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Based on interview and medical record review, the hospital failed to administer insulin (medication to treat high blood glucose) doses according to physicians' orders in three out of 4 patients' medical records reviewed (Patients 83, 84, and 85). Incorrect doses of insulin and not administering Dextrose 50% (medication given intravenously to treat very low blood glucose levels) can potentially impact patients by allowing blood glucose levels to remain too high or too low affecting the brain, heart, kidneys, and circulatory systems.

Findings:

On 5/11/11, review of Patient 83, 84, and 85's medical records revealed a physician order for insulin infusion. The nursing staff dosed insulin by following a preprinted order sheet in each patient's medical record. The nurses followed a chart on the order sheet to determine the insulin dose to be administered. The insulin dose was based on the result of the patient's most recent blood glucose (blood sugar) level. The insulin concentration was determined by mixing 100 units of regular insulin in 100 milliliters (ml) of normal saline to yield a concentration of one unit/ml. The blood glucose level goal for all patients, was 140-180 milligrams/deciliter (mg/dL).

a. On 5/11/11 at 1332 hours, review of Patient 83's medical record revealed an insulin infusion order on 4/20/11. On 4/21/11 at 0140 hours, the blood glucose result was 227 mg/dL. According to the preprinted order sheet, the insulin dose should have been increased by one unit to 5 units/hour. According to RN 30 and what was documented in Patient 83's medical record, the dose was not increased and remained at 4 units/hour. The next blood glucose level at 0300 hours was higher at 235 mg/dL.

b. On 5/11/11 at 1351 hours, review of Patient 84's medical record revealed an insulin infusion order on 4/16/11. On 4/17/11 at 0100 hours, the blood glucose result was 133 mg/dL. According to the preprinted order sheet, the insulin infusion should have been been decreased by 1 unit/hour and since the patient was receiving 1 unit/hour, RN 30 stated, "According to the order sheet, the infusion should have been turned off." RN 30 was unable to find a physician order that would allow the infusion to continue running.

c. On 5/11/11 at 1415 hours, review of Patient 85's medical record revealed an insulin infusion order on 4/8/11. On 4/8/11 at 1900 hours, the blood glucose result was 69 mg/dL. The patient's physician ordered ? ampule of Dextrose 50%. RN 30 was asked to locate documentation on the medication administration record (MAR) that Patient 85's nurse administered the Dextrose 50%. RN 30 said he could not find documentation the Dextrose was administered. The next blood glucose level was 108 mg/dL.

On 4/8/11 at 2340 hours, Patient 85's blood glucose level was 150 mg/dL. According to the order sheet, the insulin dose should have been decreased by 1 unit but this was not documented as done and Patient 85 continued to receive 2 units/hour.

During a previous survey completed on 12/16/10, the hospital was not able to ensure that Patient 70 was accurately administered doses of insulin based on the insulin order sheet. In the hospital's Plan of Correction submitted 3/29/11, the hospital stated it would be auditing medical records of insulin infusion patients to determine if doses were administered correctly. The hospital provided documentation on 5/11/11 that the above insulin administration errors for Patients 83, 84, and 85 were captured in their audits and they were continuously working on correcting these errors. According to Pharmacist 6, medical record audits were performed weekly since 3/28/11.


22781

Based on observation and interview, the hospital failed to ensure oral medications were not stored on the same shelf with potentially toxic topical medications in the ED's Pyxis (Emergency Department's automated drug dispensing cabinet). The hospital also failed to list the first drug to expire on the outside of the emergency medication code blue cart in the NICU (Neonatal Intensive Care Unit's cart used in emergencies that contain drugs and supplies). The hospital failed to ensure that the NICU code blue cart was sealed by a pharmacist and not a nurse.

Findings:

1. On 5/10/11 at 1100 hours, the Pyxis in the ED-2 station was found to have an oral medication (activated charcoal which is used to treat drug overdoses) on the same shelf as providine-iodine (a topical liquid disinfectant that can be hazardous if taken orally).
The California Code of Regulations,Title 22, section 70263(q)(5) states, "External use drugs in liquid, tablet, capsule, or powder form shall be segregated from drugs for internal use."

2. On 5/11/11 at 1106 hours, during a tour of the NICU, the emergency drug list attached to the code blue cart showed Adenosine 6 milligrams/2 milliliter injection as the first drug to expire in the cart. It expired on 10/31/11. On further inspection of the drugs inside the cart, it was noted that the first drug to actually expire was Atropine 0.1 milligrams/ milliliter on 8/1/11 and not Adenosine.

Pharmacist 6 stated, the list of drugs attached to the outside of the cart was not the correct list of drugs stored in the cart. The correct list should have had Atropine as the first drug to expire.

California Code of Regulations, Title 22, section 70263(f)(2) states, "The contents of the container shall be listed on the outside cover and shall include the earliest expiration date of any drugs within."

3. On 5/11/11 at 1146 hours, Pharmacist 6 stated, "In NICU the nurses replace the drug box in the code blue cart as necessary and they seal the cart."

California Code of Regulations, Title 22, section 70263(f)(2) states, "The emergency drug supply shall be stored in a clearly marked portable container which is sealed by the pharmacist in such a manner that a seal must be broken to gain access to the drugs."


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20059

Based on observation and interview, the hospital failed to document the date the vial was opened on insulin vials (medication to treat diabetes), to ensure it was not used passed its expiration date when it becomes ineffective.

Findings:

On 5/10/11 at 1100 hours, located inside the ED-2 emergency department refrigerator was an opened vial of regular insulin U-100. According to Pharmacist 6, there should have been a date recorded on the vial when it was opened so staff knew when the medication expired. According to Pharmacist 6, the hospital's policy states insulin vials, once opened, are given 28 days before they expire and should not be used. Without a known expiration date for an opened vial, nurses could continue administering the medication after it expired and when the potency could not be guaranteed.