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Based on record review and staff interview it was determined the Registered Nurses failed to ensure diabetic medication and care was provided to meet the patients' needs and hypertension medication and neuro vascular checks were not provided as ordered by the physician for 5 (#1, #3, #4, #5, #8) of 10 sampled patients.

Findings include:

1. Patient #1 presented to the Emergency Department (ED) on 7/15/13 following a fall at the Assisted Living Facility (ALF), where she was resided. The patient was found to have a fractured pelvis and a mild subdural hematoma. Review of laboratory results revealed a blood glucose of 304. The ED physician documented the patient had acute hyperglycemia. The patient was admitted.

Review of the list of home medications revealed no documentation of any medication to treat diabetes. Further review of the medical record revealed the ALF had provided a copy of the Medication Administration Record (MAR) that indicated the patient was receiving levemir insulin. This was not added to the home medication list by nursing for medication reconciliation and therefore not considered by the physician for continuation in the hospital. The insulin was not ordered initially for the patient.

A nurse performed a point of care blood glucose test at 11:44 a.m. on 7/16/13 and noted the blood glucose was 210. There was no documentation of any action taken in response to the elevated blood glucose. An order for sliding scale insulin was entered at 3:53 p.m. and 3 units of insulin were administered at that time.

Review of the blood glucose monitoring revealed at 4:06 p.m. on 7/19/13 the blood glucose was 314. According to the sliding scale insulin order, the patient should have received 5 units of insulin. Review of the MAR revealed the nurse administered 6 units in error. The Clinical Nurse Coordinator (CNC)was present during the record review on 9/17/13 at approximately 11:00 a.m. and confirmed the above findings.

2. Patient #3 was admitted on 7/15/13 with the diagnosis of type II diabetes. The physician ordered point of care blood glucose monitoring before meals and at night. Review of documentation of blood glucose monitoring revealed the nurse failed to document a blood glucose result before lunch on 7/19/13. The CNC was present during the review of the record on 9/17/13 at approximately:00 p.m. and confirmed the finding.

3. Patient #4 was admitted on 9/16/13 with the diagnosis of uncontrolled diabetes. The physician ordered point of care blood glucose monitoring with sliding scale insulin coverage before meals and at night. Review of the glucose monitoring revealed at 11 a.m. on 9/17/13 the blood glucose was 314. Based on the sliding scale insulin order the patient should have received 8 units of regular insulin. Review of the MAR revealed the nurse administered 10 units in error.

4. Patient #5 was admitted on 9/12/13 with the diagnosis of left sided weakness and hypertension. The physician ordered Apressoline 10 milligrams intravenously every 4 hours as needed for systolic blood pressure over 150. Review of vital signs revealed the blood pressure was 196/84 at 10:48 a.m. on 9/15/13. The patient had been ordered Vasotec on a routine basis and this medication was administered at that time. The nurse failed to reassess the blood pressure following the Vasotec until 2:53 p.m.,which was approximately 3 hours later. The blood pressure was documented as 194/84. There was no intervention for the elevated blood pressure until 6:37 p.m. Apressoline 10 milligrams was administered intravenously. There was no explanation as to why another 3 1/2 hours passed before the Apressoline was administered.

5. Patient #8 was admitted on 9/14/13 with a fractured left femoral head fracture. The patient was taken to surgery for repair of the fracture on 9/16/13. Following the surgery, the physician ordered neuro vascular checks every hour x 2 and then every 4 hours x 24 hours. Review of documentation of the checks revealed there was no check performed from 8 a.m. until 3:40 p.m. on 9/17/13. This was greater than 7 1/2 hours between checks.


The CNC was present during the review of the records for patients #4,#5, #8 on 9/18/13 between 10 a.m. and 2 p.m. and confirmed the above findings.