HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility did not always endure that medication and nourishment refrigerators were maintained in an acceptable temperature range.

Findings were:

According to PBAHealth.com:

"Keep everything in the center:
Store products on the central shelves of the fridge, not in bins or door compartments. Also, keep medications at least two to three inches away from the floor, coils, walls, ceiling, and vents to limit fluctuations in temperature.

Set a policy for out-of-range temperatures:
Temperatures that are too warm or too cold can harm drugs.
Create and adhere to a pharmacy policy for dealing with out-of-range temperatures. If drugs are exposed to conditions that are too hot or cold, you may need to take action, such as checking with the drug manufacturer to find out if a medication should be discarded."

Nourishment and Medication refrigerator logs were checked for the months of January through current date (March 10, 2020). The refrigerator temperature range was between 34F and 46F. Temperatures frequently fell below the desired range with no notation as to corrective measures taken.

The recurrent out of range temperatures were confirmed by the Hospital Administrator on March 10, 2020. It was also acknowledged that there was no area on the form for reporting or correcting the issue.

Based on a review of facility documentation and staff interview, the facility failed to ensure that all drugs, biologicals and intravenous medication were administered according to written physician orders for 2 of 4 patients with sliding scale insulin orders [Patients #1 and #5].

Findings were:

Facility policy entitled "Insulin Administration," approved 6/22/15, included the following:
"Purpose:
To promote safe administration of insulin to patients.
Policy:
Insulin is to be administered by a licensed person, per a physician's order ..."

Facility policy with subject "Medication Administration High Alert Medications," last reviewed 1/18/19, included the following:
"Purpose:
It is the intent of Schleicher County Medical Center to provide for safe administration of all high alert medication.
Policy:
The nurse administering any high alert medication will have a second nurse verify and document with initials that the correct dosage of medication is given ... See attachment for a list of High-Alert Medications ..."
Review of the attached listing included "Insulin, subcutaneous and IV ..."

A review of the medical record of Patient #1 revealed a physician's order for administration of insulin on a sliding scale dependent on the patient's blood sugar level. An order written by the physician on 3/4/20 included directions to administer from 0 to 12 units of insulin based on that level with orders to test the patient's blood sugar prior to meals and at bedtime.

- On 3/5/20 at 7:05 a.m., the patient's blood sugar was 239 and she was administered 5 units of regular insulin per the sliding scale. It was taken again at 11:40 a.m. when it was 290 and the patient was administered 8 units of regular insulin at 12:40 p.m. according to the sliding scale. There was not another blood sugar level documented until 8:15 p.m. that evening, yet Patient #1 was administered 5 units of regular insulin at 5:40 p.m. Thus, it was impossible to determine whether or not a correct dosage of insulin was administered.

- On 3/6/20, a blood sugar at 7:10 a.m. was 162 and the patient received an appropriate amount of insulin. At 11:50 a.m. on that date, the blood sugar was 339 and the patient received 10 units of regular insulin per the sliding scale. At 12:30 p.m., the provider changed the sliding scale order, but still with orders to measure blood sugar prior to meals and at bedtime. No additional blood sugars were documented on 3/6/20 for Patient #1, yet she was administered 2 units of regular insulin at 8:19 p.m.

- On 3/10/20, Patient #1 received 2 units of regular insulin at 12:00 p.m. according to the sliding scale. Yet her blood sugar level was documented not prior to this, but after, at 12:30 p.m. as 236. According to the change in the sliding scale ordered by the provider at 10:00 a.m. on 3/10/20, for a level of 236, the patient should have received 4 units of insulin.

Patient #5 was also order to receive Humalog insulin according to a sliding scale ordered by the provider on 4/15/2019 with blood sugar levels to be obtained prior to meals and at bedtime.

- On 4/16/19, at 12:00 noon, the patient had a blood sugar level of 205. According to the sliding scale, she should have received 4 units. At 12:00 p.m., it was noted on the medication administration that sliding scale insulin was held for Patient #5. The reason for it being held could not be found in the patient record.

- On 4/17/19, prior to breakfast Patient #5's blood sugar was 171 for which she should have received 2 units of Humalog insulin according to the sliding scale. At 11:50 a.m., her level was 226 for which she should have received 4 units according to the sliding scale. On that date, sliding scale insulin was again held the entire day with no documentation noting the reason.


At varying times, the documentation of the accu-check results and the amount of sliding scale insulin actually administered, was found in at least three different locations either on the medication administration record or the graphic flow sheet, and thus appeared chaotic.

The above findings were confirmed with the hospital administrator in an interview on the afternoon of 3/11/20.