HospitalInspections.org

Based on documentation in 1 of 1 medical records reviewed of a patient with an indwelling insulin pump (#5), review of hospital policies and procedures, and interview it was determined that the nursing staff failed to develop, maintain, and follow a care plan which was based on initial and ongoing patient assessment, hospital Standards of Care and policy and procedure, and physician's orders related to the patient's blood glucose (CBG) monitoring and insulin administration needs. Findings are as follows:

Documentation in the medical record of Patient #5 reflected that he/she was admitted from the emergency room to the trauma service unit on 8/13/09 at 1700 with right and left proximal humerus fractures sustained as a result of a fall. The patient's diagnoses also included insulin dependent diabetes mellitus (IDDM) for which he/she was identified as having an insulin pump.

According to physician history and physical, orthopedic consultation, and discharge summary documents the right side fracture was determined to require surgery while non-surgical intervention was provided for the left side fracture. On the days prior to surgery, the right extremity was placed in a shoulder immobilizer and a sling provided for the left extremity. The patient underwent surgical repair of the right side fracture on 8/17/09. After surgery the patient was transferred to the intensive care unit as a result of post-operative respiratory complications. On 8/18/09 the patient was transferred back to trauma service from where he/she was discharged to home on 8/23/09.

Documentation in the record reflected that the patient's injuries and the subsequent non-surgical and surgical interventions limited his/her ability to use his/her upper extremities and affected his/her mental condition. For example: On 8/13/09 at 2000 Patient Assessment Summary documentation reflected that the patient had minimal range of motion of fingers and upper extremities were without range of motion due to bilateral humerus fractures; on 8/14/09 at 0800 Patient Assessment Summary documentation reflected that the patient was unable to feed self and required one to one assistance; on 8/14/09 on the Conditions of Patient Registration Patient Consent and Acknowledgement form someone recorded "unable to sign d/t medical condition"; on 8/16/09 at 1945 Patient Assessment Summary documentation reflected that the patient experienced "mild confusion at times especially [related to] time"; on 8/17/09 on the Patient Informed Consent form for ORIF Right Proximal Humerus surgery someone recorded "unable to sign"; and on an undated Patient Informed Consent form for Central Venous Catheter Placement someone recorded "unable to sign d/t fractures".

The hospital policy titled Adult and Pediatric Patients on continuous Subcutaneous Insulin Infusion (Insulin Pump) Management described the use of an insulin pump: "The pump is intended to be used continuously and delivers insulin 24 hours a day according to a programmed plan unique to each pump wearer and prescribed by his or her physician. A small amount of insulin is given continually...This insulin keeps blood glucose in the desired range between meals and overnight. When food is eaten, the patient programs the pump to deliver a 'bolus dose' of insulin matched to the amount of food that will be consumed (called an insulin-to-carbohydrate ratio). Carbohydrate ratios can vary for different meals. A bolus can also be delivered when blood glucose levels are elevated (called a correction factor)." The policy included the following requirements: "If the patient is unable to deliver a 'bolus', the nurse will call the doctor to obtain orders for alternate insulin delivery...The physician, nurse, or diabetes educator will assess the patient's ability to maintain operation of the insulin pump, deliver bolus doses of insulin, and accurately self-test blood glucose during the acute hospital stay...If the patient is able to be responsible for the insulin pump therapy, a written physician's order must specify that the patient may 'self administer' insulin via pump. A specific order shall be written to include specific insulin administered and route. Order should also specify blood sugar goal is between 'x' and 'y'...A written physician's order must specify that the patient may monitor their blood glucose and use their own glucometer...It is the nurse's responsibility to document the following on the Metabolic Record...blood glucose meter used by the patient; insulin pump used by the patient, and insulin type, dose, route, and frequency; Patient's stated Insulin-to-Carbohydrate ratio or Ratios and Correction Factor."

On 8/13/09 at 1611, the day of admission, documentation on the Nursing Admission Assessment under Endocrine/Hematologic History erroneously reflected that Patient #5 had "NIDDM" (non-insulin dependent diabetes mellitus). That was the only reference to blood glucose or diabetes on that assessment.

The Adult Trauma Admit Orders dated 8/13/09 included an order for "Pt. to manage insulin pump and all insulin requirements". Those orders did not include the specific insulin administered, the CBG goal between 'x' and 'y', and that the patient could use his/her own CBG meter in accordance with policy.

On the day of admission, or thereafter, there was no baseline documented which identified the patient's CBG and insulin needs and goals, his/her history of CBG levels and bolus administrations, his/her usual insulin pump routine and management, and whether or not he/she had all the necessary CBG and pump equipment and supplies with him/her. There was no evidence of an assessment of the patient's physical and mental abilities to independently and accurately perform CBGs, operate and maintain the insulin pump, and deliver bolus doses of insulin if necessary, tasks which would require the functional use of ones hands and fingers and clear mental cognition. There was no documentation which reflected that self-management in relation to the patient's impairments under the circumstances had been discussed with him/her and that he/she had been fully informed of the possible risks of such.

On 8/17/09 at 0530 Multidisciplinary Progress Notes documentation reflected that "Pt. upset and tearful when [his/her] Insulin pump started alarming. Pt. feels frustrated because [he/she] has limited use of [his/her] hands and also feels 'out of sorts' [related to] narcotics. [He/she] is upset that we can not manage [his/her] Insulin pump for [him/her]. It has been explained to [him/her] several times during [his/her] hospital stay that we can not and that if [he/she] can't the pump needs to be turned off and MDs will write Insulin orders for [him/her] while [he/she] is here..." This was the first documentation of any communication with the patient related to this matter.

On 8/17/09 at approximately 0900 the patient was transferred to the surgical unit for repair of his/her right humerus. At 1635 later that same day he/she was transferred from the post-anesthesia recovery unit to the intensive care unit.

On 8/17/09 at 1800 the physician ordered CBG monitoring and sliding scale insulin using the hospital's Adult Subcutaneous Insulin Order Pre-Printed Orders form. The orders recorded on the form were for CBGs AC (before meals) and HS (hour of sleep) if patient eating meals; CBGs at least every 6 hours if the patient is NPO (nothing by mouth); and "Regular Human Insulin Units give a.c". More detailed orders recorded on the form specified an amount of insulin to be given "AC meals" based on seven identified CBG ranges. For example: If CBG was 261 to 300, 8 units of insulin was to be administered. If CBG was greater than 300, 10 units of insulin was to be given.

On 8/17/09 at 2200 the Metabolic Record (MR) reflected that the patient's CBG was 296 and staff administered 10 units of Regular Insulin. However, there were no orders for insulin administration at bedtime. The sliding scale orders were for before meals only.

Those sliding scale orders were in effect until 8/18/09 at 1725 when the physician wrote an order to discontinue the sliding scale insulin and let the patient manage his/her CBGs and insulin pump. There was no corresponding documentation to reflect that the patient's abilities to self-manage had been assessed.

On 8/18/09 at 1800 the patient arrived back on the trauma unit from the intensive care unit.

On 8/19/09 at 1830, although there was no corresponding assessment documented, the physician again ordered CBG monitoring and sliding scale insulin using the hospital's Adult Subcutaneous Insulin Order Pre-Printed Orders form. Those were the last orders related to insulin administration in the patient's record. The orders recorded on the form were for CBGs AC and HS if patient eating meals; and "Regular Human Insulin Units give a.c". More detailed orders recorded on the form specified an amount of insulin to be given "AC meals" based on seven identified CBG ranges. For example: If CBG was 181 to 220, 6 units of insulin was to be administered. The orders also specified a different amount of insulin to be given at "Bedtime" based on the seven identified CBG ranges. For example: If CBG was 181 to 220 at bedtime, 4 units of insulin was to be given.

On 8/19/09 at 2030 the MR reflected that the patient's CBG was 201 and staff administered 6 unit of Regular Insulin. However, the bedtime orders for a CBG of 201 required the administration of 4 units

On 8/19/09 at 2100 Patient Assessment Summary documentation reflected that "pt emotional, crying after talking with [spouse] who is refusing to support pt's needs around insulin pump...pt without use of hands at this time". There was no information related to what the specific needs around the insulin pump the spouse was not supporting.

On 8/20/09 at 1640 and 2235; 8/21/09 at 0635, 1215, 1655, and 2200; and on 8/22/09 at 0700 and 1200, there was no evidence on the MR or the Medication Administration Record (MAR) to reflect that insulin was administered by staff as specified on the sliding scale orders. CBGs at those times ranged from 101 to 237 which would have required administration of between 2 units and 8 units of insulin per the sliding scale orders, however, there was no documentation of insulin administration. On 8/22/09 the MR and the MAR revealed no evidence that the patient's CBG was obtained before dinner and insulin administered if necessary in accordance with the CBG result.

Handwritten notations made on the MAR on 8/20, 8/22, and 8/23/09 reflected "we are checking CBGs only - pt has own insulin pump". However, there was no documentation to reflect why this change occurred in lieu of the physician's orders nor to reflect that the physician had been notified or was aware that those sliding scale orders were not being followed.

Documentation on the MR for the dates of hospitalization did not clearly or consistently reflect which CBG meter was being used and by whom. On nine occasions the space for identification of the meter was blank. On two other occasions a meter # is written in and then circled without explanation. On other occasions during the times that the patient was under orders to self-manage various hospital meter #'s are recorded and it is unclear whether the patient or staff obtained the CBGs.

Further, documentation on the MR for the dates of hospitalization did not include the patient's carbohydrate information as required by policy. Those spaces on the form were blank for the duration of the hospitalization and that documentation was not found elsewhere in the record.

The hospital policy titled Standards of Care - Adult Patient's with Type 1 or Type 2 Diabetes identified that the "Care provided will assist the patient and family in meeting the following expectations: Maintenance of blood glucose in the range of [greater than] 70 or [less than or equal to] 140 mg/dL or as ordered by physician."

Documentation on the MR revealed that the patient's CBGs were greater than 140 on 32 of the 41 times they were recorded. On 14 of those 32 times the CBGs were in excess of 200, and on 3 of those 32 times they were in excess of 300.

These findings were shared with the Director of Patient Care Services on 2/24/10.