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Based on record review and interview, the facility failed to ensure physicians were ordering Carbohydrate controlled diets for Diabetic patients, resulting in patients experiencing elevated blood sugars and requiring the administration of insulin. (Patients #1 and #3)

Findings:

Review of the facility provided policy Patient Care Orders (last reviewed 12/2019) reflected, "It is the policy of the Ascension Seton that patient care orders will be complete, clear, accurate, and legible such that there is no ambiguity regarding the order.

The essential elements outlined in the procedures section of this document will be utilized to enhance a safe continuum of patient care. Across the hospitalization from admission to discharge ...

Definitions:

Ambiguous Orders - orders that are open to having several possible meanings or interpretations; that are difficult to comprehend, or those that lack clarity.
...Authorized prescribing Practitioner and Clinical Staff will manage patient care orders effectively to provide safe care."


Review of Patient #2's Medical Records dated 4/7/21 reflected:

Patient #2's History and Physical - A 71-year-old male was admitted following anterior cervical fusion. Patient #2 had a medical history of Hypertension, and Insulin-dependent Diabetes.

Review of Staff #6, MD, Physician's Orders, for patient #2, reflected, "Diet Type Soft." The diet order did not include a carbohydrate-controlled diet to manage the patient's blood glucose levels.
Medications: insulin aspart (Novolog Medium dose sliding scale) 0-12 units subcutaneous qid AC bedtime, Form: Injection


Patient #2's medication orders stated in part, "insulin aspart (Novolog Medium dose sliding scale) 0-12 units subcutaneous qid AC bedtime (four times a day and at bedtime), Form: Injection. Correctional Scale based on POC (Clinical Point of Care) Blood Glucose level (amount of sugar in the blood):

71-149= no insulin aspart;
150-199=2 units;
200-249= 4 units;
250-299= 6 units;
300-349= 8 units;
350-399= 10 units"


Review of Patient #2's POC glucometer readings and Medication administration records reflected:

4/7/21 at 11:42 am - Glucose 266, covered with 6 units of (fast acting) Novolog

4/7/21 at 5:07 pm- Glucose 280, no (fast acting) Novolog was given

4/7/21 at 6:00 pm- given scheduled, 20 Units of (long acting) glargine insulin (administered once a day)

4/7/21 at 8:45 pm- Glucose 362, no (fast acting) Novolog was given

4/8/21 at 8:07 am Glucose 241, no (fast acting) Novolog was given


Review of Patient #1's medical record, dated 4/12/21 reflected:

Patient #1's History and Physical - A 70-year-old-male admitted for Right sided weakness. Patient #1 had a medical history of Hypertension, Diabetes Mellitus type 2, and Hyperlipidemia.


Review of Staff #7, MD Physician's Orders for patient #1, dated 4/12/21 at 3:24 pm reflected, "Mechanical Soft, Modified Liquid: thin Liquids, Chopped/moist. 1:1 feed assist. Meds 1x1 or whole in pudding. Aspiration precautions: fully upright, small single sips/bites, slow pace, no straws." The diet order did not include a carbohydrate-controlled diet to manage the patient's blood glucose levels.

Review Patient #1's POC glucometer readings and Medication administration records reflected the following:

4/12/21 at 8:26 pm, Glucose 208, covered with 2 units of Novolog

4/13/21 at 7:43 am, Glucose 188, covered with 1unit of Novolog

4/13/21 at 11:31 am, Glucose 252, covered with 3 units of Novolog

4/13/21 at 5:30 pm, Glucose 185, covered with 1 unit of Novolog

4/13/21 at 9:05 pm, Glucose 212, covered with 2 units of Novolog


On 4/16/2, in an Administrative office, Staff #5, Medical Officer when asked if a Diabetic patient should receive a Carbohydrate-Controlled diet stated, " ...It's determined by conversations with the patient ...Sugar control is upmost to impact healing, absolutely important ...We work with the Diabetic educator."

Based on observation, interview, and record review, the facility failed to protect and promote each patient's rights when:

-The facility's physicians did not order carbohydrate-controlled diets resulting in diabetics receiving sugared items for 2 of 5 diabetic patients reviewed (Patients #1 and #2). Cross refer A0049.

- Diabetic patients where not provided carbohydrate-controlled diets, placing the patients at risk for hyperglycemic events, decreased wound healing, and possible organ damage for 3 of 5 diabetic patients reviewed (Patients #1, 2, and 3). Cross refer A0144.

-The facility's quality program identified a carbohydrate controlled diet was not ordered for a diabetic patient in October of 2020, which resulted in uncontrolled blood glucose. During the survey in April 2021, carbohydrate controlled diets were still not ordered for diabetic patients. (Patients #1 and 2). Cross refer A0273.

- The facility's Nursing staff did not clarify dietary orders and did not intervene when diabetic patients were sent sugared items, resulting in elevated blood sugars for 2 of 5 diabetic patients reviewed (Patients #1 and #2). Cross refer A0386.

Based on review of medical records, observation, and staff interview, the facility failed to ensure each patient had the right to receive care in a safe setting when 3 of 5 diabetic patients reviewed were not provided carbohydrate-controlled diets. (Patients # 1, 2, and 3)


Findings:

Review of the facility provided policy Patient Care Orders (last reviewed 12/2019) reflected, "It is the policy of the Ascension Seton that patient care orders will be complete, clear, accurate, and legible such that there is no ambiguity regarding the order."


Review of Patient #1's medical record, dated 4/12/21 reflected:

Patient #1's History and Physical - A 70-year-old-male admitted for Right sided weakness. Patient #1 had a medical history of Hypertension, Diabetes Mellitus type 2, and Hyperlipidemia.
There was no order for a carbohydrate-controlled diet to manage the patient's blood glucose levels.

An observation on the morning of 4/13/21, on the facility's 6N inpatient unit, revealed Patient #1's meal tray being delivered to the unit. The meal ticket was on the tray and listed the patient's name and diet ordered as NDD2: Mechanical Altered, thin liquids. The meal tray contained 3 sugar packets and a half cup of sugared chocolate pudding.

On 4/15/21, by email exchange, when asked if Patient #1 was still receiving sugar and experiencing elevated blood sugars, Staff #1, Quality Director wrote, "Yes, he continued to receive the mechanical soft diet, until discharged to home."


Review of the Physician's Progress Impression Plan note for patient #1, dated 4/13/21 at 7:56 pm reflected, "DM type, uncontrolled, hgbA1c is 10.8 [measurement of diabetic risk, greater than 6.5% is indicative of diabetes], DM (Diabetes Management education)." The physician did not address changing the patient's diet to carbohydrate controlled.


On 4/16/21, in an Administrative office, Staff #5, Medical Officer stated, "The doctors rely on the Dietitian's expertise."

Patient #1's Dietary Consult note dated 4/14/21 at 2:57 pm, reflected, "Patient has little knowledge of diabetes pathology and self- management [sic] skills."

The Diabetes educator did not address or recommend changing patient #1's diet to a carbohydrate-controlled diet.


On 4/16/21, at 3:00 pm, in an Administrative office, when asked why Patient #1's diet was not changed to a Carbohydrate Controlled diet, Staff #6, Diabetes Educator stated, "I thought the patient's swallowing was a greater issue." When asked if she was aware of the foods that would be delivered to a person on a Mechanical soft diet, Staff #6 stated, "I don't know what is on the tray ...I'm not a Dietitian ...I review basic diets with the patients, monitoring, insulin teaching, and survival skills."

Review Patient #1's POC (Clinical Point of Care) glucometer readings and Medication administration records reflected from 4/12/21 to 4/13/21, Patient #1 required insulin coverage, for elevated blood sugars, 5 times.


Review of Patient #2's Medical Records dated 4/7/21 reflected:

Patient #2's History and Physical- A 71-year-old male was admitted following anterior cervical fusion. Patient #2 had a medical history of Hypertension, and Insulin-dependent Diabetes.

Patient #2's Physician #6's Orders dated 4/17/21 at 9:15 am reflected, "Diet Type Soft." The diet order did not include a carbohydrate-controlled diet to manage the patient's blood glucose levels.


On 4/13/21, during an interview in the administrative office, when asked if Patient #2's soft diet would include sugar, Staff #13, Clinical Dietitian stated, "There are no restrictions."


Review of Patient #2's POC (Clinical Point of Care) glucometer readings and Medication administration records reflected from 4/07/21 to 4/08/21, Patient #2 required insulin coverage for elevated blood sugars 4 times. Three of the interventions were not administered as ordered.


Review of Patient #3's facility provided Quality Department General Investigation Form, dated 10/22/2020, reflected, " ...Staff #6,MD entered a Regular diet order after surgery even though the patient was a documented diabetic and taking multiple types of insulin. The diet order was changed by the Hospitalist on 9/18 to carb controlled. Pts Glucose levels averaged between 200 - 300 with one reading in the 400s..."


Staff #1 confirmed the facility was not monitoring whether or not diabetics were receiving Carbohydrate-Controlled diets. Staff #1 stated, "We are already tracking if patients are hypoglycemic, I'm all over it. I've already started sending out emails."

Based on observation, interview, and record review, the facility's Patient Safety & Improvement Program failed to consider or monitor for the prevalence of incorrect diet orders for diabetic patients, resulting in elevated blood sugars and requiring insulin coverage for 2 out of 5 diabetic patients reviewed for carbohydrate-controlled diets (Patients # 1 and 2).

Findings:

Review of the facility provided Patient Safety & Performance Improvement Program & Plan (last revised 4/2016), reflected, ...Responsibilities and Expectations

- focus on high-risk, low-volume, or problem-prone areas

- Consideration of the incidence, prevalence, and severity of problems

- Affect health outcomes, patient safety, and quality of care



Review of Patient #3's facility provided, Quality Departments,General Investigation Form, dated 10/22/2020, reflected, " ...Dr.#6, entered a Reqular diet order after surgery even though the patient was a documented diabetic and taking multiple types of insulin. The diet order was changed by the Hospitalist on 9/18 to carb controlled. Pts Glucose levels averaged between 200 - 300 with one reading in the 400s ...

Risk Mitigation Poll and recommendation:

What is the probability of this type of feedback recurring? Remotely

Completed by: Staff #3, Charge nurse"


On 4/16/21, during an interview in the administrative office, when asked why the probability was marked as "remotely," Staff #1, Quality Director stated, "She probably thought the doctor doesn't admit very many patients." Staff #1 confirmed the facility was not monitoring whether or not diabetics are receiving Carbohydrate-Controlled diets. Staff #1 stated, "We are already tracking if patients are hypoglycemic, I'm all over it. I've already started sending out emails."


Review of Patient #1's medical record, dated 4/12/21 reflected: Patient #1's History and Physical - A 70-year-old-male admitted for Right sided weakness. Patient #1 had a medical history of Hypertension, Diabetes Mellitus type 2, and Hyperlipidemia.

Review of Patient #1's Physician's Orders dated 4/12/21 at 3:24 pm reflected, "Mechanical Soft, Modified Liquid: thin Liquids, Chopped/moist. 1:1 feed assist." The diet order did not include a carbohydrate-controlled diet to manage the patient's blood glucose levels.

Patient #1's POC glucometer readings and Medication administration records from 4/12/21 to 4/13/21 reflected Patient #1 required insulin coverage for elevated blood sugars 5 times.


Review of Patient #2's Medical Records dated 4/7/21 reflected Staff #6, MD was the admitting physician: Patient #2's History and Physical- A 71-year-old male was admitted following anterior cervical fusion. Patient #2 had a medical history of Hypertension, and Insulin-dependent Diabetes.


Review of Staff #6's admission orders for Patient #2 reflected in part, "Diet Type Soft." (The diet order did not include a carbohydrate-controlled diet to manage the patient's blood glucose levels.)
Medications: insulin aspart (Novolog Medium dose sliding scale) 0-12 units subcutaneous qid AC bedtime, Form: Injection

Review Patient #2's POC (Clinical Point of Care) glucometer readings and Medication administration records reflected from 4/07/21 to 4/08/21, Patient #2 required insulin coverage for elevated blood sugars 4 times. Three of the interventions had not been administered.


The facility's quality program identified a carbohydrate controlled diet was not ordered for a diabetic patient in October of 2020, which resulted in uncontrolled blood glucose. During the survey in April 2021, carbohydrate controlled diets were still not ordered for diabetic patients.

Based on observation, interview, and record review, the facility's Nursing staff failed to clarify the diet orders for 3 of 5 diabetic patients reviewed (patients #1, 2, and 3), and failed to administer, physician ordered, Correctional Scale based insulin on elevated Blood Glucose levels for Patient #2, placing the patients at risk for hyperglycemic events, decreased wound healing, and possible organ damage.

Findings:

Review of the facility provided policy Patient Care Orders (last reviewed 12/2019) reflected, "It is the policy of the Ascension Seton that patient care orders will be complete, clear, accurate, and legible such that there is no ambiguity regarding the order.

The essential elements outlined in the procedures section of this document will be utilized to enhance a safe continuum of patient care. Across the hospitalization from admission to discharge ...

Definitions:

Ambiguous Orders - orders that are open to having several possible meanings or interpretations; that are difficult to comprehend, or those that lack clarity.

...Authorized prescribing Practitioner and Clinical Staff will manage patient care orders effectively to provide safe care.

Personnel permitted to receive written or electronic orders from an Authorized Prescribing Practitioner will use the following guidelines:

1. ALL Patient Care Orders

A. All orders will be legible, complete, clear, and accurate, such that there is no ambiguity.

Orders will be assessed for ambiguity by all disciplines receiving them and be clarified prior to acting upon the order ..."


Review of Patient #2's Medical Records dated 4/7/21 reflected: Patient #2's History and Physical- A 71-year-old male was admitted following anterior cervical fusion. Patient #2 had a medical history of Hypertension, and Insulin-dependent Diabetes.

Patient #2's Staff, #6, MD's Orders dated 4/17/21 at 9:15 am reflected, " Diet Type Soft." The diet order did not include a carbohydrate-controlled diet to manage the patient's blood glucose levels.

Patient #2's Medications stated in part, "insulin aspart (Novolog Medium dose sliding scale) 0-12 units subcutaneous qid AC bedtime, Form: Injection

Correctional Scale based on POC Blood Glucose level:
71-149= no insulin aspart;
150-199=2 units;
200-249= 4 units;
250-299= 6 units;
300-349= 8 units;
350-399= 10 units"


Patient #2's POC glucometer readings and Medication administration records reflected:

4/7/21 at 11:42 am - Glucose 266, covered with 6 units of (fast acting) Novolog

4/7/21 at 5:07 pm- Glucose 280, no (fast acting) Novolog was given

4/7/21 at 6:00 pm- given scheduled, 20 Units of (long acting) glargine insulin (administered once a day)

4/7/21 at 8:45 pm- Glucose 362, no (fast acting) Novolog was given

4/8/21 at 8:07 am Glucose 241, no (fast acting) Novolog was given


On 4/13/21, during an interview, in the administrative office, when asked about the missing insulin doses, Staff #3, Charge Nurse, confirmed the finding and stated, "It doesn't look like anything was given at that time ...he was given the 20 units at 6:00."


Review of the facility provided policy Medication Administration, (approved 03/2020) reflected, "Purpose: To ensure the safe handling and accurate administration of medications ...Medications will be documented on an electronic medication administration record. "


Review of the facility provided policy Compass System for Documentation, (last revised 09/2019) reflected, "RNs (including Nursing Faculty) are responsible for:

1. Documenting aspects of patient care provided as related to position, scope of practice, Seton policy and privileges within the EHR

2. Reviewing the plan of care ...
4. Completing tasks appropriate to patient assignment

5. Reviewing and signing all orders entered into Compass ..."


On 4/13/21, during an interview, in the administrative office, when asked if Patient #2's soft diet would include sugar, Staff #13, Clinical Dietitian, stated, "There are no restrictions."


Review of Patient #1's medical record, dated 4/12/21 reflected: Patient #1's History and Physical - A 70-year-old-male admitted for Right sided weakness. Patient #1 had a medical history of Hypertension, Diabetes Mellitus type 2, and Hyperlipidemia.


Review of Staff #7, MD's orders for Patient #1, dated 4/12/21 at 3:24 pm, reflected, "Mechanical Soft, Modified Liquid: thin Liquids, Chopped/moist. 1:1 feed assist. Meds 1x1 or whole in pudding. Aspiration precautions: fully upright, small single sips/bites, slow pace, no straws." The diet order did not include a carbohydrate-controlled diet to manage the patient's blood glucose levels.

Patient #1's Medications stated in part, "Insulin aspart subcutaneous qid AC bedtime, Form: injection.
Sliding Scale
71-149= 0 units
150-199= 1 unit
200-249= 2 units
250-249= 3 units
300-349= 4 units
350-399= 5 units"


Review Patient #1's POC glucometer readings and Medication administration records reflected the following:

4/12/21 at 8:26 pm, Glucose 208, covered with 2 units of Novolog

4/13/21 at 7:43 am, Glucose 188, covered with 1 unit of Novolog

4/13/21 at 11:31 am, Glucose 252, covered with 3 units of Novolog

4/13/21 at 5:30 pm, Glucose 185, covered with 1 unit of Novolog

4/13/21 at 9:05 pm, Glucose 212, covered with 2 units of Novolog


An observation on the morning of 4/13/21, on the facility's 6N in-patient unit, revealed Patient #1's meal tray being delivered to the unit. The meal ticket was on the tray and listed the patient's name and diet ordered as NDD2: Mechanical Altered, thin liquids. The meal tray contained 3 sugar packets and a half cup of sugared chocolate pudding. Staff #9, Med Surgical Supervisor was shown the meal tray. The tray was placed back on the food cart for delivery. Staff #1, Quality Director was notified.

A follow-up, on 4/15/21, by email exchange, when asked if Patient #1 was still receiving the mechanical soft diet, which included sugar? Staff #1, Quality Director wrote, "Yes, he continued to receive the mechanical soft diet, until discharged to home."

Review of the Patient #1's Physician's Progress Impression Plan note, dated 4/13/21 at 7:56 pm reflected, "DM type, uncontrolled, hgbA1c is 10.8, DM (Diabetes Management education)".
The Physician did not address changing the patient's diet to carbohydrate controlled.

On 4/16/21, in an Administrative office, Staff #5, Medical Officer stated, "The doctors rely on the Dietitian's expertise."

On 4/13/21, during an interview, in the administrative office, when asked if the Dietitians see all diabetic patients, Staff #4, Clinical Dietitian, stated, "If the physician orders a consult or we get referrals from nursing."

Review of the Dietary Consult note dated 4/14/21 at 2:57 pm, reflected, "Patient has little knowledge of diabetes pathology and self- management [sic] skills." (The Diabetes educator did not address or recommend changing the patient's diet to a carbohydrate-controlled diet.)

On 4/16/21, at 3:00 pm, in an Administrative office, when asked why Patient #1's diet was not changed to a Carbohydrate Controlled diet, Staff #6, Diabetes Educator stated," I thought the patients swallowing was a greater issue." When asked if she was aware of the foods that would be delivered to a person on a Mechanical soft diet, Staff #6 stated, "I don't know what is on the tray ...I'm not a Dietitian ...I review basic diets with the patients, monitoring, insulin teaching, and survival skills."


Review of Patient #3's medical record reflected a 78-year-ole female admitted to outpatient for lower back pain. Patient #3 has a history of diabetes and thyroid disease.

Review of the facility provided Quality department's investigative response to Patient #3's complaint about not being placed on a Diabetic diet, dated November 11, 2020, reflected, " ...Regarding concerns with diet orders; review of our records indicate that initially a Regular diet was ordered after surgery. The diet order was changed by the Hospitalist on 9/18/20 to Carb Controlled. Your glucose levels averaged between 200 - 300 with one reading in the 400s. We will use this example to educate staff to ensure they are placing diet orders more effectively going forward ..."

Review of Patient #3's medical records reflected on 9/16/20 at 8:40 pm, "Medications: Insulin aspart subcutaneous qid AC bedtime, Form: injection.
Sliding Scale
71-149= 0 units
150-199= 1 unit
200-249= 2 units
250-249= 3 units
300-349= 4 units
350-399= 5 units"

Review Patient #3's POC (Clinical Point of Care) glucometer readings and Medication administration records reflected the following:

9/12/20 at 8:26 pm, Glucose 208, covered with 2 units of Novolog

9/13/20 at 7:43 am, Glucose 188, covered with 1unit of Novolog

9/13/20 at 11:31 am, Glucose 252, covered with 3 units of Novolog

4/13/21 at 5:30 pm, Glucose 185, covered with 1 unit of Novolog

4/13/21 at 9:05 pm, Glucose 212, covered with 2 units of Novolog

This failure placed diabetic patients at risk for hyperglycemic events, decreased wound healing, and possible organ damage.

Based on interview and record review, the facility failed to provide wound care discharge instructions for a 79-year-old patient, documented as needing educational reinforcement for the care of their surgical wound. (Patient #3)

Findings include:

On 12/16/20, Patient #3 placed a complaint with Texas Health and Human Services, alleging the patient was sent home without instructions for the care of her surgical incision.

During an interview on the afternoon of 4/13/21, in the administrative conference room, when asked to locate the patient's wound care teaching and discharge instructions Staff #4, Risk Manager stated, "...specific to dressing changes, I'm not seeing that...She had a follow-up appointment with the surgeon."

Review of Patient #3's Patient and Family Education, dated 9/18/20 at 3:28 pm, reflected "Wound/PUP/Skin Care Education ...Needs reinforcement"

Review of Patient #3's Physician's orders dated, 9/18/20 at 10:22 am reflected, wound care orders for a lumbar incision, "dressing change with paper tape and dry dressing q 12 hours and PRN, begin after drain removal."

On 4/16/21, in the administrative office, Staff #3, Charge Nurse stated, "Reinforcement, something we write for pretty much everyone, they are all taking narcotics so they all need reinforcement ...If the Doctor doesn't order it , the order doesn't drive it. We can't enter these orders ...the nurse wouldn't have known they needed wound care instructions."

Review of Patient #3's Surgical Documentation dated 9/16/20 reflected, " ...performed a posterior bilateral partial laminectomy ...I closed the skin using Vicryl and staples." The staples had not been removed while in the hospital.