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Based on clinical record review and staff interview the facility failed to, ensure the quality of nursing care provided to each patient is in accordance with established standards for practice of nursing care. This failure affectced 4 of 10 sampled patients (Patient #1, #3, #4 and #8) as evidenced by failure to administer medications timely and accurately.


The findings include:


1. Clinical record review conducted on 02/11/13 revealed Patient # 1 was admitted to the facility on 01/05/13, diagnoses include Insulin Dependent Diabetes.

Physician Orders dated 01/05/13 at 5:12 AM includes Metformin 1000 mg twice a day with meals.

Physician Order dated 01/05/13 at 8:13 AM documents Lantus (Insulin) 50 units at bedtime; Aspart Insulin, sliding scale three times a day before meals and at bedtime as follows: 71-120 give 6 units, 121-150 give 8 units, 151-200 give 10 units, 200-250 give 12 units and greater than 251 give 15 units.

Review of the Medication Administration Record (MAR) dated 01/05/13 revealed Patient #1 received the Metformin 1000 mg scheduled at 8 AM with meals for 11:04 AM administration. In addition 6 units of Insulin, was given at 11:06 AM, based on a glucose reading of 103 obtained at 8:24 AM.

Further review of the MAR revealed Patient # 1 was given Metformin 500 mg on 01/05/13 at 5:24 PM instead of the prescribed dose of 1000 mg. The entry notes reason "Nursing Judgment " .

Phone interview was conducted with Registered Nurse # 1 on 02/12/13 at 11:32 AM, who stated on inquiry the medications were not available from the pharmacy; the unit has two Pyxis, but not all medications are available. The nurse said he was not sure if this was the case on this particular incident; but he would have taken the scheduled medications from the Pyxis. The Nurse verbalized, he most likely gave the Metformin 500 mg per patient request, and he made a mistake by selecting the wrong reason on the drop down menu. The nurse acknowledged the medications and Insulin were administered late and stated he did not document an explanation for the incorrect dose.

Interview with The Director of Pharmacy was conducted on 02/11/13 at 11:48 AM. The Director explained, the Pharmacy delivers medication to the units every two hours, (8 10, 12,2,4); missing medication slips are electronically created by right clicking the medication on the MAR and a label is created in the Pharmacy or the nurse can call the pharmacy directly. The Director presented the Pyxis inventory for the Telemetry Unit. All medications prescribed to Patient # 1 were available in the Pyxis with quantities ranging from 20 to 50, with the exception of the Insulin as the Pyxis do not have the capability to hold refrigerated medications. The Director stated she is not able to create an actual count of the medications available the day in question, but the inventory on each unit is based on the demand and each unit needs are evaluated constantly by Pharmacy. The Director explained the delay in receiving the medications was due to miscommunication with the Pharmacy, and that the 10 AM delivery went to the emergency room first and arrived to the unit closer to 11 AM.

Phone interview with Registered Nurse # 2 was conducted on 02/12/12 at 12:05 PM. The Nurse stated she received the patient the evening of 01/05/13; the patient was anxious regarding changes in her medication. The day nurse had reported he had given half the Metformin dose because the patient's glucose was not high and the patient was scheduled to get Insulin at night.


2. Clinical record review conducted on 02/11/13 revealed Patient # 3 was prescribed Lispro Insulin three times a day before meals on 02/04/13 at 3:38 PM with the following sliding scale. Blood sugar 60-150 no insulin, 151-199 give 2 units, 200-249 give 4 units, 250-299 give 6 units, 300-349 give 8 units, 350-400 give 10 units, greater than 400 give 12 units and call physician.

Review of the Point of Care glucose results disclosed documented glucose readings on 02/06/13 at 4:18 AM of 254. No coverage was provided. Glucose readings on 02/07/13 at 6:01 AM document results of 298, no Insulin coverage was provided.

Interview with the Director of Pharmacy was conducted on 02/11/13 at approximately 2:10 PM. The Director explained Lispro insulin should be given with food, the patient received the scheduled oral hypoglycemic Glipizide, and the nurses most likely did not administer Insulin coverage for the elevated glucose results because it was not meal time. The Director was made aware of an entry documenting Patient # 3 received 8 units of Lispro on 02/04/13 at 11:47 PM, as a late dose, which is not a meal time.


3. Clinical record review conducted on 02/11/13 revealed Patient # 4 was prescribed Regular Insulin every two hours on 02/07/13 at 12:14 AM with the following sliding scale. Blood sugar 60-149 give no insulin, 150-199 give 2 units, 200-249 give 3 units, 250-29 give 4 units and 300-349 give 5 units, 350 and greater give 6 units and call the physician.

Review of the Point of Care glucose results failed to disclose documented glucose readings on 02/07/13 at 4 AM, 8 AM and 10 AM.

Further review of the patient's electronic record failed to yield substantiative evidence indicating glucose monitoring was done for Patient #4 every two hours as prescribed.


4. Clinical record review conducted on 02/11/13 revealed Patient # 8 was prescribed regular Insulin three times a day, before meals and at bedtime on 02/08/13 at 6:34 PM with the following sliding scale. Blood sugar 70-99 no coverage, 200-250 give 2 units, 251-300 give 4 units, 301-350 give 6 units and 351-400 give 8 units. Physician order dated 02/08/13 at 7:20 PM documents Lantus 12 units at bedtime.

Review of the Point of Care glucose results revealed documented glucose reading on 02/10/13 at 9:07 PM as 239 and on 02/11/13 at 9:48 as 255. Further review of the Medication Administration Record failed to disclose evidence that the prescribed coverage was given.

Interview with the Director of the Telemetry Unit was conducted on 02/12/13 at approximately 9:50 AM. The Director stated if the physician order Insulin coverage it should have been given despite the fact the patient has scheduled insulin at bedtime.


Interview with the Clinical Informatics Personnel, and the Director of Risk Management was conducted on 02/11/13 at approximately 2 PM. Review of the electronic nurses notes, physician orders, nursing communication screens and notations on the administration record relating to Patients #1, #3, # 4 and # 8 failed documented evidence regarding why the insulin coverage or glucose monitoring was not done as ordered.


Facility policy titled " Timely Administration of Scheduled Medications " specified "Time Critical" scheduled medications is defined as those medications where early or delayed administration of maintenance doses of greater than 30 minutes before or after the schedule dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect.

The following mediations are time-critical an should be administered within 30 minutes before and after the scheduled time when the clinical situation allows: Medication with dosing schedule more frequently than every 4 hours (e.g. every two hours or every three hours). Medications that require administration within a specified period of time before, with, or after meals such as rapid, short or ultra-short acting insulins and certain anti-diabetic agents. "

Based on clinical record review and staff interview the facility failed to ensure the quality of nursing care provided to each patient is in accordance with established standards of practice for nursing care. This failure affected 2 of 10 sampled patients (Patient # 6 and Patient # 7) as evidenced by failure to monitor vital signs during blood transfusions.


The Findings include:


Facility policy titled " Transfusion of Blood Components " documents " Monitor and record vital signs. Any change in the condition of the patient may signal the development of a transfusion complication. Pre-transfusion, 15 minutes post initiation of transfusion and post transfusion vitals are mandatory.

Review of the Clinical record for Patient # 7 revealed a physician order dated 02/07/12 to transfuse two units of packed cells and to transfuse the patient with two units of packed cells if hematocrit less than 24.

Transfusion record dated 02/08/13 documents the transfusion started on 02/08/13 at 12:30 AM. The record failed to document pre and post transfusion assessment with vital signs.

Transfusion record dated 02/08/13 documents another transfusion started on 02/08/13 at 3:30 AM. The record fails to document the pre transfusion, 15 minutes post initiation and post transfusion assessment with vital signs.

During an interview with the Clinical Informatics personnel on 02/11/13 at 2 PM she further review the electronic nurse's notes, physician orders, nursing communication screens, flowsheets and notations on the medication administration record for Patient #7 but was unable to provide documentation (evidence) of the vital signs taken for Patient # 6.