HospitalInspections.org

Based on policy review, medical record review, and interview the facility failed to ensure medication reconciliation was completed timely for 1 patient (Patient #2) of 3 patients reviewed for medication reconciliation of 7 patients reviewed.

The findings include:

Review of the facility's policy "Medication Reconciliation - Admission and Discharge", last reviewed 3/1/2022 showed "...Medication reconciliation will be performed to clarify any discrepancies between the patient's actual medication regimen and the most recent record of prescribed medications. Medications to be reconciled are all prescriptions...over-the-counter and...herbal medication the patient is taking. This will allow the physician to review the patient's drug regimen and order the appropriate medications and dosages upon admission, across the continuum of care and upon the patient's discharge. Medication reconciliation will be an interdisciplinary process between patient, physician, pharmacy and nursing designed to decrease adverse drug events or potential adverse drug events and provide positive therapeutic outcomes for the patient. Upon admission, and upon discharge, all medications must be reconciled. Reconciliation must be performed within 24 hours of each action. Medications of an urgent nature will be reconciled within 3 hours. When a patient is admitted and discharged, the Medication Reconciliation Admission and Discharge Physician Orders will be filled out by the Nurse or Physician...The nurse will then list the patient's home medications, making sure to list all prescription drugs, over-the-counter medications and herbal medications...The physician and/or designee will then review each medication. The physician may order the medication to be continued during the patient's hospitalization by designating resume or if discontinuation of the medication is desired, discontinue would be noted...The nurse and/or pharmacist will review each medication to confirm that it has been reconciled. The admitting or attending physician will be contacted for any clarifications needed or omissions...Clarifications and medications ordered after the physician has signed the form must be written or changed via CPOE [computerized physician order entry]..."

Medical record review of Emergency Department (ED) Physician Documentation showed Patient #2 presented to the ED by ambulance with complaint abdominal pain and altered mental status on 3/10/2022. Patient #2 reported a history of diabetes and was on Insulin at home. The patient's blood glucose was 246 on 3/10/2021 at 12:26 PM. Patient #2 was admitted to the facility from the ED with diagnoses including Altered Mental Status, Hyperammonemia, and Urinary Tract Infection.

Medical record review of an Admission History and Physical dated 3/10/2021 at 5:25 PM showed Patient #2 had a history of Diabetes Mellitus Insulin Requiring Type, Depression. Continued review showed "...Will clarify her home medications with the family and will resume all her home medications as before..."

Medical record review showed Patient #2's home medications included Basaglar KwikPen (long acting insulin) 100 units (u)/ (per) milliliter (ml) subcutaneous (SQ-injected under skin) daily, Novolin N U-100 (short acting insulin) SQ, Trulicity Pen (not insulin but used to control high blood glucose in patient with Type 2 Diabetes) 1.5 milligrams (mg)/0.5 ml SQ, and Quetiapine (antipsychotic) 50 mg oral (by mouth) extended release.

Medical record review of a physician order for Patient #2 dated 3/10/2021 at 5:32 PM showed an order for Quetiapine. The order did not include the dose, frequency, or route for administration. The order status was changed to "...voided..." on 3/12/2021 at 1:45 PM.

Medical record review of a physician order for Patient #2 dated 3/12/2021 (2 days after initial order) at 9:00 PM showed "...Quetiapine 50 mg...extended release...1 tab [tablet], oral, QPM [every night]..."

Medical record review of Patient #2's serum blood glucose levels (blood test) and point of care (POC) blood glucose levels showed the reference range for glucose was 70-100 mg/dL (deciliter). Patient #2's blood glucose results were as follows:
*3/10/2021 at 12:12 PM - POC glucose 275 mg/dL
*3/10/2021 at 1:13 PM - Serum blood glucose 246 mg/dL
*3/11/2021 at 7:38 AM - POC glucose 180 mg/dL
*3/11/2021 at 11:10 AM - POC glucose 185 mg/dL
*3/11/2021 at 3:30 AM - Serum blood glucose 226 mg/dL
*3/12/2021 at 7:05 AM - Serum blood glucose 292 mg/dL
*3/12/2021 at 7:28 PM - POC glucose 315 mg/dL
*3/13/2021 at 7:18 AM - Serum Blood glucose 286 mg/dL
*3/13/2021 at 10:21 AM - POC glucose 327 mg/dL

Medical record review of a nursing note dated 3/13/2021 at 9:40 AM showed Patient #2's daughter stated the patient "...had not had insulin and she needs it. I [nursing supervisor] spoke with primary nurse and there is no insulin ordered..."

Medical record review of Patient #2's physician orders showed no order for insulin from 3/10/2021-3/12/2021. Continued review showed a physician order dated 3/13/2021 at 10:08 AM for "...Insulin lispro [fast acting insulin] (HumaLOG sliding scale)...Subcutaneous, QID [4 times per day] (WM [with meals] and Bedtime)..." Sliding scale administer for blood glucose:
< (less than) 150 mg/dL= 0 units
151-200 mg/dL= 2 units
201-250 mg/dL= 4 units
251-300 mg/dL= 6 units
301-350 mg/dL= 8 units
351-400 mg/dL=10 units
>(greater than) 400 mg/dL= 12 units and call provider


Medical record review of Patient #2's Medication Administration Record (MAR) showed the patient did not receive Quetiapine until 3/12/2021. Further review showed the patient did not receive Insulin until 3/13/2021. Continued review showed orders to "...Please check and clarify patients home meds..." from 3/11/2021-3/13/2021.

During a telephone interview on 3/21/2021 at 8:00 PM, Patient #2's daughter stated she provided the patient's medication list to the ED staff as well as the admission nurse on the medical surgical unit. The patient's daughter stated Patient #2 had been insulin dependent for approximately 10 years. Patient #2's blood sugar had been elevated for 3 days before she received insulin.

During an interview on 3/22/2022 at 11:55 AM, in the conference room, the Chief Quality Officer (CQO) confirmed Patient #2's blood glucose levels were out of range and confirmed Insulin was not ordered for the patient until 3/13/2022. The CQO confirmed Quetiapine was ordered on 3/10/2021 and confirmed Patient #12 did not receive the medication until 3/12/2021. The CQO stated he did not know why the order was not completed until 3/12/2021.

During an interview on 3/22/2022 at 12:00 PM, in the conference room, the Pharmacy Director stated all admission medication orders were reviewed by a pharmacist. The medication orders were checked for accuracy, completeness of the orders, and ensured there were no contraindications for the medications. The Pharmacy Director stated orders that were incomplete (missing dose, route, frequency) could not be "...pushed through..." until the order is clarified with the physician. The Pharmacy Director stated he did not know why it took so long for the Quetiapine to be clarified.

During a telephone interview on 3/25/2022 at 1:30 PM, the Acute Care Director confirmed the nurses were expected to verify and clarify pending medication orders. Continued interview revealed "...Based on her [Patient #2] history of Diabetes and taking insulin at home the nurse was expected to report the out of range glucose levels to a physician and inquire about treatment. The Acute Care Director stated "...She [Patient #2] did go a few days without medicine...unacceptable to go days without a current order..."