and it is returned to the Omnicell after the medication pass.

Interview on 10/31/24 at 11:45AM with Staff (E), Director of Nursing, stated being aware of a multidose insulin vial, admelog (lispro) 100 units/milliliters was observed on 10/30/24 at 03:00 PM on the A-side nursing station counter. Staff (E) verified the emergency department staff were not following the policy "Medication Administration," that included all medications must not be left at the bedside and must remain in secure storage until administered to the patient by authorized personnel. The nurse draws up the required dose and returns the insulin vial back to the appropriate drawer in ADC (Automated Dispensing Cabinet).