HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that one patient was administered their insulin medication according to the order of their practitioner. This failure increased the risk for the patient to have elevated blood sugar levels which could lead to patient harm.

Findings:

During a review of the clinical record for Patient 1 on September 1, 2015, at 9:45 AM, the patient was noted to have an order for insulin (Lispro - a medication used to reduce sugar level in the blood), per sliding scale (a dosing scale used to determine the dose of insulin medication to be given based on the patient's blood sugar level), every 6 hours subcutaneously (beneath the skin). Order details included "Administer within 15 minutes before a meal." The blood sugar result on September 1, 2015, at 6:15 AM, was recorded to be 181. The sliding scale indicated 1 unit of insulin should be given for a blood sugar result between 151-200. The Medication Administration Record (MAR) for September 1, 2015, was reviewed, and it was found the 5th Floor night shift Regisitered Nurse (RN 1) documented at 6:22 AM, the insulin Lispro as "Not given - Not appropriate".

During a concurrent interview with the 5th Floor day shift Registered Nurse (RN 2 - who relieved RN 1 from duty), and the Director of Medical/Surgical/Telemetry (Med/Surg/Tele) Units, when RN 2 was asked whether she had given any insulin. She responded by stating, "No, it wasn't scheduled during my shift." When asked whether the patient had received a meal, she stated, "Yes." The Director of the Med/Surg/Tele Units stated, "Because the patient did not have a meal, the nurse wanted to hold the insulin to avoid a low blood sugar." When she was asked what her expectation would be to ensure the patient received their medication, she stated, "I would expect RN 2 to repeat the fingerstick (blood sugar check)."

Further review of the clinical record revealed a follow-up blood sugar check was not done, and documentation indicated the patient ate 100% of the breakfast meal.

A review of the hospital's policy & procedure, titled "Medications - Standardized Time Schedule - policy number 8720.0293, effective date 3/91, revised date 3/12, Definitions 2.0" indicated the following:

"Time-critical scheduled medications: are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial suboptimal therapy or pharmacologic effect...It is the responsibility of all clinical staff authorized to administer medications to administer scheduled medications in the time frames set forth in this policy...Oral/Topical/Subcutaneous medication standard administration times are as follows: before (AC) meals - 0730, 1130, and 1630".

Further review of the MAR confirms that no insulin doses were given from 6:00 AM to 10:00 AM, on September 1, 2015, despite a meal having been provided and eaten by the patient.