HospitalInspections.org

Based on policy review, record reviews, and interviews, the facility failed to administer medications as ordered by the physician for 3 patients (#3, #11, and #12) of 17 patients reviewed.

The findings included:

Review of the facility's policy number PCS-212.09 titled Patient Touch Medication Administration, dated 6/5/2007, revealed, "...Prior to administering a medication the assigned caregiver or another nurse must verify the order...Documentation on the MAR [Medication Administration Record] is kept current...the MAR documents all medication administrations performed through the Patient Touch System [computerized pharmacy program] over the previous 24 hours...the handheld will be used to record medication events at the point of administration...Documenting a 'not given' medication is used when a dose is not going to be given due to the patient's condition or medication availability...".

Medical record review revealed Patient #3 was admitted to the facility on 2/27/15 with diagnoses which included Insulin Dependent Diabetes Mellitus (IDDM).

Further review of the medical record revealed physician's orders dated 2/27/15 for Sliding Scale Insulin (a dose of insulin adjusted to the patient's blood sugar level) Novolin R (a synthetic insulin) be given four times a day, before meals and at bedtime. The sliding scale dosage was:
Blood Glucose level 0.0 to 69, call MD (medical doctor).
Blood Glucose level 70 to 100, give no insulin.
Blood Glucose level 111 to 149 give 2 units of insulin.
Blood Glucose level 150 to 199 give 3 units of insulin.
Blood Glucose level 200 to 249 give 4 units of insulin.
Blood Glucose level 250 to 299 give 6 units of insulin.
Blood Glucose level 300 to 349 give 8 units of insulin.
Blood Glucose level 350 to 400 give 12 units of insulin.
Blood Glucose level over 400 call MD.

Review of Patient #3's MAR dated 3/2/15 revealed the patient's blood glucose level at 11:08 AM was 264, and at 4:00 PM it was 263 with no documentation of any insulin being given (according to the sliding scale order the patient was prescribed 6 units at 11:08 AM and at 4:00 PM).

Interview with the Risk Manager on 12/1/15 at 3:00 PM, in the board room confirmed Patient #3's blood glucose levels on 3/2/15 required she be administered 6 units of insulin at 11:08 AM and 4:00 PM and there was no documentation of the insulin being administered. Further interview with the Risk Manager confirmed it was facility policy for staff to document when a medication is not given and there was no documentation of the patient's insulin being held.

Medical record review revealed Patient #11 was admitted to the facility on 11/24/15 with diagnoses which included IDDM.

Further review of the medical record revealed Patient #11 had a physician's order dated 11/24/15 for Sliding Scale Insulin four times a day, before meals and at bedtime. The sliding scale dosage was:
Blood Glucose level 0.0 to 69, call MD.
Blood Glucose level 70 to 100, give no insulin.
Blood Glucose level 111 to 149 give 2 units of insulin.
Blood Glucose level 150 to 199 give 3 units of insulin.
Blood Glucose level 200 to 249 give 4 units of insulin.
Blood Glucose level 250 to 299 give 6 units of insulin.
Blood Glucose level 300 to 349 give 8 units of insulin.
Blood Glucose level 350 to 400 give 12 units of insulin.
Blood Glucose level over 400 call MD.

Review of the MAR dated 11/30/15 revealed Patient #11 had a blood glucose level of 244 (4 units of insulin ordered) at 11:00 AM and 153 (3 units of insulin ordered) at 4:00 PM with no documentation of insulin being administered.

Interview with the Unit Director on 12/1/15 at 10:00 AM, at the 1 North Nurses Station, confirmed there was no documentation of Patient #11 being administered the ordered insulin at 11:00 AM and 4:00 PM on 11/30/15. Further interview with the Unit Director confirmed there was no documentation of the patient's insulin being held.

Medical Record Review revealed Patient #12 was admitted on 11/22/15 with diagnoses which included IDDM.

Further review of the medical record revealed Patient #12 had a physician's order dated 11/23/15 for Sliding Scale Insulin four times a day, before meals and at bedtime. The sliding scale dosage was:
Blood Glucose level 0.0 to 69, call MD.
Blood Glucose level 70 to 100, give no insulin.
Blood Glucose level 111 to 149 give 2 units of insulin.
Blood Glucose level 150 to 199 give 3 units of insulin.
Blood Glucose level 200 to 249 give 4 units of insulin.
Blood Glucose level 250 to 299 give 6 units of insulin.
Blood Glucose level 300 to 349 give 8 units of insulin.
Blood Glucose level 350 to 400 give 12 units of insulin.
Blood Glucose level over 400 call MD.

Further review of the medical record revealed on 11/30/15 the patient had a blood glucose level of 170 (3 units of insulin ordered) at 11:00 AM and 158 (3 units of insulin ordered) at 4:00 PM, with no documentation of insulin being administered.

Interview with the Unit Director on 12/1/15 at 10:00 AM, at the 1 North Nurses Station, confirmed there was no documentation of Patient #12 being administered the ordered insulin at 11:00 AM and 4:00 PM on 11/30/15. Further interview with the Unit Director confirmed there was no documentation of the patient's insulin being held.