HospitalInspections.org

Based on staff interview and clinical and administrative record review, the facility failed to ensure medications were administered as prescribed by the physician and according to accepted standards of practice for 1 of 3 patients reviewed for medication administration (Patient #4).


The findings included:


The facility's policy regarding "Medication Safety Plan" last revised 07/17 documents "Patient assessment: prior to receiving non-emergent medications, the patient receives at a minimum, a focused assessment. Baseline information, vital signs are assessed and documented. After receiving medications, the patient is assessed for changes in symptoms and vital signs."


Review of the clinical record for Patient #4 conducted on 11/27/18 revealed the physician prescribed on 11/26/18 Humalog insulin sliding scale as follows:
For blood glucose 151-200 give 2 units
201-250 give 4 units
251-300 give 6 units
301-350 give 8 units
351-400 give 10 units


Medication Administration Record dated 11/27/18 documents Patient #4's blood glucose at 5:51 AM was 318, the patient received 10 units of insulin, instead of the 8 units prescribed.
At 9:50 AM, the patient's blood glucose was 253 and the patient received 2 units of insulin, instead of the 6 units prescribed.


An interview was conducted on 11/27/18 at approximately 12;15 PM with the Director of the Unit and The Coordinator, who confirmed the nurse documented administering an amount not prescribed by the physician.

Based on policy review, clinical record review and interview the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 1 of 2 sampled patients (Patient #5) as evidenced by failure to reassess patient's condition after completion of blood transfusion as specified per facility policy.


The findings included:

Facility policy titled "Blood Product Administration" dated 07/18 documents "To provide guidelines for the safe administration of blood products within the facility. Procedure for Monitoring and Documentation:
All patient areas will document vitals and any transfusion reactions at the following intervals.
Baseline vital signs must be taken 30 minutes prior to beginning transfusion.
5 minutes after initiation of transfusion and as patient condition requires
15 minutes after initiation of transfusion
30 minutes after initiation of transfusion
1 hour after initiation of transfusion
Every hour thereafter until transfusion is complete
A final set of vital signs should be documented 30 minutes after end time.



Clinical record review conducted on 11/28/18 revealed Patient #5 was prescribed a blood transfusion, one unit of red blood cells on 10/16/18 due to low hemoglobin.

The record indicates the blood transfusion was initiated on 10/16/18 at 2:16 PM.

Review of the Nurses Notes, Nursing Shift Assessments and Assessment and Reassessment documentation and blood administration record failed to provide evidence the patient baseline vital signs were obtained 30 minutes prior to the infusion and there is no evidence the patient was reassessed 30 minutes after the completion of the blood transfusion.

Interview with The Senior Risk Manager and The Director of Advanced Clinical on 11/28/18 at 11:26 AM confirmed there is no evidence the nursing staff completed a baseline assessment 30 minutes prior to the initiation of the blood transfusion. Furthermore, there is no evidence the nursing staff reassessed the patient 30 minutes post transfusion as mandated by the facility policies and procedures.