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Based on document review and staff interview, the hospital failed to ensure nursing care and services were supervised and evaluated for each diabetic patient, in accordance with physician orders and policy. Therefore, the Condition of Participation, 42 CFR 482.23, Nursing Services, was NOT met. This has the potential to affect all patients receiving care at this Hospital.

Findings Include:

1. The Hospital failed to ensure patients with insulin pumps were appropriately assessed and cared for, including blood sugar checks, insulin administration, and obtaining timely orders for care of diabetic patients during hospital admission.
See A395-A

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient, with an insulin pump, the Hospital failed to ensure patients with insulin pumps were appropriately assessed and cared for: including blood sugar checks, insulin administration, and obtaining timely orders for care of diabetic patients during hospital admission. This has the potential to affect all patients, with an insulin pump, serviced by the hospital, one in the last 12 months.

Findings include:

1. Policy #: POC-13, Diabetic Care Protocol (last reviewed/revised by the hospital 12/17/2118) was reviewed on 1/30/2020 at approximately 12:30 PM. On page 2, the policy indicated, "j. If the patient using an insulin pump is at high risk for self harm or suicide the physician may choose to write orders for the pump to be disconnected and insulin to be administered by the nurse via insulin syringe each time it is needed in order to protect the safety of the patient."

2. Pt #1 Admission date: 12/26/2019
Diagnosis: suicidal ideation with plan to overdose on insulin. Pt #1's record was reviewed 1/29/2020 through 1/30/2020. According to Pt #1's record: Pt #1 is a type one diabetic on an insulin pump. Intake documentation indicated Pt #1 arrived at the hospital on 12/26/19 at 11:50 PM. Pt #1 was on a insulin pump at time of admission. The patient possession checklist for admission indicated "Items that require secured storage in med room... diabetic pump... yes". The form lacked the patient signature. There was no documentation of the discontinuation of the pump or a physicians order to discontinue the pump. During the admission assessment on 12/27/2019 at 2:00 AM, registered nurse (E #6) documented a blood sugar at 110 mg/dl (milligrams per deciliter) and obtained order to recheck blood sugar at 7:30 AM. No other blood sugars were documented until 2/27/20 at 10:15 AM. On 12/27/2019 at 6:00 AM, E #6 documented that an order was obtained for sliding scale Humalog (fast acting insulin that starts working in 15 minutes after injection and peaks in about an hour, and will continue to work for 2-4 more hours). The record lacked any documentation for the reason for obtaining the insulin order. On 12/27/2019 at 9:00 AM, the history and physical exam was performed on Pt #1 by MD #1. MD #1 wrote an order to start Lantus 10 units every morning (long acting insulin). On 12/27/2019 at 9:00 AM, an order was written to give Pt #1 the insulin pump back. The order was written by registered nurse (E #5) and signed by MD #1. There is no documentation that the pump was returned to Pt #1. On 12/27/2019 at 10:15 AM, the blood sugar check was 393 and 10 units of Lantus insulin was given. On 12/27/2019 at noon (12:00 PM) the blood sugar check was 525 and 16 units of Humalog insulin was given. On 12/27/2019 at 1:49 PM the blood sugar was checked with result of 325 and 8 units of Humalog insulin given. On 12/27/2019 at 5:59 PM, the pre-dinner blood sugar was checked with result of 191. Five (5) units of Humalog insulin given per order along with 2 units from sliding scale order for a total of (5 plus 2) 7 units Humalog insulin given. On 12/27/2019 at 7:45 PM, E #4 checked Pt #1 ' s blood sugar with a result of 253. Physician notified of Pt #1's "continued increased blood sugar level along with nausea and vomiting episodes." Severity and duration of the nausea and vomiting episodes were not documented. Physician notified registered nurse(E #4) to send Pt #1 to ED (emergency department) for further evaluation of increased blood sugar levels along with nausea and vomiting. On 12/27/2019 at 8:15 PM documentation of ambulance arrival and Pt #1 sent to emergency department along with insulin pump given to paramedic to take to hospital with Pt #1.

3. An interview was conducted with the Chief Nursing Officer ( E#2) on 1/29/2020 at approximately 12:20 PM, in the Board Room. E#2 assumed this position approximately 3 months ago. E#2 stated the hospital does the following: They do not take patients with wounds, unless they are self-harming in nature. They do take patients with nebulizers and inhalers, but they are locked up in the nursing medication room and they have to be monitored while using them. They do not do IV's due to suicidal risks. They do insulin pumps and if the patient is not suicidal, the pump can remain on, but if the patient is suicidal and/or has made any comment about overdosing on insulin, the pump would be discontinued with a doctor's order and locked in the nursing medication room. "We can consult their medical doctor if there is a crisis, but we have our own medical doctor. We don't use the community physician orders. Our medical doctor would reorder meds. The medical doctor is on-call, not on-site. We had a patient with an insulin pump, be became unstable, so was sent out (to the ER). All the medications are communicated nurse-to-nurse on admits and then goes through the psychiatrist for orders. Some of the medications we do not have, like some of the hormonal meds, HIV meds, seizure meds, so if unable to get the patient to bring in their's from home, we may see a delay for getting med due to having to order them from the pharmacy. The medical doctor does clearance (assessment) within 24 hours to say whether the patient can stay here or not (due to unresolved medical issues). The medical reconciliation is done in the ED. We get report from the community and have the patient bring the bottles (medication bottles) and we check with their pharmacy to verify them, if we need to. Many patients don't refill their medications and we can determine when they were last filled. Our pharmacy is open 8:00 AM to 4:00 PM and we have a night cabinet, so the nurses can obtain our formulary meds if they need to."

4. An interview was conducted with the Youth Manager (registered nurse -E#3) on 1/30/2020 at approximately 12:35 PM, in the Board Room. E#2 was present. E#3 stated that he/she helps out on the adult floor whenever needed. E #3 stated, "We rarely have insulin pump patients and I've haven't experienced this (caring for a patient with an insulin pump). The medication reconciliation process is the same during the day as it is at night. The orders should be received on the floor. We can occasionally do it at intake, but that isn't the usual. We don't have diabetic protocols. It would be per orders. We do sliding scale insulin and carb counts per doctor's orders."

5. A phone interview was conducted with the registered nurse ( E#6) on 1/30/2020 at approximately 2:00 PM, from the Board Room. E#2 was present. E#6 stated, "I remember (Pt #1). I went down to intake and I asked (Pt #1) to remove it (the insulin pump) during the contraband search (1/27/2019 at approximately 12:30 AM)... later (during the nursing admission assessment at 2:00 AM), I checked the blood sugar and it was 110 and called the doctor (MD#1) for orders. That's when I told (MD#1) about the insulin pump and discontinuing it because of SI (suicidal ideation) with the plan to OD on insulin, that we removed the pump, and the blood glucose. I guess I didn't document everything. This was my first time taking care of someone with one (an insulin pump). No, we haven't had any training on them We don't have them that much. I remember checking his (Pt #1) blood sugar somewhere around 4:30 (AM) and 5:00 (AM) (was not documented in the record). I remember it was higher, but I can't remember what it was. I asked (the doctor) for sliding scale (the order was written at ~ 6:00 AM and no insulin was documented as given at that time)."

6. A phone interview was conducted with the Medical Doctor (MD#1) on 1/30/2020 at approximately 2:20 PM from the Board Room. Dr. Saad stated remembering Pt #1 and stated, "They (the staff) called me because the patient (Pt #1) was suicidal and had an insulin pump. They had already detached the pump before they call me. Usually I add a long-acting and/or a short-acting insulin, which is what I did when they called in the morning (2/27/19) and the sliding scale was ordered. When I made rounds, I then ordered Lantus (a long-acting insulin), so that the patient was covered appropriately. You treat type I (diabetes) the same way you treat type 2 (diabetes), with ac and hs (before meals and at bedtime) accuchecks and sliding scale. No, it doesn't matter if they (type I patients) have an insulin pump or not. You treat them with the same coverage of long-acting, like Lantus, and sliding scale with ac and hs accuchecks. When the patient is not suicidal, they can keep their pump and I believe I was told the patient was no longer suicidal after I'd made my rounds, therefore, he could have his pump back."

7. A phone interview was conducted with the registered nurse (E#4) on 1/31/2020 at approximately 9:20 AM. E#4 stated working the 3 PM-11 PM shift and remembered Pt #1. In report, I was told the patient came in with SI (suicidal ideation) with a plan to OD on insulin. Pt #1 was a Type I and had an insulin pump that was removed for safety. Pt #1's blood sugars were high and had sliding scale (insulin) and they were coming down. The patient was vomiting and an anti-nausea med had been ordered and Zofran had been given. For me, Pt #1 was vomiting, so I got an order for Phenergan, but the patient refused it. Pt #1 sugars had been up to 500s and down. Pt #1 was still nauseate, and couldn't eat or drink. I didn't feel comfortable and wanted the patient to go to ER for evaluation, so I called the doctor and reported that the patient had had an insulin pump that was dc'd (discontinued) with increasing blood sugars and vomiting unretractably, so we sent him to the ER. The medical doctor can call for a consult with and endocrinologist, if he/she wants to, but we don't call them. I did speak with the parent (of Pt #1). The parent had called when I was in with the patient and when I was on the phone with the doctor. The patient had called the parent and reported about the blood sugars and coming down and that Pt #1 had never felt like this before and I told the parent that we were going to send Pt #1 out (to the ER) and the parent was glad. I believe this was a first for me (taking care of a patient that had had an insulin pump). I would follow the doctor's orders."


8. An interview was conducted with the registered nurse (E#5) on 1/31/2020 at approximately 9:20 AM in the Board Room. E#2 was present. E#3 stated having worked for the hospital for 3 ½ years. E #5 remembered Pt #1 and stated, "I helped take care of (Pt #1) that morning. I thought (Pt #1) could have the pump. I wasn't aware of the insulin OD statement. I wasn't told that, so I got the order that (Pt #1) could have it. When they (other staff) told me, I just told them not to put it back on. I forgot to say anything to the doctor and I didn't write an order. I was misinformed. We don't have patient assignments, we are all responsible for all the patients. We (the nurses) tag teamed with him (Pt #1). I kept his mom updated and probably talked to her at least four times that shift. I know about insulin pumps, because I have a friend that has one. I don't know that we would ever consider doing an insulin pump with 1:1 observation. I think it would still be too high of a risk. They could say they were checking their pump, mess with it, and still OD."






B. Based on document review and interview, it was determined for 1 of 1 (Pt #7) patient who required the use of a CPAP (Continuous positive airway pressure/power is a form of positive airway pressure ventilator, which applies mild air pressure on a continuous basis to keep the airways continuously open in people who have respiratory issues, such as sleep apnea), the hospital failed to ensure physician orders for CPAP were followed. This has the potential to affect all patients serviced by the hospital and require the use of CPAP, which the hospital is uncertain as to the number of patients per year with a CPAP.

Findings include:

1. Pt #7 Admission date:1/27/2020 Discharge date: 1/30/2020
Diagnoses: major depressive disorder with a history of sleep apnea. On 1/27/20, there was a physician order for CPAP at NOC (night) for sleep apnea - pt (patient) may use own from home". There was no documentation to indicate Pt #7 had used the CPAP at night as ordered.

2. An interview was conducted with the Youth Manager (E#3) on 1/31/2020 at approximately 11:10 AM. E#3 reviewed the record of Pt #7 and stated, "I fill in on that unit. I don't see it (the CPAP) charted anywhere. It should have been put into the nursing orders and we should have charted it, but we didn't."

Based on document review and interview, it was determined for 1 of 10 (Pt #4) patients, the psychiatric hospital failed to ensure nursing care plans included the nursing care to be provided to meet the patient's needs. This has the potential to affect all patients serviced by the psychiatric hospital, with an average daily census of 38 adults and 24 adolescent/youth.

Findings include:

1. Pt #4 Admission date: 12/18/2019
Diagnoses: major depressive disorder, disruptive mood dys-regulation disorder, and suicidal/homicidal ideation. Pt #4's record was reviewed on 1/29/2020 at approximately 2:30 PM. On 12/18/2019, the "Initial Nursing Treatment Plan" (the nursing care plan) indicated "Problem/Short-term Goals... suicidal...self-harming... medication safety... programming..." The Plan lacked specific interventions, treatment modality, and frequency/duration".

2. An interview was conducted with the Youth Manager (E#3) on 1/31/2020 at approximately 11:50 AM. E#3 reviewed Pt #4's record and stated, "That was me. I didn't mark them and I should have (the interventions, treatment modality, and frequency/duration)."