HospitalInspections.org

Based on medical record review and document review, the physician was not accountable for assuring the accuracy of the medications ordered for Patient #1.

Findings Include:

Review of the policy " Approved Abbreviations " effective 1/2010 revealed no evidence the following abbreviations are approved for use: " ac, qd or M-ff".

Review of the medication list sent form the primary physician office dated 7/19/10 at 1620 revealed the following: "Lantus 100 unit/M ff-inject as directed once daily."

Review of the medication reconciliation form dated 7/19/10, no time available, revealed the following documentation:
- "Lasix ___ 40 mg BID". The route is illegible.
- "Humulin R 100 units BID SQ is crossed out. "10 units ac meals TID___" is written above. The underlined portion is illegible. The sections "give med" and "do not give med" are both checked off.
- " Lantus___ unit ' s qd " is entered in the same space underneath the Nitrodur entry. The original dosage for Lantus is illegible. "75" is written over the original entry and has a line through it. The number " 15 " is circled and written underneath the medication entry. The medication is checked off to continue administration.
-" qd " is documented throughout the medication reconciliation list and is not an approved facility abbreviation.

The physician signed off on the medication reconciliation form/orders despite the discrepancy in Lantus dose, the use of unapproved abbreviations and illegible and unclear entries.

Based on medical record and document review, nursing staff failed to assess and evaluate the care for Patient #1.

Findings Include:

Review of the policy " Approved Abbreviations " effective 1/2010 revealed no evidence the following abbreviations are approved for use: " ac, D5O, hs or qd " .

Review of the medication reconciliation form dated 7/19/10, no time available, revealed the following documentation:
- "Lasix ___ 40 mg BID". The route is illegible.
- "Humulin R 100 units BID SQ is crossed out. "10 units ac meals TID___" is written above. The underlined portion is illegible and "ac" is an unapproved abbreviation. The sections "give med" and "do not give med" are both checked off.
- " Lantus___ unit ' s qd " is entered in the same space underneath the Nitrodur entry. The original dosage for Lantus is illegible. "75" is written over the original entry and has a line through it. The number " 15 " is circled and written underneath the medication entry. The medication is checked off to continue administration.

Review of nursing health history dated 7/19/10 at 1730 revealed the patient has type II diabetes " controlled by insulin ac and hs" and takes 16 units of Lantus at night.

Review of the Medication Administration Record (MAR) dated 7/19/10 at 2000 revealed Lantus 75 units subcutaneous was administered.

Review of licensed practical nursing (LPN) progress note dated 7/20/10 at 0630 revealed Patient #1 complained of being " warm & clammy " . A stat finger-stick done and blood sugar was 34. O2, sugar and cookies were given after lab drew Patient #1's blood. The charge nurse is aware. Review of the Diabetic record dated 7/20/10 at 0630 revealed a blood glucose level of 34. OJ with sugar and cookies given. The lab drew blood and the physician was called. At 0650 the blood glucose is 47. There is no evidence to indicate the patient was assessed by a registered nurse (RN).

Review of nursing progress notes dated 7/20/10 at 0800 revealed the patient complained of feeling very shaky. One amp of D5O IV was given. Review of the MAR dated 7/20/10 at 0800 revealed one amp of D5O IV was administered.

Review of facility documentation dated 11/8/10 (date of DOH onsite investigation) revealed on 7/19/10 Lantus 75 units was administered to the patient subcutaneously at bedtime. The Lantus dosage was not verified. The patient had a hypoglycemic episode in the morning (blood sugar 34). Hospital policy and procedures were not followed. The medication reconciliation form was incomplete and medication correction did not follow hospital policy.

Based on medical record and document review, staff failed to report a drug administration error to the hospital QAPI program.

Findings Include:

Review of medication reconciliation form dated 7/19/10, no time available, revealed " Lantus___ unit ' s qd " entered in the same space underneath the Nitrodur entry. The original dosage for Lantus is illegible. "75" is written over the original entry and has a line through it. The number " 15 " is circled and written underneath the medication entry. The medication is checked off to continue administration and signed off by the physician.

Review of nursing health history dated 7/19/10 at 1730 revealed the patient takes 16 units of Lantus at night.

Review of the Medication Administration Record (MAR) dated 7/19/10 at 2000 revealed Lantus 75 units subcutaneous was administered.

Review of nursing progress notes dated 7/20/10 at 0630 revealed the patient complained of being " warm & clammy " . A stat finger-stick done and blood sugar was 34. O2 with sugar and cookies given after lab drew blood. At 0800 Patient #1 complained of feeling shaky. One amp of DSO IV was administered.

Review of facility documentation dated 11/8/10 (date of DOH onsite visit) revealed Patient #1 received Lantus 75 units subcutaneously on 7/19/10 at bedtime and had a hypoglycemic episode in the morning (blood sugar 34).

No evidence was found to indicate nursing or medical staff reported the medication error to the hospital QAPI program prior to the DOH onsite investigation on 11/8/10 or that the use of unapproved abbreviations was addressed.